Removal of metallic tracheobronchial stents in lung transplantation with flexible bronchoscopy

Background  

Airway complications are among the most challenging problems after lung transplantation, and Self-Expandable Metallic Stents (SEMS) are used to treat airway complications such as stenosis or malacia at the bronchial anastomosis sites. Several transplantation centers are reluctant to use SEMS since their removal is sometimes needed and usually requires the use of rigid bronchoscopy under general anesthesia. The objective of the current report is to describe our experience in SEMS retrieval by flexible bronchoscopy under conscious sedation.     

Prevalence of Bordetella pertussis and Bordetella parapertussis in Infants Presenting to the Emergency Department with Bronchiolitis

Background: The clinical presentation of Bordetella pertussis can overlap with that of respiratory syncytial virus (RSV), and coinfection does occur, but management differs. Hypothesis: The prevalence of B. pertussis is < 2% among Emergency Department (ED) patients with bronchiolitis. Our secondary hypothesis was that the prevalence of Bordetella parapertussis is also < 2% among these patients. Methods: Nasal washings were obtained from children up to 18 months of age (inclusive) who presented to a county hospital ED with a clinical diagnosis of bronchiolitis. These washings were frozen to −70°C before testing for B. pertussis and B. parapertussis using species-specific real-time polymerase chain reaction (PCR) assays. The assays were optimized to target conserved regions within a complement gene and the CarB gene, respectively. A Bordetella spp. genus-specific real-time PCR assay was designed to detect the Bhur gene of B. pertussis, B. parapertussis, and B. bronchiseptica. RSV antigen detection was also performed. Results: There were 227 patients enrolled. After exclusions, 204 remained in the analysis. RSV antigen testing was positive in 109/186 (59%) of the patients in whom it was performed. All samples were tested for B. pertussis. B. parapertussis testing could not be completed on 23 samples. No cases (0/204; 95% confidence interval [CI] 0–1.8%) tested positive for B. pertussis or B. parapertussis (0/181; 95% CI 0–2%). Conclusion: The prevalence of B. pertussis in children presenting to the ED with bronchiolitis was < 2%.     

High-Intensity Statins Are Associated With Increased Incidence of Hypoglycemia During Hospitalization of Individuals Not Critically Ill

BackgroundSerum cholesterol is inversely associated with incident hypoglycemia among patients admitted to internal medicine wards. We examined the association between statin use and incidence of hypoglycemia among patients who were not critically ill.MethodsIn this retrospective study, we included all patients discharged between January 1, 2010, to December 31, 2013 from internal medicine units at the Wolfson Medical Center. Excluded were patients with hepatocellular or cholestatic liver disease upon admission. Patients were allocated to 4 groups, according to diabetes mellitus status (yes or no) and serum albumin < 3.5 g/dL (yes or no) on admission. Regression analysis was used to examine the association of incident hypoglycemia during hospitalization and statin treatment (yes or no), and later, statin intensity.ResultsIncluded in this analysis were 31,094 patients (mean age 68.9 ± 17.5 years, 48.4% males, 21.7% with diabetes mellitus). Logistic regression models showed that among patients with low admission serum albumin, administration of high-intensity statins was associated with increased incidence of hypoglycemic events compared to patients not treated with statins (odds ratio [OR] 1.303, 95% confidence interval [CI] 1.016-1.671, P = 0.037), whereas treatment with low-intensity statins was associated with less hypoglycemic events (odds ratio 0.590, 95% confidence interval 0.396-0.879, P = 0.010). Among patients with normal serum albumin, no association was found between incident hypoglycemia and statin intensity. These findings were significant regardless of diabetes mellitus status.ConclusionStatin treatment in general is associated with reduced incidence of hypoglycemia. However, among patients with low serum albumin upon admission, use of high-intensity statins is associated with an increased risk of hypoglycemic events regardless of diabetes mellitus status.     

Significant Delay in the Detection of Desaturation between Finger Transmittance and Earlobe Reflectance Oximetry Probes during Fiberoptic Bronchoscopy: Analysis of 104 Cases

Purpose

There is clinical significance to a delay in response time for detecting desaturation by pulse oximetry. Our aim in this study was to compare the response time of the reflectance and transmittance saturation probes during fiberoptic bronchoscopy (FOB) under monitored anesthesia care.

Methods

A prospective study included 104 patients scheduled for FOB. Patients were monitored with transmittance (finger) and reflectance (ear) oximetry probes. The response time was evaluated during desaturation and resaturation. We also acquired blood tests for arterial oxygen saturation to assess the agreement with the oximetry probes.

Results

Ninety patients had a desaturation episode during FOB and were included in the final analysis. Mean time difference between the reflectance ear probe (reference probe) and transmittance finger probe for the detection of desaturation (SpO2 = 90%) was + 36 s (CI 27.0–45.0, P < 0.001). The time difference between probes at end of desaturation episode (SpO2 = 95%) was + 31 s (CI 19.0–43.0; P < 0.001). A significant difference in response time was evident throughout the episode in all saturation values. The reflectance ear probe showed better agreement with arterial blood gases. The bias (and precision) for the earlobe and finger oximeters were of 0.24 (1.04) and 2.31 (3.37), respectively.

