Role and Mechanism of Galactose-Alpha-1,3-Galactose in the Elicitation of Delayed Anaphylactic Reactions to Red Meat

Abstract

Purpose of Review

The alpha-Gal (α-Gal) syndrome is characterized by the presence of IgE antibodies directed at the carbohydrate galactose-alpha-1,3-galactose (α-Gal). In this article, we review the presence of α-Gal in food and non-food sources; we discuss the evolutionary context of the antibody response to α-Gal and highlight immune responses to α-Gal and other carbohydrates.

Recent findings

IgE antibodies have been associated with delayed allergy to red meat. In addition to food, drugs, and other products of animal origin are increasingly perceived as a risk for patients sensitized to α-Gal. The link between tick bites and anti-α-Gal IgE-antibody production that has been established first by epidemiological studies has now been confirmed in mouse models.

Summary

The anti-α-Gal immune response is complex and characterized by a unique feature. IgM and IgG antibodies have been found to confer protection against pathogens whereas the IgE-response to α-Gal is detrimental and causes severe reactions upon exposure to mammalian meat and other products.

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Role and Mechanism of Galactose-Alpha-1,3-Galactose in the Elicitation of Delayed Anaphylactic Reactions to Red Meat

Abstract

Purpose of Review

The alpha-Gal (α-Gal) syndrome is characterized by the presence of IgE antibodies directed at the carbohydrate galactose-alpha-1,3-galactose (α-Gal). In this article, we review the presence of α-Gal in food and non-food sources; we discuss the evolutionary context of the antibody response to α-Gal and highlight immune responses to α-Gal and other carbohydrates.

Recent findings

IgE antibodies have been associated with delayed allergy to red meat. In addition to food, drugs, and other products of animal origin are increasingly perceived as a risk for patients sensitized to α-Gal. The link between tick bites and anti-α-Gal IgE-antibody production that has been established first by epidemiological studies has now been confirmed in mouse models.

Summary

The anti-α-Gal immune response is complex and characterized by a unique feature. IgM and IgG antibodies have been found to confer protection against pathogens whereas the IgE-response to α-Gal is detrimental and causes severe reactions upon exposure to mammalian meat and other products.

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Salvage surgery for advanced stage head and neck squamous cell carcinoma following radiotherapy or chemoradiation

Abstract

Purpose

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma (HNSCC) is known to result in poor prognosis. As there are only small and heterogeneous studies available with wide variety in outcome measures, our purpose was to select and pool literature according to specific criteria.

Methods

Systematic review and meta-analysis of clinical outcome after salvage surgery for recurrent advanced stage HNSCC following primary radiotherapy or chemoradiation.

Results

16 of 3956 screened studies were included for analysis (729 patients). Pooled 5-year OS was 37% (95% CI 30–45%, 12 studies, 17 outcome measurements, 540 patients). Outcome was presented for larynx (6 studies, 397 patients), hypopharynx (2 studies, 47 patients), larynx and hypopharynx combined (3 studies, 69 patients) or separately (1 study, 134 patients), oral cavity (1 study, 11 patients), oropharynx (1 study, 34 patients) and multiple subsites combined (2 studies, 37 patients). There was no significant difference in survival outcome between subsites (p_{heterogeneity} = 0.8116). The pooled tumor-positive resection margin rate was 32% and pooled re-operation rate 17%. Complication rates from the pooled data were: fistulas 33%, wound infections 24% and flap failure 3%. Treatment-related mortality rate was 1% and mean hospital stay was 23 days.

Conclusions

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma after primary (chemo)radiotherapy is a good last resort curative treatment option, resulting in 37% overall survival at 5 years. As data from advanced stage non-laryngeal tumors were sparse, no solid conclusions can be drawn with regard to outcome differences between tumor subsites.

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Annual Meeting Abstracts of the Society of Skeletal Radiology (SSR) 2019, Scottsdale, Arizona, USA

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Highlights of the annual scientific meeting of the 25th congress of the European Society of Musculoskeletal Radiology (ESSR) 2018, Amsterdam, The Netherlands

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Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review

Abstract

Luxatio erecta humeri (LEH), also known as inferior shoulder dislocation, is uncommon, comprising about 0.5% of all cases of shoulder dislocation. Synchronous bilateral LEH is exceedingly rare and, to our knowledge, there are no descriptions of axillary nerve injury on magnetic resonance imaging (MRI) following LEH. We present a case of traumatic bilateral LEH in a 59-year-old woman who fell from a fast-moving mobility scooter and sustained direct axial loading forces on the fully abducted shoulders. Both shoulders were successfully reduced using the traction–countertraction technique in the emergency department. In this article, we describe the characteristic features of LEH on plain radiography and the pattern of acute soft-tissue injuries on MRI. We emphasize the importance of reviewing the axillary neurovascular bundle, which by virtue of its location beneath the shoulder joint, is prone to injury in inferior shoulder dislocation and thus has a substantial impact on functional recovery. This important complication is unfortunately not routinely examined by radiologists, partly because of the paucity of literature highlighting its clinical significance.

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Radiation dose reduction for musculoskeletal computed tomography of the pelvis with preserved image quality

Abstract

Objective

To analyze the impact of pelvic computed tomography (CT) technique optimization on estimated dose and subjective and objective image quality.

Materials and methods

An institutional review board (IRB)-approved retrospective records review was performed with waived informed consent. Five CT scanners (various manufacturers/models) were standardized to match the lowest dose profile on campus via subjective assessment of clinical images by experienced musculoskeletal radiologists. The lowest dose profile had previously been established through image assessment by experienced musculoskeletal radiologists after a department-wide radiation dose reduction initiative. A consecutive series of 60 pre- and 59 post-optimization bony pelvis CTs were analyzed by two residents, who obtained signal-to-noise ratio for femoral cortex and marrow, gluteus medius muscle, and subcutaneous and visceral fat in a standardized fashion. Two blinded attending radiologists ranked image quality from poor to excellent.

Results

Pre- and post-optimization subjects exhibited no difference in gender, age, or BMI (p > 0.2). Mean CT dose index (CTDIvol) and dose–length product (DLP) decreased by approximately 45%, from 39± 14 to 18± 12 mGy (p < 0.0001) and 1,227± 469 to 546± 384 mGy-cm (p < 0.0001). Lower body mass index (BMI) was associated with a larger dose reduction and higher BMI with higher DLP regardless of pre- or post-optimization examination. Inter-observer agreement was 0.64–0.92 for SNR measurements. Cortex SNR increased significantly for both observers (p < 0.02). Although qualitative image quality significantly decreased for one observer (p < 0.01), adequate mean quality (3.3 out of 5) was maintained for both observers.

Conclusion

Subjective and objective image quality for pelvic CT examination remains adequate, despite a substantially reduced radiation dose.

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How we do it: shifting MR arthrogram compounding from the fluoroscopy suite to the sterile pharmacy

Abstract

Objective

To assess the impact of shifting arthrogram injectate compounding from the fluoroscopy suite to the main hospital sterile pharmacy on cost, examination delays, and infection rates.

Materials and Methods

All arthrograms from the 12 months before (629 in total) and the 12 months after (699 in total) the change in arthrogram preparation procedure were compared to identify differences in examination delays and infection rate. The arthrogram formulation was sent to the Compounder's International Analytical Laboratory for stability testing. Finally, cost per injection analysis was performed to compare fluoroscopy suite with sterile pharmacy compounding.

Results

In the 699 arthrograms performed in the 12 months following transfer of arthrogram preparation to the main hospital pharmacy, there were 0 reported examination delays, 0 reported infections, and a 53% decrease in the material cost per arthrogram. There were three recorded instances of fluoroscopy suite preparation of arthrogram injectate due to unexpected add-on patients. Outside stability testing determined that the arthrogram injectate retained at least 90% potency 30 h post-preparation.

Conclusion

Shifting the compounding of the arthrogram injectate from the fluoroscopy room to the main hospital sterile pharmacy provides a modest cost saving and can be accomplished without examination delays or any increase in infection rate. It brought our practice into compliance with USP797, which is the current guideline for compounding practitioners, by transferring the compounding preparation of the arthrogram injectate from a procedure room to the sterile pharmacy.

