Mild Systemic Disease Research Articles

Age, gender, and systemic condition effects on anxiety in oral surgery patients: An analysis of different assessment tools

ObjectiveThe aim of this study was to determine the effect of the oral surgery and dental anesthesia on anxiety in patients, by comparing two anxiety scales. The study designed to evaluate the effect of physical status, age and gender on anxiety and to compare anxiety and need for information. MethodsA total of 91 patients, categorized as ASA-I and ASA-II based on ASA (American Society of Anesthesiology) scoring, were assessed utilizing the BAI (Beck Anxiety Inventory) and APAIS (Amsterdam Preoperative Anxiety and Information Scale) tests. The groups were compared by using the Mann-Whitney U test, and the Spearman's rank correlation coefficient (p < .05). ResultsBAI, APAIS-A and APAIS-B values were significantly higher in ASA-II individuals compared to ASA-I. APAIS and BAI values were correlated with each other in the ASA-I group, while APAIS-B was not correlated with other values in the ASA-II group. Anxiety scores were higher in female patients. Age was inversely correlated with anxiety, while the need for information did not change. ConclusionThe APAIS may provide more detailed information to evaluate anxiety in the group with mild systemic disease. The need for information is higher in patients with chronic disease, regardless of their anxiety status.

338 Profile of older adults post hip fracture: a pre and post-Covid comparison

Abstract Background The Irish Government implemented public health measures during the COVID-19 pandemic, including self-isolation among older citizens. Within our rehabilitation centre, the multidisciplinary team remarked on what they perceived to be negative health repercussions from ‘cocooning’, particularly those admitted following hip fracture. We sought to compare patient cohorts in 2019 and 2022. Methods Data was examined from the Irish Hip Fracture Database online portal specific to our Model 3 hospital for 2019 and 2022. Subset analysis was performed on hip fracture patients admitted to an off-site rehabilitation centre using that hospital’s electronic patient database. Results 245 hip fractures were recorded in 2019 and 380 in 2022. In 2019 37% were aged between 80–89, 12% were over 90. In 2022 45% were aged between 80–89, 14% were over 90. ASA grade pre-operatively; in 2019, 33% were classed as normal or with mild systemic disease, 61% were in the severe systemic disease category. The same categories in 2022 were 41% and 55% respectively. Discharge destination for patients in 2019 and 2022 respectively were as follows: discharged directly home 27% vs 25%, discharged to offsite rehabilitation 32% vs. 38%, new Long-Term Care (LTC) admission 2% vs 3%. Our rehabilitation unit received 26 patients in 2019 and 39 in 2022. The average timed up and go (TUG) on admission in 2019 vs 2022 was 38.7 and 53.7 seconds respectively. Conclusion There was a 55% increase in the number of patients presenting with hip fracture post Covid. Despite similar age and co-morbidity profiles patients average TUG was 39% slower post Covid. Less patients were discharged directly home in 2022, more patients required a period of rehabilitation and the number of new admissions to LTC increased. This small study supports our hypothesis surrounding the detrimental effects of cocooning on older patients.

A Comparative Analysis Between Spinal and General Anesthesia for Orthopedic Surgery

