Τετάρτη 30 Νοεμβρίου 2016

Phlegmonous esophagitis treated by endoscopic drainage

Abstract

Phlegmonous esophagitis is a rare and sometimes fatal condition. Cases surgically treated have been reported previously; however, surgical approaches may be risky in the elderly. An 86-year-old woman presented with a sore throat and high fever after eating fish. She was first diagnosed with a deep cervical abscess, and conservative treatment was initially selected. However, her respiratory failure worsened, so emergent tracheostomy and surgical drainage were performed. Computed tomography showed intramural low-density lesions along the entire length of the esophagus and she was diagnosed with phlegmonous esophagitis. To avoid surgical intervention, endoscopic drainage was first attempted. Mucosal incision was made on the lower esophagus guided by endoscopic ultrasonography, using the insulated-tip electrosurgical knife. After the endoscopic drainage, her general health status improved, and the esophageal wall thickness was reduced. While some cases have recovered with conservative treatment, endoscopic drainage may be useful in certain patients.



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Phlegmonous esophagitis treated by endoscopic drainage

Abstract

Phlegmonous esophagitis is a rare and sometimes fatal condition. Cases surgically treated have been reported previously; however, surgical approaches may be risky in the elderly. An 86-year-old woman presented with a sore throat and high fever after eating fish. She was first diagnosed with a deep cervical abscess, and conservative treatment was initially selected. However, her respiratory failure worsened, so emergent tracheostomy and surgical drainage were performed. Computed tomography showed intramural low-density lesions along the entire length of the esophagus and she was diagnosed with phlegmonous esophagitis. To avoid surgical intervention, endoscopic drainage was first attempted. Mucosal incision was made on the lower esophagus guided by endoscopic ultrasonography, using the insulated-tip electrosurgical knife. After the endoscopic drainage, her general health status improved, and the esophageal wall thickness was reduced. While some cases have recovered with conservative treatment, endoscopic drainage may be useful in certain patients.



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Assessment of oxidative/nitrative modifications of plasma proteins, selected ROTEM parameters and kinetics of fibrinogen polymerization in patients with multiple myeloma at diagnosis

Abstract

Patients with multiple myeloma (MM) are at increased risk of thrombosis. Growing evidence indicates that oxidative and nitrative modifications of proteins, including fibrinogen, may lead to changes in hemostasis. The study compares samples from patients with MM at diagnosis and healthy volunteers with regard to the oxidative/nitrative modifications of proteins, ROTEM and thrombin-catalyzed fibrin polymerization. The content of carbonyl groups in plasma proteins of patients with MM was significantly higher than in controls (2.981 vs. 1.807 nmol/mg of protein, p = 0.005), while no differences were seen in the concentrations of nitrated proteins. Maximum clot firmness readings were significantly higher in the samples of patients than in controls according to FIBTEM test (23.5 vs. 15 mm, p = 0.006). The lag time of the fibrin polymerization process and the velocity of clot lysis (V Lys) were found to be significantly higher in the group of MM patients than controls. In contrast, no marked differences were identified between studied groups in reference to maximal velocity of fibrin polymerization process (V max), maximal absorbance (A max) and plasmin amidolytic activity values. In conclusion, our study demonstrates that at the time of diagnosis, patients with MM demonstrated greater oxidative stress than healthy volunteers, which is reflected in a higher amount of carbonylated proteins. Some prothrombotic features found in ROTEM tests in MM patients were not confirmed by turbidimetry.



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Treatment of lung tumours with high-energy microwave ablation: a single-centre experience