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4-year-old boy referring for diffuse joint stiffness and progressive bilateral visual impairment

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Reliability of patellotrochlear index in patellar height assessment on MRI—correction for variation due to change in knee flexion

Abstract

Objectives

To assess the reliability of patellotrochlear Index (PTI) in patellar height assessment on successive MRI scans in asymptomatic patients.

Materials and methods

Sixty-four patients with two successive MRI scans (128 studies) of the same knee for non-patellofemoral joint symptoms were identified retrospectively. PTI and knee flexion angle were assessed independently by three observers to assess interobserver reliability. The effect of knee flexion on PTI was assessed by comparing the change in values of PTI in each patient correlated with change in knee flexion.

Results

Sixty-four MRIs of patients (M:F) aged between 18 and 35 years (mean 24.6) years were assessed. The mean PTI for initial scan group was 0.33% (95% CI: 0.29–0.37; SD: 0.15) and consecutive scan group was 0.30% (CI: 0.27–0.33; SD: 0.3). The difference was not significant (p = 0.097 using a paired t test) with high inter-observer correlation (0.9) in both sets. Spearman's rho for knee flexion angle and PTI was found to be positive and statistically significant (0.41; p = 0.001). A linear regression model was derived using a scatter chart of change in PTI with change in knee flexion for each patient. The gradient of the linear regression line was used to estimate a cPTI (corrected PTI) value (corrected to 0 degrees of knee flexion), defined as cPTI = PTI – 1.3a (a = knee flexion angle).

Conclusions

This study demonstrates high inter-observer correlation of PTI on MRI and high test–retest reliability indicating unconscious quadriceps contraction does not change the index sufficiently. Knee flexion significantly alters PTI, increased patellotrochlear engagement with flexion increases the index. We propose use of the formula cPTI = PTI -1.3a to correct the index to 0 degree knee flexion in clinical practice.

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Case report: urinoma in the proximal thigh mimicking a soft tissue neoplasm

Abstract

Soft tissue tumors form a heterogeneous group of benign and malignant lesions. Those with a high fluid content may be particularly challenging in diagnosis. We present a 78-year-old man with a dolorous, progressive mass in the adductor region of the lower left extremity. At the end of a long diagnostic pathway, the pseudocystic tumor was eventually identified as a urinoma, caused by a prostatosymphyseal fistula that had occurred as a late complication of transurethral resection of the prostate. Our finding represents a rare variant of soft tissue tumors in the lower extremities, which MR-based urography can help to reveal.

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4-year-old boy referring for diffuse joint stiffness and progressive bilateral visual impairment

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Preliminary investigation of brown adipose tissue assessed by PET/CT and cancer activity

Abstract

Objective

To determine the role of brown adipose tissue (BAT) in cancer activity.

Materials and methods

The study group comprised 142 patients (121 female, 21 male; mean age, 49 ± 16 years) who underwent F18-FDG PET/CT (PET/CT) for staging or surveillance of cancer and who were BAT-positive on PET/CT. BAT volume by PET/CT, abdominal (visceral and subcutaneous) fat and paraspinous muscle cross-sectional areas (CSA) were assessed. Groups with and without active cancer on PET/CT were compared using a two-sided paired t test. Linear regression analyses between BAT and body composition parameters were performed.

Results

There were 62 patients (54 female, eight male) who had active cancer on PET/CT and 80 patients (67 female, 13 male) without active cancer. Groups were similar in age and BMI (p ≥ 0.4), abdominal fat and muscle CSA, fasting glucose, and outside temperature at time of scan (p ≥ 0.2). Patients who had active cancer on PET/CT had higher BAT volume compared to patients without active cancer (p = 0.009). In patients without active cancer, BAT was positively associated with BMI and abdominal fat depots (r = 0.46 to r = 0.59, p < 0.0001) while there were no such associations in patients with active cancer (p ≥ 0.1). No associations between BAT and age or muscle CSA were found (p ≥ 0.1).

Conclusions

BAT activity is greater in patients with active cancer compared to age-, sex-, and BMI-matched BAT-positive patients without active cancer, suggesting a possible role of BAT in cancer activity.

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Added value of MRI to X-ray in guiding the extent of surgical resection in diabetic forefoot osteomyelitis: a review of pathologically proven, surgically treated cases

Abstract

Objective

This study retrospectively evaluated the added value of MRI over X-ray in guiding the extent of amputation in a cohort of patients with surgically treated, pathologically proven osteomyelitis.

Materials and methods

A database search revealed 32 cases of pathology-proven diabetic forefoot osteomyelitis between 2006 and 2016, in which X-ray, MRI, and surgery occurred within 30 days. Data collection included extent of osteomyelitis reported on imaging and extent of subsequent amputation using a point system. Added value of MRI over X-ray in guiding surgical resection was stated if the X-ray was negative, MRI was positive, and there was MRI–surgical concordance; if both modalities were positive, X-ray was discordant whereas the MRI was concordant; or if MRI detected an abscess. Two-tailed Fisher's exact test compared proportions.

Results

In 9 cases that were positive on both modalities, MRI identified an average of 1.2 additional bone segments of disease. There was surgical agreement with X-ray in 3 out of 31 cases (9.7%, 95%CI 0–20.1) and with MRI in 17 out of 31 cases (55%, 37.3–72.4; p < 0.0001). There was an added value of MRI over X-ray in guiding surgical treatment in 64.5% of cases (95% CI 47.7%–81.4%). MRI added value in 5 out of 9 X-rays positive for osteomyelitis and in 15 out of 22 negative (p value was not significant).

Conclusion

Magnetic resonance imaging demonstrated added value over X-ray in guiding surgical management in both X-ray-negative and -positive cases. Although multiple factors are involved in determining the degree of surgical excision, MRI is a clinically useful component of the diagnostic algorithm in patients who undergo surgical treatment.

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Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture

Abstract

Objective

To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration.

Materials and methods

We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen's kappa statistic was used to assess inter-reader agreement.

Results

In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was −12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively).

Conclusion

Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.

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3D-MRI versus 3D-CT in the evaluation of osseous anatomy in femoroacetabular impingement using Dixon 3D FLASH sequence

Abstract

Objective

To determine if hip 3D-MR imaging can be used to accurately demonstrate femoral and acetabular morphology in the evaluation of patients with femoroacetabular impingement.

Materials and methods

We performed a retrospective review at our institution of 17 consecutive patients (19 hips) with suspected femoroacetabular impingement who had both 3D-CT and 3D-MRI performed of the same hip. Two fellowship-trained musculoskeletal radiologists reviewed the imaging for the presence and location of cam deformity, anterior–inferior iliac spine variant, lateral center-edge angle, and neck–shaft angle. Findings on 3D-CT were considered the reference standard. The amount of radiation that was spared following introduction of 3D-MRI was also assessed.

Results

All 17 patients suspected of FAI had evidence for cam deformity on 3D-CT. There was 100% agreement for diagnosis (19 out of 19) and location (19 out of 19) of cam deformity when comparing 3D-MRI with 3D-CT. There were 3 type I and 16 type II anterior–inferior iliac spine variants on 3D-CT imaging with 89.5% (17 out of 19) agreement for the anterior–inferior iliac spine characterization between 3D-MRI and 3D-CT. There was 64.7% agreement when comparing the neck–shaft angle (11 out of 17) and LCEA (11 out of 17) measurements. The use of 3D-MRI spared each patient an average radiation effective dose of 3.09 mSV for a total reduction of 479 mSV over a 4-year period.

Conclusion

3D-MR imaging can be used to accurately diagnose and quantify the typical osseous pathological condition in femoroacetabular impingement and has the potential to eliminate the need for 3D-CT imaging and its associated radiation exposure, and the cost for this predominantly young group of patients.

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High-resolution ultrasound in the assessment of the distal biceps brachii tendinous complex

Abstract

Objective

To establish a high-resolution US technique that enables a systematic morphometric examination of the three components that form the distal biceps brachii tendinous complex; the internal bicipital aponeurosis, the distal biceps brachii tendon and the external bicipital aponeurosis (also known as lacertus fibrosus).