Background: Many surgeries can be performed with spinal anesthesia (SA) or general anesthesia (GA). However, there are only limited and confounding data available regarding costs and anesthesia-related times. Hip or knee replacement are common orthopedic surgeries that can be performed using SA or GA without differences regarding mortality or morbidity. Observational studies have suggested that spinal anesthesia may be associated with lower risks of death, delirium and major medical complications and with shorter lengths of stay in the hospital than general anesthesia. The aim of this study was to assess and compare the effects of spinal versus general anesthesia on postoperative outcomes in patients undergoing orthopedic surgery. Material &amp; Methods: This was a comparative observational study and was conducted in the Department of Anesthesiology of Holy Family red crescent Medical College Hospital, Dhaka, Bangladesh during the period from March,2021 to March,2023. In this study we included 200 patients undergoing orthopedic surgery. The patients were randomly divided into two groups – Group A (Patients who were given general anesthesia) &amp; Group B (Patients who were given spinal anesthesia). Results: In total 200 patients from both the groups completed the study. In our study we found majority (44.5%) of our patients were aged 60-69 years and most of our patients were female (56%) compared to male (44%).The mean age of our patients was 61.73 ± 7.92 years. The mean BMI was 31.67±3.24 kg/m.2Among all patients ,48% had mild systemic disease and followed by 31.5% had severe systemic disease. Majority (43.5%) of our patients had hypertension, 31% had diabetes. Vomiting was found 47% in group A on contrary only 23% had vomiting in spinal group. We found the mean anesthesia induction time was significantly higher in spinal group. Anesthesia time was lower in spinal group while PACU time was higher in group B. Time duration of surgery was significantly lower in spinal group. After 24 hours, spinal group showed less pain score than general anesthesia group. Conclusion: In our study, we found that SA is associated with less fixed and variable costs and lower postoperative pain scores during the stay in the PACU. Therefore, SA is a more reasonable alternative to GA in the immediate postoperative period for patients undergoing hip or knee replacement. When compared to general anaesthesia, spinal anaesthesia provides better operating circumstances, better postoperative pain control, and faster postoperative recovery.

Effect of Intraoperative Esketamine Infusion on Postoperative Sleep Disturbance After Gynecological Laparoscopy

Postoperative sleep disturbance (PSD) is common in patients after surgery. To examine the effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery. This single-center, double-blind, placebo-controlled randomized clinical trial was conducted from August 2021 to April 2022 in the First Affiliated Hospital of Zhengzhou University in China. Participants included patients aged 18 to 65 years with an American Society of Anesthesiologist Physical Status classification of I to III (with I indicating a healthy patient, II a patient with mild systemic disease, and III a patient with severe systemic disease) who underwent gynecological laparoscopic surgery. Patients were randomly assigned to either the esketamine group or control group. Data were analyzed using the per protocol principle. Patients in the esketamine group received a continuous infusion of esketamine, 0.3 mg/kg/h, intraoperatively. Patients in the control group received an equivalent volume of saline. The primary outcome was the incidence of PSD on postoperative days (PODs) 1 and 3. Postoperative sleep disturbance was defined as a numeric rating scale score of 6 or higher or an Athens Insomnia Scale score of 6 points or higher. The secondary outcomes included postoperative anxiety and depression scores using the Hospital Anxiety and Depression Scale, postoperative pain using the visual analog scale, postoperative hydromorphone consumption, and risk factors associated with PSD. A total of 183 female patients were randomized to the control group (n = 91; median [IQR] age, 45 [35-49] years) and the esketamine group (n = 92; median [IQR] age, 43 [32-49] years). The incidence of PSD in the esketamine group was significantly lower than in the control group on POD 1 (22.8% vs 44.0%; odds ratio [OR], 0.38 [95% CI, 0.20-0.72]; P = .002) and POD 3 (7.6% vs 19.8%; OR, 0.33 [95% CI, 0.13-0.84]; P = .02). There were no differences in postoperative depression and anxiety scores between the 2 groups. Postoperative hydromorphone consumption in the first 24 hours (3.0 [range, 2.8-3.3] mg vs 3.2 [range, 2.9-3.4] mg; P = .04) and pain scores on movement (3 [3-4] vs 4 [3-5] points; P < .001) were significantly lower in the esketamine group than in the control group. On multivariable logistic regression, preoperative depression (OR, 1.31; 95% CI, 1.01-1.70) and anxiety (OR, 1.67; 95% CI, 1.04-1.80) scores, duration of anesthesia (OR, 1.04; 95% CI, 1.00-1.08), and postoperative pain score (OR, 1.92; 95% CI, 1.24-2.96) were identified as risk factors associated with PSD. Results of this trial showed the prophylactic effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery. Further studies are needed to confirm these results. Chinese Clinical Trial Registry Identifier: ChiCTR2100048587.

Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis

BackgroundInternational guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.Method1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery.Results725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months.ConclusionPatients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery.Trial registration: Not applicable.