Abstract

The purpose of our study is to report safety, technical success, effectiveness, local progression-free survival (LPFS) and overall survival of percutaneous microwave ablation (MWA) to treat lung tumours unsuitable for surgery. Nineteen patients with thirty-one tumours (mean diameter 2.4 cm) underwent percutaneous MWA in 28 sessions. Microwave ablation was carried out using a 2450-MHz generator (Emprint/Covidien, Boulder, CO, USA). Procedures were performed under cone-beam CT (CBCT) and under fluoro-CT (one session) guidance. Safety, technical success, effectiveness, LPFS and overall survival (OS) were evaluated. Safety was defined as the frequency of major and minor complications. The efficacy was evaluated on the basis of imaging characteristics, using RECIST criteria. CT follow-up was performed at 1, 3 and 6 months and yearly. LPFS was defined as the interval between MWA treatment and evidence of local recurrence, if there was any. OS was defined as the percentage of patients who were still alive. We registered one major complication (purulent hydro-pneumothorax). Minor complications were spontaneously resolved (pneumothorax and perilesional haemorrhagic effusion). Technical success was 100%. Residual disease was registered in two cases, one of whom was retreated. Complete ablation was obtained in the remaining cases (90.3%). During available follow-up (mean 9.6 months), 9/31 tumours demonstrated local recurrence. Five tumours were retreated, and none of them presented residual disease during follow-up (LPFS 22.6%). Overall survival was 93.8%. Percutaneous high-energy MWA is a safe, effective and confident technique to treat lung tumours not suitable for surgery.



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Assessment of oxidative/nitrative modifications of plasma proteins, selected ROTEM parameters and kinetics of fibrinogen polymerization in patients with multiple myeloma at diagnosis

Abstract

Patients with multiple myeloma (MM) are at increased risk of thrombosis. Growing evidence indicates that oxidative and nitrative modifications of proteins, including fibrinogen, may lead to changes in hemostasis. The study compares samples from patients with MM at diagnosis and healthy volunteers with regard to the oxidative/nitrative modifications of proteins, ROTEM and thrombin-catalyzed fibrin polymerization. The content of carbonyl groups in plasma proteins of patients with MM was significantly higher than in controls (2.981 vs. 1.807 nmol/mg of protein, p = 0.005), while no differences were seen in the concentrations of nitrated proteins. Maximum clot firmness readings were significantly higher in the samples of patients than in controls according to FIBTEM test (23.5 vs. 15 mm, p = 0.006). The lag time of the fibrin polymerization process and the velocity of clot lysis (V Lys) were found to be significantly higher in the group of MM patients than controls. In contrast, no marked differences were identified between studied groups in reference to maximal velocity of fibrin polymerization process (V max), maximal absorbance (A max) and plasmin amidolytic activity values. In conclusion, our study demonstrates that at the time of diagnosis, patients with MM demonstrated greater oxidative stress than healthy volunteers, which is reflected in a higher amount of carbonylated proteins. Some prothrombotic features found in ROTEM tests in MM patients were not confirmed by turbidimetry.



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Treatment of lung tumours with high-energy microwave ablation: a single-centre experience

Abstract

The purpose of our study is to report safety, technical success, effectiveness, local progression-free survival (LPFS) and overall survival of percutaneous microwave ablation (MWA) to treat lung tumours unsuitable for surgery. Nineteen patients with thirty-one tumours (mean diameter 2.4 cm) underwent percutaneous MWA in 28 sessions. Microwave ablation was carried out using a 2450-MHz generator (Emprint/Covidien, Boulder, CO, USA). Procedures were performed under cone-beam CT (CBCT) and under fluoro-CT (one session) guidance. Safety, technical success, effectiveness, LPFS and overall survival (OS) were evaluated. Safety was defined as the frequency of major and minor complications. The efficacy was evaluated on the basis of imaging characteristics, using RECIST criteria. CT follow-up was performed at 1, 3 and 6 months and yearly. LPFS was defined as the interval between MWA treatment and evidence of local recurrence, if there was any. OS was defined as the percentage of patients who were still alive. We registered one major complication (purulent hydro-pneumothorax). Minor complications were spontaneously resolved (pneumothorax and perilesional haemorrhagic effusion). Technical success was 100%. Residual disease was registered in two cases, one of whom was retreated. Complete ablation was obtained in the remaining cases (90.3%). During available follow-up (mean 9.6 months), 9/31 tumours demonstrated local recurrence. Five tumours were retreated, and none of them presented residual disease during follow-up (LPFS 22.6%). Overall survival was 93.8%. Percutaneous high-energy MWA is a safe, effective and confident technique to treat lung tumours not suitable for surgery.