Materials and methods

Fifty cryopreserved cadaver body donor elbows were dissected to obtain morphometric reference values and to establish reliable landmarks for the US examination. Then, a systematic US technique was designed and validated by a one-to-one US/dissection analysis of 11 cryopreserved cadaver body donor elbows. Finally, the systematic US technique was carried out in 44 healthy volunteers and morphometric parameters were compared to those obtained in the first part of the study.

Results

Mean dissection reference values: internal bicipital aponeurosis width 39.61 mm (10.02 SD) and thickness 0.75 mm (0.24 SD), distal biceps brachii tendon width 8.38 mm (1.87 SD) and thickness 2.73 mm (0.69 SD), external bicipital aponeurosis width 11.17 mm (5.84 SD) and thickness 0.85 mm (0.28 SD). One-to-one US/dissection correlation was overall good (intraclass correlation coefficient 0.876, p < 0.0001). When comparing volunteer US/dissection measurements, significant differences were encountered in all measures except for internal bicipital aponeurosis width. However, the overall magnitude of such significant differences was < 0.7 mm.

Conclusions

Using the systematics hereby proposed, high-resolution US is reliable for the morphometric assessment of the distal biceps brachii tendinous complex. The external bicipital aponeurosis is morphometrically the most variable structure.

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Plexiform fibrohistiocytic tumor: imaging features and clinical findings

Abstract

Objective

To describe the imaging features of plexiform fibrohistiocytic tumor and its associated clinical findings.

Materials and methods

An institutional database was searched to identify all patients with a pathological diagnosis of plexiform fibrohistiocytic tumor. The electronic medical record was reviewed for relevant clinical data. Radiologic images of the primary tumor site were reviewed by two radiologists to assess primary, residual, or recurrent tumor with respect to tumor location, size, morphology, MR signal characteristics and enhancement, and involvement of adjacent structures.

Results

Thirteen patients with imaging of the primary tumor site were identified [eight female, five male; mean age, 15.9 years (range, 3–41 years)]. Plexiform fibrohistiocytic tumor typically manifested as a solitary, painless, firm, slow-growing lesion centered in the subcutaneous tissues, with a predilection for the upper extremity or head and neck region. Most tumors had a purely plaque-like or infiltrative morphology at MRI; some demonstrated no round or oval mass. Tumors were predominantly isointense to muscle on T1-weighted imaging and hyperintense on fluid-sensitive imaging, and enhanced after gadolinium contrast administration. Five patients (38%) had residual tumor after initial surgery, resembling postoperative changes. No patient had recurrent tumor. One patient (8%) developed metastases to local lymph nodes and to the lung. No patient died from plexiform fibrohistiocytic tumor.

Conclusions

Plexiform fibrohistiocytic tumor often manifests as a plaque-like or infiltrative process, sometimes without a round or oval mass, most commonly in the subcutaneous tissues of the upper extremity or head and neck region. Residual tumor is often present after initial surgery, and may be indistinguishable from postoperative changes.

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Radiologic evaluation of fracture healing

Abstract

While assessment of fracture healing is a common task for both orthopedic surgeons and radiologists, it remains challenging due to a lack of consensus on imaging and clinical criteria as well as the lack of a true gold standard. Further complicating this evaluation are the wide variations between patients, specific fracture sites, and fracture patterns. Research into the mechanical properties of bone and the process of bone healing has helped to guide the evaluation of fracture union. Development of standardized scoring systems and identification of specific radiologic signs have further clarified the radiologist's role in this process. This article reviews these scoring systems and signs with regard to the biomechanical basis of fracture healing. We present the utility and limitations of current techniques used to assess fracture union as well as newer methods and potential future directions for this field.

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Salvage surgery for advanced stage head and neck squamous cell carcinoma following radiotherapy or chemoradiation

Abstract

Purpose

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma (HNSCC) is known to result in poor prognosis. As there are only small and heterogeneous studies available with wide variety in outcome measures, our purpose was to select and pool literature according to specific criteria.

Methods

Systematic review and meta-analysis of clinical outcome after salvage surgery for recurrent advanced stage HNSCC following primary radiotherapy or chemoradiation.

Results

16 of 3956 screened studies were included for analysis (729 patients). Pooled 5-year OS was 37% (95% CI 30–45%, 12 studies, 17 outcome measurements, 540 patients). Outcome was presented for larynx (6 studies, 397 patients), hypopharynx (2 studies, 47 patients), larynx and hypopharynx combined (3 studies, 69 patients) or separately (1 study, 134 patients), oral cavity (1 study, 11 patients), oropharynx (1 study, 34 patients) and multiple subsites combined (2 studies, 37 patients). There was no significant difference in survival outcome between subsites (p_{heterogeneity} = 0.8116). The pooled tumor-positive resection margin rate was 32% and pooled re-operation rate 17%. Complication rates from the pooled data were: fistulas 33%, wound infections 24% and flap failure 3%. Treatment-related mortality rate was 1% and mean hospital stay was 23 days.

Conclusions

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma after primary (chemo)radiotherapy is a good last resort curative treatment option, resulting in 37% overall survival at 5 years. As data from advanced stage non-laryngeal tumors were sparse, no solid conclusions can be drawn with regard to outcome differences between tumor subsites.

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Browser's notes

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Annual Meeting Abstracts of the Society of Skeletal Radiology (SSR) 2019, Scottsdale, Arizona, USA

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2sIwrrs

Highlights of the annual scientific meeting of the 25th congress of the European Society of Musculoskeletal Radiology (ESSR) 2018, Amsterdam, The Netherlands

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Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review

Abstract

Luxatio erecta humeri (LEH), also known as inferior shoulder dislocation, is uncommon, comprising about 0.5% of all cases of shoulder dislocation. Synchronous bilateral LEH is exceedingly rare and, to our knowledge, there are no descriptions of axillary nerve injury on magnetic resonance imaging (MRI) following LEH. We present a case of traumatic bilateral LEH in a 59-year-old woman who fell from a fast-moving mobility scooter and sustained direct axial loading forces on the fully abducted shoulders. Both shoulders were successfully reduced using the traction–countertraction technique in the emergency department. In this article, we describe the characteristic features of LEH on plain radiography and the pattern of acute soft-tissue injuries on MRI. We emphasize the importance of reviewing the axillary neurovascular bundle, which by virtue of its location beneath the shoulder joint, is prone to injury in inferior shoulder dislocation and thus has a substantial impact on functional recovery. This important complication is unfortunately not routinely examined by radiologists, partly because of the paucity of literature highlighting its clinical significance.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2sJbe0M

Radiation dose reduction for musculoskeletal computed tomography of the pelvis with preserved image quality

Abstract

Objective

To analyze the impact of pelvic computed tomography (CT) technique optimization on estimated dose and subjective and objective image quality.

Materials and methods

An institutional review board (IRB)-approved retrospective records review was performed with waived informed consent. Five CT scanners (various manufacturers/models) were standardized to match the lowest dose profile on campus via subjective assessment of clinical images by experienced musculoskeletal radiologists. The lowest dose profile had previously been established through image assessment by experienced musculoskeletal radiologists after a department-wide radiation dose reduction initiative. A consecutive series of 60 pre- and 59 post-optimization bony pelvis CTs were analyzed by two residents, who obtained signal-to-noise ratio for femoral cortex and marrow, gluteus medius muscle, and subcutaneous and visceral fat in a standardized fashion. Two blinded attending radiologists ranked image quality from poor to excellent.

Results

Pre- and post-optimization subjects exhibited no difference in gender, age, or BMI (p > 0.2). Mean CT dose index (CTDIvol) and dose–length product (DLP) decreased by approximately 45%, from 39± 14 to 18± 12 mGy (p < 0.0001) and 1,227± 469 to 546± 384 mGy-cm (p < 0.0001). Lower body mass index (BMI) was associated with a larger dose reduction and higher BMI with higher DLP regardless of pre- or post-optimization examination. Inter-observer agreement was 0.64–0.92 for SNR measurements. Cortex SNR increased significantly for both observers (p < 0.02). Although qualitative image quality significantly decreased for one observer (p < 0.01), adequate mean quality (3.3 out of 5) was maintained for both observers.