COMPARATIVE EVALUATION OF EFFECTIVENESS OF CASEIN PHOSPHOPEPTIDE AMORPHOROUS CALCIUM PHOSPHATE AND SODIUM FLOURIDE VARNISH IN DENTINE HYPERSENTIVITY

Objective: To determine efficacy of casein phosphopeptide amorphous calcium phosphate and sodium fluoride varnish in managing dentine hypersentivity.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Foundation University College of Dentistry, Islamabad, from Jun to Nov 2020.&#x0D; Methodology: Patients of both gender 20-60 years of age with ASA “American Society of Anesthesiologists physical status classification” status I (completely healthy fit patient) or status II (patient has mild systemic disease) diagnosed with dentine hypersensitivity of incisors, canines, premolars with clinical evidence of erosion, abrasion, gingival recession not requiring restorative treatment were enrolled in the study. At first visit baseline, dentine hypersentivity was recorded by means of tactile and evaporative stimuli, response was quantified using visual analogue scale. Patients were randomly divided in two groups 1-casein phosphopeptide amorphous calcium phosphate, 2-sodium fluoride varnish desensitizing agent was applied conferring to manufacturer instructions. Visual analogue scale readings were assessed at base line and post treatment valueswas recorded at 7th, 15th, 30th day.&#x0D; Results: Total 80 patients enrolled in the study with a mean age of 36.26 ± 8.91 years and age-range of 21-60 years. Visual analogue scale results of group-1 (n=40) were recorded at baseline as 5.9 ± 0 .94, 7th day 1.9 ± 0.92, 15th day 1.4 ± 0 .81 and 30th day 1.0 ± 0.71. In case of group-2 Visual Analogue Score recorded to be 6.2 ± 1.24,3.2 ± 0.81, 3.0 ± 0.52 and 2.7 ± 1.12 at baseline, 7th, 15th, and 30th day respectively.&#x0D; Conclusion: Casein phosphopeptide amorphous..................

Effects of different antidepressant classes on dental implant failure: A retrospective clinical study.

Previous studies have suggested an association between taking antidepressants and dental implant failure. This study aimed to investigate the association of different antidepressant classes with dental implant failure. This retrospective study included patients that received dental implants at the University of Florida from 2011 to 2016. The variables of implant failure, antidepressant use and classes (selective serotonin reuptake inhibitors [SSRI], serotonin-norepinephrine reuptake inhibitors [SNRI], tricyclic antidepressants [TCA], atypical antidepressants [AA], and monoamine oxidase inhibitors [MAOI]), age, sex, smoking, mild systemic diseases, and implant location were obtained from patients' records. Odds ratio (OR) and confidence interval (CI) of implant failure in patients taking different antidepressant classes, in relationship to non-antidepressant users, were estimated, and the influence of multiple variables on implant failure were investigated. A total of 771 patients and 1,820 implants were evaluated. The statistically significant predictors for implant failure included smoking (OR=5.221), use of antidepressants (OR=4.285), posterior maxilla location (OR=2.911), mild systemic disease (OR=2.648), and age (OR=1.037) (P<0.05). The frequency of implant failure was 33.3% in TCA users, 31.3% in SNRI users, 6.3% in SSRI users, 5.2% in Atypical antidepressant users, and 3.9% in non-users. Significant associations were observed between the use of SNRI (OR: 11.07; 95% CI: 3.265 to 33.82) and TCA (OR: 12.16; 95% CI: 1.503 to 71.58) and implant failure (P<0.05). Users of antidepressants were at higher risk of implant failure than non-users. Patients taking SNRI and TCA were at the highest risk of implant loss, when compared with non-users. Conclusions about TCA, however, are based on a limited number of cases.

Intersection of Bias, Structural Racism, and Social Determinants With Health Care Inequities.