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“The Crossroad between Dentistry and Medicine” at ADEE & AMEE

By Prof. Rui Amaral Mendes and Dr. Seema Biswas

In August, taking advantage of having our annual meetings in the same city – the beautiful Barcelona – ADEE (the Association for Dental Education in Europe) and its medical counterpart, AMEE (the Association for Medical Education in Europe), convened efforts to hold a joint scientific and business meeting under the topic of: "The crossroad between Dentistry and Medicine".

More than a mere morning workshop's theme, this is a major trend worldwide and should be regarded as one of the major challenges pending upon two of the major stakeholders as far as Heathcare providing is concerned.

According to the World Health Organization, Interprofessional Education (IPE) is a necessary step in planning a "collaborative practice-ready" health workforce that is better prepared to respond to local and global health needs. A similar opinion is shared by ADEE's American colleagues from ADEA.

Still, the important thing is how we, educators, can use a potentially good idea and put in to good use, ensuring that our students get the best possible training, in line with the most recent FDI definition of oral health, as an "integral part of general health and well-being".

Hence, being, as we are, well-aware and committed to this evolving educational paradigm of Interprofessional Education and Learning and Interprofessional Collaborative Practice (IPCP), one must also consider the prospects of a partnership that makes the best out of each other's know-how, while keeping in mind that the European Directive 2005/36/EC, issued by the European Parliament and by the Council, establishing the EU legal foundations for the recognition of professional qualifications, makes it even more pertinent, not to say imperative, that both ADEE and AMEE join efforts in a combine approach advocating for new European Directives calling for a competencies-based approach for the education of dentists and physicians.

We often forget that according to the World Health Organisation, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".
Hence, when we think about Dental Education and overall services's provision, we can not help to feel that we are currently at a crossroad: one that demands us to move "outside the box" of our Dental Schools and Dental offices, while engaging with the needs of our communities at home and vulnerable communities across the world.

Education, even at the undergraduate level, and service provision are, therefore, intricately linked. We have to accept that we need to train dentists who are far more than just competent technicians, but rather health professionals responsible for oral health and health in general. Dentists need to get to know their patients and their communities better if they are to provide truly effective care.

There is a need for those involved in Dental Education to take the lead on incorporating global health into the undergraduate dental curriculum and to boost global health in postgraduate practice. The key focus should be to provide better dental care to patients at home, work on improving access (for free or at low cost) for patients at home and to fill the gap where dentists are scarce.

Due to socio-economic, cultural and political reasons, large segments of the world's population have limited or no access to regular dental care. Assisting the development of dental services in these areas should be regarded as a win- win strategy for both the developed and developing world as opportunities for training, practice and research lend themselves to twinning established successful programs at home with programmesfor the world's most vulnerable communities.

It's within this context, that, as we look through the feedback of the ADEE and AMEE meetings and workshops in global health, it becomes clear the enthusiasm for global health across all the medical disciplines. This enthusiasm seems centred on clinical practice: global health in the workplace, renewed focus on ensuring that the most vulnerable of our patients receive the best of clinical care, setting an example in the workplace to trainees who are going the extra mile to ensure that they address ALL the health needs of their patients and moving forward together to address the determinants of health in our undergraduate teaching programmes.

Thus, as ADEE and AMEE discuss the modern teaching agenda, we remind ourselves that global health is comprehensive healthcare and research. At BMJ Case Reports, we have the opportunity to put together the input of authors from across the world and emphasise priorities in addressing health disparities and access to healthcare. We have case reports from Trinidad in the West Indies (link) to Queensland in Australia (link). What is key is not so much the reach across the globe as the fact that authors are clinicians writing about patients they see locally daily.

As clinicians write about global health issues, we encourage students to do this, too. Global health problems cannot be tackled without a strong evidence base. Our cases are hugely valuable for teaching and to assist students as they begin to write. These case are also a powerful tool in bringing about improvements in health and should be used again and again as we advocate for our patients. There is extensive guidance on our website, and, as editors we are always to eager to engage with authors on how to make BMJ Case Reports more accessible to our readers and promote excellence in research and education.



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