Conclusion

Subjective and objective image quality for pelvic CT examination remains adequate, despite a substantially reduced radiation dose.

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How we do it: shifting MR arthrogram compounding from the fluoroscopy suite to the sterile pharmacy

Abstract

Objective

To assess the impact of shifting arthrogram injectate compounding from the fluoroscopy suite to the main hospital sterile pharmacy on cost, examination delays, and infection rates.

Materials and Methods

All arthrograms from the 12 months before (629 in total) and the 12 months after (699 in total) the change in arthrogram preparation procedure were compared to identify differences in examination delays and infection rate. The arthrogram formulation was sent to the Compounder's International Analytical Laboratory for stability testing. Finally, cost per injection analysis was performed to compare fluoroscopy suite with sterile pharmacy compounding.

Results

In the 699 arthrograms performed in the 12 months following transfer of arthrogram preparation to the main hospital pharmacy, there were 0 reported examination delays, 0 reported infections, and a 53% decrease in the material cost per arthrogram. There were three recorded instances of fluoroscopy suite preparation of arthrogram injectate due to unexpected add-on patients. Outside stability testing determined that the arthrogram injectate retained at least 90% potency 30 h post-preparation.

Conclusion

Shifting the compounding of the arthrogram injectate from the fluoroscopy room to the main hospital sterile pharmacy provides a modest cost saving and can be accomplished without examination delays or any increase in infection rate. It brought our practice into compliance with USP797, which is the current guideline for compounding practitioners, by transferring the compounding preparation of the arthrogram injectate from a procedure room to the sterile pharmacy.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2sEIczl

4-year-old boy referring for diffuse joint stiffness and progressive bilateral visual impairment

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2MuEPEg

Reliability of patellotrochlear index in patellar height assessment on MRI—correction for variation due to change in knee flexion

Abstract

Objectives

To assess the reliability of patellotrochlear Index (PTI) in patellar height assessment on successive MRI scans in asymptomatic patients.

Materials and methods

Sixty-four patients with two successive MRI scans (128 studies) of the same knee for non-patellofemoral joint symptoms were identified retrospectively. PTI and knee flexion angle were assessed independently by three observers to assess interobserver reliability. The effect of knee flexion on PTI was assessed by comparing the change in values of PTI in each patient correlated with change in knee flexion.

Results

Sixty-four MRIs of patients (M:F) aged between 18 and 35 years (mean 24.6) years were assessed. The mean PTI for initial scan group was 0.33% (95% CI: 0.29–0.37; SD: 0.15) and consecutive scan group was 0.30% (CI: 0.27–0.33; SD: 0.3). The difference was not significant (p = 0.097 using a paired t test) with high inter-observer correlation (0.9) in both sets. Spearman's rho for knee flexion angle and PTI was found to be positive and statistically significant (0.41; p = 0.001). A linear regression model was derived using a scatter chart of change in PTI with change in knee flexion for each patient. The gradient of the linear regression line was used to estimate a cPTI (corrected PTI) value (corrected to 0 degrees of knee flexion), defined as cPTI = PTI – 1.3a (a = knee flexion angle).

Conclusions

This study demonstrates high inter-observer correlation of PTI on MRI and high test–retest reliability indicating unconscious quadriceps contraction does not change the index sufficiently. Knee flexion significantly alters PTI, increased patellotrochlear engagement with flexion increases the index. We propose use of the formula cPTI = PTI -1.3a to correct the index to 0 degree knee flexion in clinical practice.

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Case report: urinoma in the proximal thigh mimicking a soft tissue neoplasm

Abstract

Soft tissue tumors form a heterogeneous group of benign and malignant lesions. Those with a high fluid content may be particularly challenging in diagnosis. We present a 78-year-old man with a dolorous, progressive mass in the adductor region of the lower left extremity. At the end of a long diagnostic pathway, the pseudocystic tumor was eventually identified as a urinoma, caused by a prostatosymphyseal fistula that had occurred as a late complication of transurethral resection of the prostate. Our finding represents a rare variant of soft tissue tumors in the lower extremities, which MR-based urography can help to reveal.

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4-year-old boy referring for diffuse joint stiffness and progressive bilateral visual impairment

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Preliminary investigation of brown adipose tissue assessed by PET/CT and cancer activity

Abstract

Objective

To determine the role of brown adipose tissue (BAT) in cancer activity.

Materials and methods

The study group comprised 142 patients (121 female, 21 male; mean age, 49 ± 16 years) who underwent F18-FDG PET/CT (PET/CT) for staging or surveillance of cancer and who were BAT-positive on PET/CT. BAT volume by PET/CT, abdominal (visceral and subcutaneous) fat and paraspinous muscle cross-sectional areas (CSA) were assessed. Groups with and without active cancer on PET/CT were compared using a two-sided paired t test. Linear regression analyses between BAT and body composition parameters were performed.

Results

There were 62 patients (54 female, eight male) who had active cancer on PET/CT and 80 patients (67 female, 13 male) without active cancer. Groups were similar in age and BMI (p ≥ 0.4), abdominal fat and muscle CSA, fasting glucose, and outside temperature at time of scan (p ≥ 0.2). Patients who had active cancer on PET/CT had higher BAT volume compared to patients without active cancer (p = 0.009). In patients without active cancer, BAT was positively associated with BMI and abdominal fat depots (r = 0.46 to r = 0.59, p < 0.0001) while there were no such associations in patients with active cancer (p ≥ 0.1). No associations between BAT and age or muscle CSA were found (p ≥ 0.1).

Conclusions

BAT activity is greater in patients with active cancer compared to age-, sex-, and BMI-matched BAT-positive patients without active cancer, suggesting a possible role of BAT in cancer activity.

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Added value of MRI to X-ray in guiding the extent of surgical resection in diabetic forefoot osteomyelitis: a review of pathologically proven, surgically treated cases

Abstract

Objective

This study retrospectively evaluated the added value of MRI over X-ray in guiding the extent of amputation in a cohort of patients with surgically treated, pathologically proven osteomyelitis.

Materials and methods

A database search revealed 32 cases of pathology-proven diabetic forefoot osteomyelitis between 2006 and 2016, in which X-ray, MRI, and surgery occurred within 30 days. Data collection included extent of osteomyelitis reported on imaging and extent of subsequent amputation using a point system. Added value of MRI over X-ray in guiding surgical resection was stated if the X-ray was negative, MRI was positive, and there was MRI–surgical concordance; if both modalities were positive, X-ray was discordant whereas the MRI was concordant; or if MRI detected an abscess. Two-tailed Fisher's exact test compared proportions.

Results

In 9 cases that were positive on both modalities, MRI identified an average of 1.2 additional bone segments of disease. There was surgical agreement with X-ray in 3 out of 31 cases (9.7%, 95%CI 0–20.1) and with MRI in 17 out of 31 cases (55%, 37.3–72.4; p < 0.0001). There was an added value of MRI over X-ray in guiding surgical treatment in 64.5% of cases (95% CI 47.7%–81.4%). MRI added value in 5 out of 9 X-rays positive for osteomyelitis and in 15 out of 22 negative (p value was not significant).

Conclusion

Magnetic resonance imaging demonstrated added value over X-ray in guiding surgical management in both X-ray-negative and -positive cases. Although multiple factors are involved in determining the degree of surgical excision, MRI is a clinically useful component of the diagnostic algorithm in patients who undergo surgical treatment.

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Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture

Abstract

Objective

To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration.

Materials and methods

We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen's kappa statistic was used to assess inter-reader agreement.

Results

In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was −12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively).

Conclusion

Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.

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3D-MRI versus 3D-CT in the evaluation of osseous anatomy in femoroacetabular impingement using Dixon 3D FLASH sequence

Abstract

Objective

To determine if hip 3D-MR imaging can be used to accurately demonstrate femoral and acetabular morphology in the evaluation of patients with femoroacetabular impingement.