* Abbreviation: SDoH — : social determinant of health Race, and more specifically, racism, is recognized as an important social determinant of health (SDoH) and a key driver of health inequities.1–3 The study “Race, Postoperative Complications, and Death in Apparently Healthy Children” in this issue of Pediatrics provides new evidence of race as a critical social determinant of surgical outcomes.4 The investigators demonstrate that apparently healthy Black children had a higher risk of postoperative mortality, complications, and serious adverse events than their white counterparts. Identifying these disparities using the National Surgical Quality Improvement Program pediatric database highlights the importance of health care practices to more deliberately consider equity in their quality improvement portfolios. The analyses were done among children with American Society of Anesthesiologists physical status 1 (normal healthy patients) or 2 (patients with mild systemic disease, such as mild asthma). By excluding children with significant comorbidities, this study helps advance knowledge beyond most previous pediatric disparities research focused on identifying disparities by exploring potential root causes. The findings suggest that, although preoperative comorbidities have previously been proposed as a factor contributing to postoperative disparities, they do not explain the results in the current study. Implicit racial bias has been proposed as another potential source of health care … Address correspondence to Tiffani J. Johnson, MD, MSc, Department of Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817. E-mail: tjo{at}ucdavis.edu

Neutrophil-to-lymphocyte ratio in systemic lupus erythematosus is influenced by steroids and may not completely reflect the disease activity

Objectives: Neutrophil-to-lymphocyte ratio (NLR) has emerged as an important parameter in inflammatory network and could pave the way for newer treatment strategies in systemic lupus erythematosus (SLE). The study evaluated NLR as a predictor of disease activity in SLE and attempted to relate the factors influencing the NLR. Methods: The study included 117 SLE patients fulfilling the systemic lupus international collaborating clinics/American College of Rheumatology (SLICC/ACR) criteria (2010). The subjects were classified into mild, moderate, and severe systemic lupus erythematosus disease activity index 2000 (SLEDAI 2K) groups and compared. NLR values were classified as ≤2, >2–4 and >4 groups and its relationship with study variables was evaluated by Notched box-and-Whisker plots, Spearman correlation and Mountain plot. ROC and multiple linear regression were used to verify discriminatory ability and factors influencing NLR respectively. Results: Approximately 24% (n=28) of patients each had mild and moderate SLEDAI disease activities, and 52.14% (n=61) had severe activity. Patients with severe disease activity were significantly younger (31.69±10.09 years) and were on more immunosuppressants/DMARDs. The patients in the >4 NLR group had significantly elevated total leucocyte count (TLC) 5560 (3360-11480) cells/mm3 and CRP 4.46 (0.3-48.2) mg/L and more patients were on steroid therapy. The >2-4 NLR group had moderate inverse correlation with SLEDAI. NLR, ESR, CRP, and C3 did not show agreement with SLEDAI. The NLR was associated with CRP and steroid usage and could not discriminate disease severity. Conclusion: The relationship of the NLR with SLEDAI was not consistent. NLR was associated with CRP and steroid use. NLR as a marker of inflammation or as a predictor of SLE disease activity needs further investigation.

Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States

BackgroundPost-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures. MethodsUsing the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results. ResultsFrom 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had ‘Mild Systemic Disease’ (ASA 2), 20,872 (62.6%) patients had ‘Severe Systemic Disease’ (ASA 3), and 6,006 (18.1%) had ‘Life Threatening Disease’ (ASA 4/5). The majority of patients were brought in from a ‘Home’ setting, while 10.4% of patients were admitted from a ‘Long-Term Care’ setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC. DiscussionDischarge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables. Level of evidenceLevel III, Retrospective Cohort Design, Observational Study

Dysregulation of TLR9 in neonates leads to fatal inflammatory disease driven by IFN-γ