Materials and methods

We performed a retrospective review at our institution of 17 consecutive patients (19 hips) with suspected femoroacetabular impingement who had both 3D-CT and 3D-MRI performed of the same hip. Two fellowship-trained musculoskeletal radiologists reviewed the imaging for the presence and location of cam deformity, anterior–inferior iliac spine variant, lateral center-edge angle, and neck–shaft angle. Findings on 3D-CT were considered the reference standard. The amount of radiation that was spared following introduction of 3D-MRI was also assessed.

Results

All 17 patients suspected of FAI had evidence for cam deformity on 3D-CT. There was 100% agreement for diagnosis (19 out of 19) and location (19 out of 19) of cam deformity when comparing 3D-MRI with 3D-CT. There were 3 type I and 16 type II anterior–inferior iliac spine variants on 3D-CT imaging with 89.5% (17 out of 19) agreement for the anterior–inferior iliac spine characterization between 3D-MRI and 3D-CT. There was 64.7% agreement when comparing the neck–shaft angle (11 out of 17) and LCEA (11 out of 17) measurements. The use of 3D-MRI spared each patient an average radiation effective dose of 3.09 mSV for a total reduction of 479 mSV over a 4-year period.

Conclusion

3D-MR imaging can be used to accurately diagnose and quantify the typical osseous pathological condition in femoroacetabular impingement and has the potential to eliminate the need for 3D-CT imaging and its associated radiation exposure, and the cost for this predominantly young group of patients.

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High-resolution ultrasound in the assessment of the distal biceps brachii tendinous complex

Abstract

Objective

To establish a high-resolution US technique that enables a systematic morphometric examination of the three components that form the distal biceps brachii tendinous complex; the internal bicipital aponeurosis, the distal biceps brachii tendon and the external bicipital aponeurosis (also known as lacertus fibrosus).

Materials and methods

Fifty cryopreserved cadaver body donor elbows were dissected to obtain morphometric reference values and to establish reliable landmarks for the US examination. Then, a systematic US technique was designed and validated by a one-to-one US/dissection analysis of 11 cryopreserved cadaver body donor elbows. Finally, the systematic US technique was carried out in 44 healthy volunteers and morphometric parameters were compared to those obtained in the first part of the study.

Results

Mean dissection reference values: internal bicipital aponeurosis width 39.61 mm (10.02 SD) and thickness 0.75 mm (0.24 SD), distal biceps brachii tendon width 8.38 mm (1.87 SD) and thickness 2.73 mm (0.69 SD), external bicipital aponeurosis width 11.17 mm (5.84 SD) and thickness 0.85 mm (0.28 SD). One-to-one US/dissection correlation was overall good (intraclass correlation coefficient 0.876, p < 0.0001). When comparing volunteer US/dissection measurements, significant differences were encountered in all measures except for internal bicipital aponeurosis width. However, the overall magnitude of such significant differences was < 0.7 mm.

Conclusions

Using the systematics hereby proposed, high-resolution US is reliable for the morphometric assessment of the distal biceps brachii tendinous complex. The external bicipital aponeurosis is morphometrically the most variable structure.

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Plexiform fibrohistiocytic tumor: imaging features and clinical findings

Abstract

Objective

To describe the imaging features of plexiform fibrohistiocytic tumor and its associated clinical findings.

Materials and methods

An institutional database was searched to identify all patients with a pathological diagnosis of plexiform fibrohistiocytic tumor. The electronic medical record was reviewed for relevant clinical data. Radiologic images of the primary tumor site were reviewed by two radiologists to assess primary, residual, or recurrent tumor with respect to tumor location, size, morphology, MR signal characteristics and enhancement, and involvement of adjacent structures.

Results

Thirteen patients with imaging of the primary tumor site were identified [eight female, five male; mean age, 15.9 years (range, 3–41 years)]. Plexiform fibrohistiocytic tumor typically manifested as a solitary, painless, firm, slow-growing lesion centered in the subcutaneous tissues, with a predilection for the upper extremity or head and neck region. Most tumors had a purely plaque-like or infiltrative morphology at MRI; some demonstrated no round or oval mass. Tumors were predominantly isointense to muscle on T1-weighted imaging and hyperintense on fluid-sensitive imaging, and enhanced after gadolinium contrast administration. Five patients (38%) had residual tumor after initial surgery, resembling postoperative changes. No patient had recurrent tumor. One patient (8%) developed metastases to local lymph nodes and to the lung. No patient died from plexiform fibrohistiocytic tumor.

Conclusions

Plexiform fibrohistiocytic tumor often manifests as a plaque-like or infiltrative process, sometimes without a round or oval mass, most commonly in the subcutaneous tissues of the upper extremity or head and neck region. Residual tumor is often present after initial surgery, and may be indistinguishable from postoperative changes.

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Radiologic evaluation of fracture healing

Abstract

While assessment of fracture healing is a common task for both orthopedic surgeons and radiologists, it remains challenging due to a lack of consensus on imaging and clinical criteria as well as the lack of a true gold standard. Further complicating this evaluation are the wide variations between patients, specific fracture sites, and fracture patterns. Research into the mechanical properties of bone and the process of bone healing has helped to guide the evaluation of fracture union. Development of standardized scoring systems and identification of specific radiologic signs have further clarified the radiologist's role in this process. This article reviews these scoring systems and signs with regard to the biomechanical basis of fracture healing. We present the utility and limitations of current techniques used to assess fracture union as well as newer methods and potential future directions for this field.

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Evaluation of 3D fat-navigator based retrospective motion correction in the clinical setting of patients with brain tumors

Abstract

Purpose

A 3D fat-navigator (3D FatNavs)-based retrospective motion correction is an elegant approach to correct for motion as it requires no additional hardware and can be acquired during existing 'dead-time' within common 3D protocols. The purpose of this study was to clinically evaluate 3D FatNavs in the work-up of brain tumors.

Methods

An MRI-based fat-excitation motion navigator incorporated into a standard MPRAGE sequence was acquired in 40 consecutive patients with (or with suspected) brain tumors, pre and post-Gadolinium injection. Each case was categorized into key anatomical landmarks, the temporal lobes, the infra-tentorial region, the basal ganglia, the bifurcations of the middle cerebral artery, and the A2 segment of the anterior cerebral artery. First, the severity of motion in the non-corrected MPRAGE was assessed for each landmark, using a 5-point score from 0 (no artifacts) to 4 (non-diagnostic). Second, the improvement in image quality in each pair and for each landmark was assessed blindly using a 4-point score from 0 (identical) to 3 (strong correction).

Results

The mean image improvement score throughout the datasets was 0.54. Uncorrected cases with light and no artifacts displayed scores of 0.50 and 0.13, respectively, while cases with moderate artifacts, severe artifacts, and non-diagnostic image quality revealed a mean score of 1.17, 2.25, and 1.38, respectively.

Conclusion

Fat-navigator-based retrospective motion correction significantly improved MPRAGE image quality in restless patients during MRI acquisition. There was no loss of image quality in patients with little or no motion, and improvements were consistent in patients who moved more.

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Evaluation of 3D fat-navigator based retrospective motion correction in the clinical setting of patients with brain tumors

Abstract

Purpose

A 3D fat-navigator (3D FatNavs)-based retrospective motion correction is an elegant approach to correct for motion as it requires no additional hardware and can be acquired during existing 'dead-time' within common 3D protocols. The purpose of this study was to clinically evaluate 3D FatNavs in the work-up of brain tumors.

Methods

An MRI-based fat-excitation motion navigator incorporated into a standard MPRAGE sequence was acquired in 40 consecutive patients with (or with suspected) brain tumors, pre and post-Gadolinium injection. Each case was categorized into key anatomical landmarks, the temporal lobes, the infra-tentorial region, the basal ganglia, the bifurcations of the middle cerebral artery, and the A2 segment of the anterior cerebral artery. First, the severity of motion in the non-corrected MPRAGE was assessed for each landmark, using a 5-point score from 0 (no artifacts) to 4 (non-diagnostic). Second, the improvement in image quality in each pair and for each landmark was assessed blindly using a 4-point score from 0 (identical) to 3 (strong correction).