Recognition of self-nucleic acids by innate immune receptors can lead to the development of autoimmune and/or autoinflammatory diseases. Elucidating mechanisms associated with dysregulated activation of specific receptors may identify new disease correlates and enable more effective therapies. Here we describe an aggressive in vivo model of Toll-like receptor (TLR) 9 dysregulation, based on bypassing the compartmentalized activation of TLR9 in endosomes, and use it to uncover unique aspects of TLR9-driven disease. By inducing TLR9 dysregulation at different stages of life, we show that while dysregulation in adult mice causes a mild systemic autoinflammatory disease, dysregulation of TLR9 early in life drives a severe inflammatory disease resulting in neonatal fatality. The neonatal disease includes some hallmarks of macrophage activation syndrome but is much more severe than previously described models. Unlike TLR7-mediated disease, which requires type I interferon (IFN) receptor signaling, TLR9-driven fatality is dependent on IFN-γ receptor signaling. NK cells are likely key sources of IFN-γ in this model. We identify populations of macrophages and Ly6Chi monocytes in neonates that express high levels of TLR9 and low levels of TLR7, which may explain why TLR9 dysregulation is particularly consequential early in life, while symptoms of TLR7 dysregulation take longer to manifest. Overall, this study demonstrates that inappropriate TLR9 responses can drive a severe autoinflammatory disease under homeostatic conditions and highlights differences in the diseases resulting from inappropriate activation of TLR9 and TLR7.

Demographics, risk factors, and complication or readmission rates after multiligament knee reconstruction: A retrospective cohort study

Background: Multi-ligament knee injuries are complex and relatively rare injuries. As a result outcome data available to guide treatment are limited, and management strategies often are debated. Methods: Patients who underwent multiligament knee reconstructions between 2005 and 2015 were identified in the National Surgical Quality Improvement Program (NSQIP) database using validated CPT codes. Thirty-day complication and readmission rates after multiligament knee repair or reconstruction were identified. A multivariable logistic regression model was then used to identify statistically significant associations between patient factors and outcomes. Results: We identified 481 patients with an average age of 30.1±14.9 yr, and 67.2% male predominance. Using the American Society of Anesthesiologists (ASA) classification system, 222 patients (46.2%) were “Healthy” (ASA 1), 218 patients (45.3%) had “Mild Systemic Disease” (ASA 2), and 38 (7.9%) patients had “Severe Systemic Disease” (ASA 3). Of the sample 96.3% underwent multiligament knee reconstruction on an outpatient basis with 75.9% (365 patients) of the procedures performed in an outpatient surgery center. At 30-days postoperatively, the sample had a 6.2% overall complication rate; 4.8% of patients had a minor complication, and 1.5% of patients had a major complication. The most common minor and major complications were superficial surgical site infection and pulmonary embolus, respectively. Conclusions: Multiligament knee injuries commonly occur in young, relatively healthy individuals. This study indicates that reconstructive procedures are quite safe and supports the premise that multiligament knee reconstructions can be safely performed even as an outpatient. Level of Evidence: Level III.

Oral and maxillofacial surgery and dental rehabilitation under sedation and general anesthesia

Aim: The aim of this study was to retrospectively analyze dental procedures performed under general anesthesia (GA) or deep sedation at Dicle University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery from May 2013 to May 2018.&#x0D; Methodology: This study included 182 patients treated under GA and sedation from May 2013 to May 2018. The records of these cases were reviewed retrospectively in terms of patient demographic characteristics, medical history, dental procedures, and treatment duration. Children and adults were compared in terms of general anesthesia (GA) and deep sedation (SD).&#x0D; Results: Of 182 patients (age range: 1–61 years), 63 were had an American Society of Anesthesiology (ASA) status of I (completely healthy) and 119 were of ASA II status (mild systemic disease). A total of 143 patients (60 children and 83 adults) underwent GA, while 39 patients (18 children and 21 adults) underwent deep sedation. The mean duration of the procedures performed under GA and deep sedation was 75 and 40 min, respectively. Following the procedure, 103 patients were discharged on the same day, whereas 78 patients required postoperative care and were discharged on the following day. The rnumber of patients exposed to GA and SD were 143 and 39, respectively. The number of child patients exposed to GA waas 60, while that of adults was 83.&#x0D; Conclusions: The frequency of dental rehabilitation under GA or sedation is increasing. Patients who cannot undergo dental procedures under local anesthesia can be treated under preferably GA, as long as the indications, patient characteristics, and anesthesia plan are carefully considered. Data suggest that adults are more suitable for GA than children. However, due to the risks associated with GA, anesthetic procedures should only be performed by experienced anesthetists under operating room conditions.&#x0D; &#x0D; How to cite this article: Yılmaz UN. Oral and maxillofacial surgery and dental rehabilitation under sedation and general anesthesia. Int Dent Res 2019;9(3):111-8.&#x0D; &#x0D; Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