Results

The mean image improvement score throughout the datasets was 0.54. Uncorrected cases with light and no artifacts displayed scores of 0.50 and 0.13, respectively, while cases with moderate artifacts, severe artifacts, and non-diagnostic image quality revealed a mean score of 1.17, 2.25, and 1.38, respectively.

Conclusion

Fat-navigator-based retrospective motion correction significantly improved MPRAGE image quality in restless patients during MRI acquisition. There was no loss of image quality in patients with little or no motion, and improvements were consistent in patients who moved more.

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A sputum 6 gene signature predicts future exacerbations of poorly controlled asthma

In this AMAZES RCT sub-analysis, the sputum 6GS predicts exacerbation and airway inflammatory phenotype of uncontrolled, moderate-to-severe asthma. Azithromycin appears to exert a therapeutic effect independently of 6GS-related airway inflammatory factors.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CFNQpi

Induction of human regulatory innate lymphoid cells from group 2 innate lymphoid cells by retinoic acid

This study shows a novel immune regulatory pathway that avoids excessive lung inflammation through conversion of ILC2s to ILCregs by retinoic acid that is synthesized by airway epithelial cells.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RH567T

Functional Ct Imaging For Identification Of The Spatial Determinants Of Small Airways Disease In Adult Asthma

This study analyses spatially localised ventilation heterogeneity in adult asthma using CT imaging and modelling, and presents evidence of inferior to superior ventilation gradient reversal in the disease pathogenesis.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CFNIWQ

Beta-defensins are pro-inflammatory pruritogens that activate Mrgprs

Beta-defensins increase vascular permeability in mouse skin through activation of Mrgprs expressed by mast cells. Defensins also activate Mrgprs expressed by neurons associated with itch, and induce itch themselves, establishing defensins as novel pro-inflammatory pruritogens.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RMon8l

Acculturation is Associated with Asthma Burden and Pulmonary Function in Latino Youth: The GALA II Study

High acculturation increases likelihood of diagnosed asthma whereas low acculturation is associated with lower pulmonary function and increased bronchodilator response in Latinos; cultural and behavioral practices should be considered when determining risk and managing asthma.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CCqroJ

ADRB2 p.Thr164Ile association with hospitalization depends upon asthma severity

In LABA-treated patients, the ADRB2 p.Thr164Ile only associate with asthma exacerbation risk in some patients with severe asthma but is not predictive of asthma exacerbation risk in all asthmatics.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RN6rug

Development Of Atopic Sensitization In Finnish And Estonian Children – A Latent Class Analysis In A Multicenter Cohort

In two countries differing fundamentally in environmental and socioeconomic determinants and sensitization rates, similar atopy classes were found regarding composition and disease relevance.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CDU3lP

Allergen Specific CD8+ T cells in Peanut Allergic Individuals

CD8+ T cells are seldom considered in IgE mediated food allergy; we show that peanut specific CD8+ T cells are increased in peanut allergic human subjects.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RN6kyQ

Combined liver and hematopoietic stem cell transplantation in X-linked hyper IgM syndrome

Liver disease in X-linked hyper IgM syndrome (XHIGM) is an important predictor of mortality. In case liver transplantation (LT) is required, a survival benefit is observed when LT is combined with HSCT.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CADS8M

Nanoallergen Platform for the Detection of Platin Drugs Allergies

In this study, we validated a novel nanoparticle based in vitro diagnostic technique for drug allergies to two common platinum-based chemotherapeutics, oxaliplatin and carboplatin.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RH553P

Atopic dermatitis and cardiovascular disease: what are the clinical implications?

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CDarmq

A sputum 6 gene signature predicts future exacerbations of poorly controlled asthma

In this AMAZES RCT sub-analysis, the sputum 6GS predicts exacerbation and airway inflammatory phenotype of uncontrolled, moderate-to-severe asthma. Azithromycin appears to exert a therapeutic effect independently of 6GS-related airway inflammatory factors.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CFNQpi

Induction of human regulatory innate lymphoid cells from group 2 innate lymphoid cells by retinoic acid

This study shows a novel immune regulatory pathway that avoids excessive lung inflammation through conversion of ILC2s to ILCregs by retinoic acid that is synthesized by airway epithelial cells.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RH567T

Functional Ct Imaging For Identification Of The Spatial Determinants Of Small Airways Disease In Adult Asthma

This study analyses spatially localised ventilation heterogeneity in adult asthma using CT imaging and modelling, and presents evidence of inferior to superior ventilation gradient reversal in the disease pathogenesis.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CFNIWQ

Beta-defensins are pro-inflammatory pruritogens that activate Mrgprs

Beta-defensins increase vascular permeability in mouse skin through activation of Mrgprs expressed by mast cells. Defensins also activate Mrgprs expressed by neurons associated with itch, and induce itch themselves, establishing defensins as novel pro-inflammatory pruritogens.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RMon8l

Acculturation is Associated with Asthma Burden and Pulmonary Function in Latino Youth: The GALA II Study

High acculturation increases likelihood of diagnosed asthma whereas low acculturation is associated with lower pulmonary function and increased bronchodilator response in Latinos; cultural and behavioral practices should be considered when determining risk and managing asthma.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CCqroJ

ADRB2 p.Thr164Ile association with hospitalization depends upon asthma severity

In LABA-treated patients, the ADRB2 p.Thr164Ile only associate with asthma exacerbation risk in some patients with severe asthma but is not predictive of asthma exacerbation risk in all asthmatics.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RN6rug

Development Of Atopic Sensitization In Finnish And Estonian Children – A Latent Class Analysis In A Multicenter Cohort

In two countries differing fundamentally in environmental and socioeconomic determinants and sensitization rates, similar atopy classes were found regarding composition and disease relevance.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CDU3lP

Allergen Specific CD8+ T cells in Peanut Allergic Individuals

CD8+ T cells are seldom considered in IgE mediated food allergy; we show that peanut specific CD8+ T cells are increased in peanut allergic human subjects.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RN6kyQ

Combined liver and hematopoietic stem cell transplantation in X-linked hyper IgM syndrome

Liver disease in X-linked hyper IgM syndrome (XHIGM) is an important predictor of mortality. In case liver transplantation (LT) is required, a survival benefit is observed when LT is combined with HSCT.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CADS8M

Nanoallergen Platform for the Detection of Platin Drugs Allergies

In this study, we validated a novel nanoparticle based in vitro diagnostic technique for drug allergies to two common platinum-based chemotherapeutics, oxaliplatin and carboplatin.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2RH553P

Atopic dermatitis and cardiovascular disease: what are the clinical implications?

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CDarmq

Analysis of the association of IL4 polymorphisms with orthodontic mini-implant loss

The aim of this study was to investigate the association of clinical characteristics and IL4 tag single nucleotide polymorphisms (SNPs; rs2227284 and rs2243268) with orthodontic mini-implant (MI) failure. The sample included 135 subjects of both sexes, mean age 48.7±10years (range 20–76years): 104 in the control group (patients without any MI loss) and 31 in the study group (patients presenting ≥1 MI loss). Genotypes were determined by real-time PCR. Bivariate and multivariate analyses were performed (P<0.05).

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2S0vARj

Analysis of the association of IL4 polymorphisms with orthodontic mini-implant loss

The aim of this study was to investigate the association of clinical characteristics and IL4 tag single nucleotide polymorphisms (SNPs; rs2227284 and rs2243268) with orthodontic mini-implant (MI) failure. The sample included 135 subjects of both sexes, mean age 48.7±10years (range 20–76years): 104 in the control group (patients without any MI loss) and 31 in the study group (patients presenting ≥1 MI loss). Genotypes were determined by real-time PCR. Bivariate and multivariate analyses were performed (P<0.05).

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Contributions of innate lymphocytes to allergic responses

Purpose of review Allergic diseases represent a growing global health concern, especially among pediatric populations. Current strategies for the treatment of allergies and asthma focus on limiting the severity of the symptoms; however, additional research investigating the mechanisms promoting inflammation in the context of allergic reactions may lead to the development of more effective therapeutic strategies. Recent findings Novel studies have highlighted the contributions of innate lymphocytes to the induction of inflammatory responses to allergens. Remarkably, neuron-derived signals, hormones, and even vitamins have been suggested to modulate the activity of innate lymphocytes, opening new windows of opportunity for the treatment of allergic inflammation. Summary These studies highlight the complex interactions of the nervous, endocrine, and immune system that promote pathology in the context of allergic inflammation. Further studies are required to understand these interactions in order to aid in the development of novel and much-needed therapies to treat allergic conditions. Correspondence to Mark C. Siracusa, Department of Medicine Cancer Center, G1226 Rutgers New Jersey Medical School 205 South Orange Avenue, Newark, NJ 07103, USA. Tel: +1-973-972-1265; fax: +1-973-972-2525; e-mail: mark.siracusa@rutgers.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Advances in the pathogenesis representing definite outcomes in chronic urticaria

Purpose of review We reviewed in this article, the recent advances in CSU physiopathology and potential clinical and laboratory biomarkers in CSU. Recent findings In addition to the central role of mast cells in urticaria physiopathology, increased interest in basophils has arisen. Recent data corroborate the autoimmunity pathway as one of the main pathways in mast cell activation. The association of inflammatory cytokines, heat shock proteins and staphylococcal infection with CSU are also reviewed. C-reactive protein, D-dimers, autologous serum skin test, IgE levels and FcεRI expression in basophils have shown their potential as biomarkers for disease duration, activity, severity and/or response to treatment. Summary A comprehensive understanding of chronic spontaneous urticaria mechanisms is essential to find novel biomarkers and treatments. The use of these biomarkers in clinical practice will guide us in choosing the best treatment option for our patients. Correspondence to Luis Felipe Ensina, MD, PhD, Rua Barata Ribeiro, 490, São Paulo, SP 01308-000, Brazil. Tel: +55 11 3123 5777; e-mail: drluisensina@imunologiaealergia.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2U7uznR

Contributions of innate lymphocytes to allergic responses

Purpose of review Allergic diseases represent a growing global health concern, especially among pediatric populations. Current strategies for the treatment of allergies and asthma focus on limiting the severity of the symptoms; however, additional research investigating the mechanisms promoting inflammation in the context of allergic reactions may lead to the development of more effective therapeutic strategies. Recent findings Novel studies have highlighted the contributions of innate lymphocytes to the induction of inflammatory responses to allergens. Remarkably, neuron-derived signals, hormones, and even vitamins have been suggested to modulate the activity of innate lymphocytes, opening new windows of opportunity for the treatment of allergic inflammation. Summary These studies highlight the complex interactions of the nervous, endocrine, and immune system that promote pathology in the context of allergic inflammation. Further studies are required to understand these interactions in order to aid in the development of novel and much-needed therapies to treat allergic conditions. Correspondence to Mark C. Siracusa, Department of Medicine Cancer Center, G1226 Rutgers New Jersey Medical School 205 South Orange Avenue, Newark, NJ 07103, USA. Tel: +1-973-972-1265; fax: +1-973-972-2525; e-mail: mark.siracusa@rutgers.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2DrgaNU

Advances in the pathogenesis representing definite outcomes in chronic urticaria

Purpose of review We reviewed in this article, the recent advances in CSU physiopathology and potential clinical and laboratory biomarkers in CSU. Recent findings In addition to the central role of mast cells in urticaria physiopathology, increased interest in basophils has arisen. Recent data corroborate the autoimmunity pathway as one of the main pathways in mast cell activation. The association of inflammatory cytokines, heat shock proteins and staphylococcal infection with CSU are also reviewed. C-reactive protein, D-dimers, autologous serum skin test, IgE levels and FcεRI expression in basophils have shown their potential as biomarkers for disease duration, activity, severity and/or response to treatment. Summary A comprehensive understanding of chronic spontaneous urticaria mechanisms is essential to find novel biomarkers and treatments. The use of these biomarkers in clinical practice will guide us in choosing the best treatment option for our patients. Correspondence to Luis Felipe Ensina, MD, PhD, Rua Barata Ribeiro, 490, São Paulo, SP 01308-000, Brazil. Tel: +55 11 3123 5777; e-mail: drluisensina@imunologiaealergia.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Intensivist staffing and outcome in the ICU: daytime, nighttime, 24/7?

Purpose of review Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. Recent findings Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. Summary Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence. Correspondence to Avery Tung, MD, 5841 S Maryland Ave MC 4028, Chicago, IL 60637, USA. Tel: +1 (773) 834 7937; E-mail: atung@dacc.uchicago.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Helicopter air ambulance services

Purpose of review Helicopter air ambulances are an integral component of modern trauma care, and are able to transport patients to facilities with greater capabilities, extract injured patients from hostile terrain, and speed transport to a trauma center. Recent findings HAA transport does not reduce the total time required to transport a patient, but it does reduce the time that the patient is between healthcare facilities. Factors that have been suggested to improve outcomes for trauma patients include the availability of advanced interventions, skilled personnel, speed, and trauma center access. Despite their potential benefits to the patient, HAA operations carry significant risks. HAA operations are among the most dangerous professions for both pilot and crew with a mortality rate greater than commercial fishing, loggers, and steelworkers. The US Federal Aviation Administration (FAA) has identified that the four most common causes of HAA accidents as inadvertent flight into instrument meteorological conditions, loss of control, controlled flight into terrain, and night conditions. Summary HAA operations are well tolerated and can improve patient care, but additional research is needed to improve our understanding of HAA operations and their effect on outcomes. Correspondence to Keith J. Ruskin, MD, FAsMA, FRAeS, Professor of Anesthesia and Critical Care and Biological Sciences Collegiate Division, Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Avenue MC4028, Chicago, IL 60637, USA. Tel: +1 773 834 2369; e-mail: ruskin@uchicago.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Burn injury and blood transfusion

Purpose of review Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU. Recent findings Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements. Summary A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors. Correspondence to Tina L. Palmieri, 2425 Stockton Blvd, Suite 718, Sacramento, CA 95817, USA. Tel: +1-916-453-2050; fax: +1-916-453-2373; e-mail: tlpalmieri@ucdavis.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage?

Purpose of review Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. Recent findings The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30–60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. Summary REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts. Correspondence to Dr Jürgen Knapp, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland. Tel: +41 31 632 04 96; e-mail: juergen.knapp@insel.ch Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The use of new procoagulants in blunt and penetrating trauma

Purpose of review Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. Recent findings Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. Summary There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies. Correspondence to Pratima Chowdary, Consultant Haematologist, KD Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK;. e-mails: p.chowdary@nhs.net, p.chowdary@ucl.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Intensivist staffing and outcome in the ICU: daytime, nighttime, 24/7?

Purpose of review Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. Recent findings Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. Summary Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence. Correspondence to Avery Tung, MD, 5841 S Maryland Ave MC 4028, Chicago, IL 60637, USA. Tel: +1 (773) 834 7937; E-mail: atung@dacc.uchicago.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Helicopter air ambulance services

Purpose of review Helicopter air ambulances are an integral component of modern trauma care, and are able to transport patients to facilities with greater capabilities, extract injured patients from hostile terrain, and speed transport to a trauma center. Recent findings HAA transport does not reduce the total time required to transport a patient, but it does reduce the time that the patient is between healthcare facilities. Factors that have been suggested to improve outcomes for trauma patients include the availability of advanced interventions, skilled personnel, speed, and trauma center access. Despite their potential benefits to the patient, HAA operations carry significant risks. HAA operations are among the most dangerous professions for both pilot and crew with a mortality rate greater than commercial fishing, loggers, and steelworkers. The US Federal Aviation Administration (FAA) has identified that the four most common causes of HAA accidents as inadvertent flight into instrument meteorological conditions, loss of control, controlled flight into terrain, and night conditions. Summary HAA operations are well tolerated and can improve patient care, but additional research is needed to improve our understanding of HAA operations and their effect on outcomes. Correspondence to Keith J. Ruskin, MD, FAsMA, FRAeS, Professor of Anesthesia and Critical Care and Biological Sciences Collegiate Division, Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Avenue MC4028, Chicago, IL 60637, USA. Tel: +1 773 834 2369; e-mail: ruskin@uchicago.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Burn injury and blood transfusion

Purpose of review Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU. Recent findings Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements. Summary A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors. Correspondence to Tina L. Palmieri, 2425 Stockton Blvd, Suite 718, Sacramento, CA 95817, USA. Tel: +1-916-453-2050; fax: +1-916-453-2373; e-mail: tlpalmieri@ucdavis.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2T7QATz

Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage?