Treatment of humerus fracture with wise-lock implants

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Humerus fracture is a common fracture in aging population mainly occurring due to fall, high energy trauma and sports injury. Locking plate treatment is showing good results in stabilization of the fracture. The purpose of this study is to showcase the surgical treatment and results by using Auxein locking implants for the treatment of proximal humeral fracture.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Prospectively 13 patients were treated with ORIF treatment (6 males, 7 females with an average age of 43.6years). Fracture type is classified as per the Muller AO classification of fracture, 6 patients had type 11-A1 and 7 patients had type 11-A2. 1 patient were felt under American Society of Anesthesiologists grade 2 have mild systemic disease. Clinical outcomes were assessed at 1year follow-up with visual analogue scale score at 4 week, 16 week, 24 week and 1 year.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The follow-up of patients was taken at 4&lt;sup&gt;th&lt;/sup&gt;, 16&lt;sup&gt;th&lt;/sup&gt;, 24&lt;sup&gt;th&lt;/sup&gt; and 1 year bearing good clinical results. 2 patients were encountered with pain, these were elderly patients of the age 58 and 62 and had a history of other medical commodities. One patient reported of less weigh bearing ability which was relieved with physiotherapy.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Open reduction internal fixation treatment with Pheelos 3.5 mm wise lock proximal humerus plate showed good results with improved performance and negligible complications. &lt;/p&gt;

A Trilogy of Influenza, Immunization, and Antimicrobial Resistance: A Review Article

: Influenza virus could lead in a mild acute respiratory illness or severe systemic and respiratory disease, therefore, during the activity of influenza considerable number of respiratory syndromes and complications can be related to this virus. On the other hand, risk for concomitant and post-influenza bacterial complications threat is not huge enough to consider to prescribe empiric antibiotics. Influenza vaccine prevents millions of illnesses and flu-related visits every year. Influenza immunization has clear effects on disease burden as well as the number of patients with resistant disease acquired and transmitted in communities. Vaccination program indirectly diminishes antibiotic use and reduces the exposure of bacteria to antibiotics and consequently selective pressure for resistance. It seems there is definite evidence to consider annual influenza immunization in antimicrobial stewardship program and promote the global and national health quality. Hereby, we review scientific evidence of direct and indirect effects of influenza as well as the influence of vaccination and prevention program health systems.

The use of transnasal humidified rapid insufflation ventilatory exchange in laryngeal and pharyngeal surgery: Flinders case series

Background: Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) is a new anaesthetic technique that allows for prolonged apnoeic oxygenation without intubation. THRIVE is often conducted in patients with a normal body mass index (BMI) and mild systemic disease. However, it is unclear if patients with an increased BMI or significant co-morbidities are able to safely undergo laryngeal and pharyngeal surgery with THRIVE. Methods: A 14-month retrospective case note review was conducted in patients who underwent THRIVE for ear, nose, and throat (ENT) upper airway surgery. Factors were analysed to identify relationships with the requirement for rescue ventilation: age, BMI, American Society of Anaesthesiologists (ASA) physical status, smoking status, medical history and procedure type. An analysis was performed using non-parametric tests and odds ratios. Results: THRIVE was used with the following upper airway procedures (n=56): microlaryngoscopy with injection laryngoplasty (n=7), microlaryngoscopy with biopsy (n=14), microlaryngoscopy with potassium titanyl phosphate (KTP) laser use (n=11), panendoscopy with biopsy (n=10), oesophageal dilatation (n=3), subglottic stenosis dilatation (n=10), and stapling of a pharyngeal pouch (n=1). Rescue bag and mask ventilation or intubation were required in 21% of cases (n=12). A weight of more than 80 kg or BMI more than 30 were 5.2 and 5.7 times respectively more likely to require rescue ventilation (Fisher Exact Test P=0.023 and P=0.021). Conclusions: THRIVE can be safely used for a variety of laryngeal and pharyngeal procedures. However, there is a higher likelihood of rescue ventilation if the patient is over 80 kg or has a BMI over 30. Prospective investigation with a larger dataset of patients is required to validate these results.

Blood Loss and Visibility with Esmolol vs Labetalol in Endoscopic Sinus Surgery: A Randomized Clinical Trial.

Objectives:Improved intraoperative visibility during functional endoscopic sinus surgery (FESS) decreases the risk of serious orbital or skull base injuries. Esmolol and labetalol have been used to reduce bleeding and achieve better visibility, but it remains unclear which drug is more effective. This study aims to measure visibility scores and mucosal bleeding rates for esmolol and labetalol in FESS.Methods:This is a 1-year randomized double-blind trial of adults undergoing FESS at a tertiary academic center. The inclusion criteria were as follows: age 18 or older; history of chronic rhinosinusitis (CRS) with or without nasal polyps; undergoing FESS for CRS; and American Society of Anesthesiologists (ASA) physical status 1 (healthy) or 2 (patient with mild systemic disease). The exclusion criteria were as follows: pregnancy; asthma, chronic obstructive pulmonary disease (COPD), bradycardia, heart failure, end-stage renal disease, cerebrovascular accident, diabetes mellitus; preoperative use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, or beta-blockers; and body mass index (BMI) greater than 40 kg/m2. Patients received either dose-infused esmolol or intravenous push labetalol. The primary outcome was intraoperative visibility determined by surgeon using validated scoring systems (Boezaart, Wormald). The secondary outcome was hemodynamic control (rate of blood loss, average mean arterial pressure [MAP], average heart rate [HR]). Hypothesis of no difference between drugs formed before data collection.Results:Of the 32 adults given drug (mean age = 50), 28 patients (13 esmolol and 15 labetalol) with complete data were included in the final analysis. There were no statistically significant differences between esmolol and labetalol in rate of blood loss (0.59 [0.28] vs 0.66 [0.37] mL/min, P = 0.62), average MAP (79.7 [7.5] vs 79.4 [7.7] mm Hg, P = .93), HR (72 [8.7] vs 68 [11.7] bpm, P = .26), or mean visibility scores for the Boezaart (3.1 [0.69] vs 3.1 [0.89], P = .85) and Wormald (6.1 [1.7] vs 5.9 [1.9], P = .72) grading scales.Conclusions:There were no significant differences between esmolol and labetalol in rate of blood loss, MAP control, HR, or surgical visibility in FESS. Either drug may be used, and other considerations (availability, cost) can dictate choice.