Purpose of review Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. Recent findings The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30–60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. Summary REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts. Correspondence to Dr Jürgen Knapp, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland. Tel: +41 31 632 04 96; e-mail: juergen.knapp@insel.ch Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2ATxj0P

The use of new procoagulants in blunt and penetrating trauma

Purpose of review Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. Recent findings Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. Summary There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies. Correspondence to Pratima Chowdary, Consultant Haematologist, KD Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK;. e-mails: p.chowdary@nhs.net, p.chowdary@ucl.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Population pharmacokinetic-pharmacodynamic model of propofol in adolescents undergoing scoliosis surgery with intraoperative wake-up test: a study using Bispectral index and composite auditory evoked potentials as pharmacodynamic endpoints

Abstract

Background

In adolescents limited data are available on the pharmacokinetics (PK) and pharmacodynamics (PD) of propofol. In this study we derived a PK-PD model for propofol in adolescents undergoing idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia using both Bispectral Index (BIS) and composite A-line ARX index (cAAI) as endpoints.

Methods

Fourteen adolescents (9.8–20.1 years) were evaluated during standardized propofol-remifentanil anesthesia for idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia. BIS and cAAI were continuously measured and blood samples collected. A propofol PKPD model was developed using NONMEM.

Results

The time courses of propofol concentrations, BIS and cAAI values during anesthesia, intra-operative wakeup and reduction of anesthesia were best described by a two-compartment PK model linked to an inhibitory sigmoidal Emax PD model. For the sigmoidal Emax model, the propofol concentration at half maximum effect (EC₅₀) was 3.51 and 2.14 mg/L and Hill coefficient 1.43 and 6.85 for BIS and cAAI, respectively. The delay in PD effect in relation to plasma concentration was best described by a two compartment effect-site model with a ke_o of 0.102 min^− 1, ke₁₂ of 0.121 min^− 1 and ke₂₁ of 0.172 min^− 1.

Conclusions

A population PKPD model for propofol in adolescents was developed that successfully described the time course of propofol concentration, BIS and cAAI in individuals upon undergoing scoliosis surgery with intraoperative wake-up test and reinduction of anesthesia. Large differences were demonstrated between both monitors. This may imply that BIS and cAAI measure fundamentally different endpoints in the brain.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FIcQ3h

Population pharmacokinetic-pharmacodynamic model of propofol in adolescents undergoing scoliosis surgery with intraoperative wake-up test: a study using Bispectral index and composite auditory evoked potentials as pharmacodynamic endpoints

Abstract

Background

In adolescents limited data are available on the pharmacokinetics (PK) and pharmacodynamics (PD) of propofol. In this study we derived a PK-PD model for propofol in adolescents undergoing idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia using both Bispectral Index (BIS) and composite A-line ARX index (cAAI) as endpoints.

Methods

Fourteen adolescents (9.8–20.1 years) were evaluated during standardized propofol-remifentanil anesthesia for idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia. BIS and cAAI were continuously measured and blood samples collected. A propofol PKPD model was developed using NONMEM.

Results

The time courses of propofol concentrations, BIS and cAAI values during anesthesia, intra-operative wakeup and reduction of anesthesia were best described by a two-compartment PK model linked to an inhibitory sigmoidal Emax PD model. For the sigmoidal Emax model, the propofol concentration at half maximum effect (EC₅₀) was 3.51 and 2.14 mg/L and Hill coefficient 1.43 and 6.85 for BIS and cAAI, respectively. The delay in PD effect in relation to plasma concentration was best described by a two compartment effect-site model with a ke_o of 0.102 min^− 1, ke₁₂ of 0.121 min^− 1 and ke₂₁ of 0.172 min^− 1.

Conclusions

A population PKPD model for propofol in adolescents was developed that successfully described the time course of propofol concentration, BIS and cAAI in individuals upon undergoing scoliosis surgery with intraoperative wake-up test and reinduction of anesthesia. Large differences were demonstrated between both monitors. This may imply that BIS and cAAI measure fundamentally different endpoints in the brain.

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Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine

Publication date: Available online 22 January 2019

Source: Brazilian Journal of Anesthesiology (English Edition)

Author(s): Suman Arora, Chethan Sadashivappa, Indu Sen, Neeru Sahni, Komal Gandhi, Y.K. Batra, M.S. Dhillon

Abstract

Background and objectives

Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine.

Methods

A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30 mL saline, Group R – ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 μg.kg⁻¹. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting.

Results

The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p = 0.00). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement.

Conclusion

Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement and rescue analgesic requirement did not differ.

Resumo

Justificativa e objetivos

O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, levando ao desenvolvimento de aderências, fraca Inserção do ligamento e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi realizado para comparar o período sem dor em pacientes submetidos à reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina.

Métodos

Um estudo prospectivo, randômico e duplo-cego foi conduzido com sessenta e três pacientes adultos, estado físico ASA I–II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 μg.kg⁻¹ de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação e náusea e vômito no pós-operatório.

Resultados

Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p = 0,00). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e necessidade total de analgésicos.

Conclusão

A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento e a necessidade de analgésico de resgate não fossem diferentes.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2S5vPKM

Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine

Publication date: Available online 22 January 2019

Source: Brazilian Journal of Anesthesiology (English Edition)

Author(s): Suman Arora, Chethan Sadashivappa, Indu Sen, Neeru Sahni, Komal Gandhi, Y.K. Batra, M.S. Dhillon

Abstract

Background and objectives

Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine.

Methods

A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30 mL saline, Group R – ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 μg.kg⁻¹. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting.

Results

The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p = 0.00). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement.

Conclusion

Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement and rescue analgesic requirement did not differ.

Resumo

Justificativa e objetivos

O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, levando ao desenvolvimento de aderências, fraca Inserção do ligamento e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi realizado para comparar o período sem dor em pacientes submetidos à reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina.

Métodos

Um estudo prospectivo, randômico e duplo-cego foi conduzido com sessenta e três pacientes adultos, estado físico ASA I–II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 μg.kg⁻¹ de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação e náusea e vômito no pós-operatório.

Resultados

Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p = 0,00). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e necessidade total de analgésicos.

Conclusão

A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento e a necessidade de analgésico de resgate não fossem diferentes.

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Influence of Porphyromonas gingivalis in gut microbiota of streptozotocin‐induced diabetic mice

Abstract

Objectives

Increasing evidence suggests that periodontitis can exacerbate diabetes, and gut bacterial dysbiosis appears to be linked with the diabetic condition. The present study examined the effects of oral administration of the periodontopathic bacterium, Porphyromonas gingivalis, on the gut microbiota and systemic conditions in streptozotocin‐induced diabetic mice.

Materials and Methods

Diabetes was induced by streptozotocin injection in C57BL/6J male mice (STZ). STZ and wild‐type (WT) mice were orally administered P. gingivalis (STZPg, WTPg) or saline (STZco, WTco). Feces were collected, and the gut microbiome was examined by 16S rRNA gene sequencing. The expression of genes related to inflammation, epithelial tight junctions, glucose/fatty acid metabolism in the ileum or liver were examined by quantitative PCR.

Results

The relative abundance of several genera, including Brevibacterium, Corynebacterium, and Facklamia, was significantly increased in STZco mice compared to WTco mice. The relative abundances of Staphylococcus and Turicibacter in the gut microbiome were altered by oral administration of P. gingivalis in STZ mice. STZPg mice showed higher concentrations of fasting blood glucose and inflammatory genes levels in the ileum, compared to STZco mice.

Conclusions

Oral administration of P. gingivalis altered the gut microbiota and aggravated glycemic control in streptozotocin‐induced diabetic mice.

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