Hypotension Aggravated by Dopamine in a Dog Under Isoflurane Anesthesia

Background: Hypotension (MAP &lt; 60 mmHg) is the most common complication in anesthetic practice and has been identified in 38% of canine patients undergoing general anesthesia for variety of procedures. Normalization of arterial pressure can usually be achieved by decreases in inhalant anesthetic concentrations, fluid administration, and use of inotropes/vasopressors in healthy animals (ASA I) or animals with mild systemic disease (ASA anesthetic risk II). The present report shows an ASA II dog with severe hypotensive crisis [mean arterial pressure (MAP) &lt; 50 mmHg] during general anesthesia, in which the procedure was aborted because hypotension was aggravated by dopamine.Case: A 7-year-old male Bull Terrier was anesthetized for magnetic resonance imaging (MRI) of a tumor in the face. After intramuscular acepromazine (0.01 mg/kg) and meperidine (3 mg/kg), anesthesia was induced with intravenous (IV) ketamine (1 mg/kg) and propofol (2.3 mg/kg) and maintained with isoflurane in oxygen. Ten min after induction of anesthesia MAP was 45 mmHg, while end-tidal isoflurane (ETISO) concentration was 0.5%. End-tidal isoflurane was decreased to 0.3% and an IV bolus of Lactated Ringer’s was initiated (15 mL/kg over 10 min), followed by two ephedrine boluses (0.1mg/kg, IV) administered 5 min apart. MAP remained low (&lt; 50 mmHg) and dopamine constant rate infusion (CRI) was initiated (7.5 μg/kg/min). Ten minutes after dopamine CRI was commenced, MAP was further decreased to 25-22 mmHg. Dopamine CRI was increased to 10 μg/kg/min, but MAP remained &lt; 25 mmHg. Infusion drugs and isoflurane anesthesia were stopped. After the animal was extubated MAP returned 60-70 mmHg.Discussion: Among the drugs used, isoflurane is known for decreasing blood pressure in a dose-related manner because of its vasodilating properties. Hypotension is rarely associated with low end-tidal isoflurane concentrations (0.3-0.5%) in animals that do not present previous evidence of circulatory dysfunction. Acepromazine may have contributed to the hypotensive actions of isoflurane in the case reported here because of its vasodilating effects. Acepromazine has prolonged plasma half-life (7 h) and might also have contributed to the lack efficacy of ephedrine to treat hypotension. Aggravation of hypotension (MAP decreased from 45-50 mmHg to approximately 25 mmHg) by dopamine was unexpected. Aggravation of hypotension during administration of vasopressor doses of dopamine could be related to the activation of the cardiopulmonarychemoreflex (CCR), previously known with the eponym Bezold-Jarisch reflex or due to a prevalence of dopamine´s vasodilatory effects (dopaminergic receptor stimulation) and failure of this drug in promiting increased CO and SVR at the dose ranges used (7.5 to 10 μg/kg/min).. The CCR involves activation of mechano and baroreceptors in the heart, by inotropes such as dopamine and dobutamine. This activation originates vagal afferent impulses to the nucleus tractus solitarii of the spinal cord, which in turn originates parasympathetic afferent impulses to the heart. The consequence is an increase in parasympathetic outflow and decreased sympathetic activity, ultimately producing bradycardia, hypotension, or both.Keywords: acepromazine, Bezold-Jarish reflex, cardiopulmonary chemoreflex, canine, inotropes.

Analysis of the immunological biomarker profile during acute Zika virus infection reveals the overexpression of CXCL10, a chemokine linked to neuronal damage.

BACKGROUNDInfection with Zika virus (ZIKV) manifests in a broad spectrum of disease ranging from mild illness to severe neurological complications and little is known about Zika immunopathogenesis.OBJECTIVESTo define the immunologic biomarkers that correlate with acute ZIKV infection.METHODSWe characterized the levels of circulating cytokines, chemokines, and growth factors in 54 infected patients of both genders at five different time points after symptom onset using microbeads multiplex immunoassay; comparison to 100 age-matched controls was performed for statistical analysis and data mining.FINDINGSZIKV-infected patients present a striking systemic inflammatory response with high levels of pro-inflammatory mediators. Despite the strong inflammatory pattern, IL-1Ra and IL-4 are also induced during the acute infection. Interestingly, the inflammatory cytokines IL-1β, IL-13, IL-17, TNF-α, and IFN-γ; chemokines CXCL8, CCL2, CCL5; and the growth factor G-CSF, displayed a bimodal distribution accompanying viremia. While this is the first manuscript to document bimodal distributions of viremia in ZIKV infection, this has been documented in other viral infections, with a primary viremia peak during mild systemic disease and a secondary peak associated with distribution of the virus to organs and tissues.MAIN CONCLUSIONSBiomarker network analysis demonstrated distinct dynamics in concurrence with the bimodal viremia profiles at different time points during ZIKV infection. Such a robust cytokine and chemokine response has been associated with blood-brain barrier permeability and neuroinvasiveness in other flaviviral infections. High-dimensional data analysis further identified CXCL10, a chemokine involved in foetal neuron apoptosis and Guillain-Barré syndrome, as the most promising biomarker of acute ZIKV infection for potential clinical application.

Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children

It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03). In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.