Conclusion

The data displayed by a centrally located reflectance probe are more accurate and allows for earlier identification, treatment, and resolution of desaturation events. In light of these data and the added value of the reflectance probe ability to measure transcutaneous PCO₂, we recommend monitoring bronchoscopy by a reflectance oximetry probe.

     

Efficacy and safety of a two‐drug direct‐acting antiviral agent regimen ruzasvir 180 mg and uprifosbuvir 450 mg for 12 weeks in adults with chronic hepatitis C virus genotype 1, 2, 3, 4, 5 or 6

Ruzasvir (MK‐8408, an NS5A inhibitor) and uprifosbuvir (MK‐3682, a nonstructural protein 5B nucleotide inhibitor) are highly potent direct‐acting antiviral agents for the treatment of hepatitis C virus (HCV) infection. A phase III clinical trial evaluating the two‐drug combination of ruzasvir 60 mg plus uprifosbuvir 450 mg suggested suboptimal efficacy in certain HCV genotypes (C‐BREEZE 1; NCT02759315). The aim of the present study was to evaluate the efficacy and safety of ruzasvir in combination with uprifosbuvir administered at a higher dose than that assessed in the earlier study (C‐BREEZE 2: NCT02956629/Merck protocol PN041). Treatment‐naïve or interferon (with or without ribavirin)‐experienced participants with or without compensated cirrhosis were enrolled. All participants received ruzasvir 180 mg plus uprifosbuvir 450 mg once daily for 12 weeks. The primary objectives were the proportion of participants with HCV RNA <15 lU/mL at 12 weeks after the end of study therapy (SVR12), and safety and tolerability of the study drug. Overall, 282 participants were enrolled. SVR12 (n/N) was 91.3% (42/46) in participants infected with HCV genotype (GT) 1a; GT1b, 96.7% (29/30); GT2, 91.5% (43/47); GT3, 73.8% (45/61); GT4, 98.2% (55/56); GT5, 100.0% (18/18); and GT6, 90.9% (20/22). Adverse events (AEs) were reported by 61.3% of participants; drug‐related AEs were reported by 33.3%. The most frequent (≥5% of participants) drug‐related AEs in all participants were fatigue (7.8%) and headache (7.4%). In conclusion, the two‐drug combination of ruzasvir 180 mg plus uprifosbuvir 450 mg for 12 weeks was highly effective and well tolerated in participants infected with HCV GT1, GT2, GT4, GT5 and GT6, with a lower efficacy in GT3‐infected persons.     

Familial hydrocephalus with normal cognition and distinctive radiological features

Hydrocephalus is a clinically and genetically heterogeneous condition. Individuals with posterior fossa abnormalities have an increased risk of developing hydrocephalus. The Dandy-Walker malformation, Dandy-Walker variant, and mega-cisterna magna (MCM) seem to represent a continuum of developmental anomalies of the posterior fossa. Here we describe the natural clinical history and the radiological features of a family with autosomal or X-linked dominant inheritance of MCM and hydrocephalus of variable severity. The affected family members demonstrate similar structural brain abnormalities including midline cyst, colpocephaly, MCM with a large posterior fossa and minimal vermian hypoplasia. The cognitive development of the affected individuals is normal. L1CAM and FOXC1 gene involvement in the pathogenesis of the disease in this family was excluded. The rare possibility of autosomal dominant or X-linked dominant inheritance and variable penetrance and expressivity must always be considered in genetic counseling of families with hereditary hydrocephalus.     

Maternal estimation of fetal weight as a complementary method of fetal weight assessment: a prospective clinical trial

OBJECTIVE: To assess the accuracy of fetal weight estimations performed by parturients vs. clinical and sonographic estimates. graphic estimates. STUDY DESIGN: Term parous women were included in this prospective trial. Each woman estimated the weight of her fetus. Fetal weight was also estimated sonographically and clinically. The clinical evaluations were performed by an attending gynecologist and a resident. Estimate accuracy for extreme fetal weights was evaluated separately. RESULTS: We enrolled 128 women. Maternal and resident estimations' accuracy was identical. The attending physician estimates were superior to the residents' and parturients', with a mean absolute error of 318 g and 67% of the evaluations within the 10% boundaries of the actual birth weight. Sonographic evaluation was the most accurate method, with a mean absolute error of 244 g and 76% of evaluations within 10% of the actual birth weight. When partitioned to extreme fetal weight groups (upper and lower 10th percentiles), the maternal evaluation was at least as accurate as the clinical evaluations of both the attending and resident. CONCLUSION: Maternal evaluation of the fetus's weight is as accurate as physicians' clinical estimations, and is advised as a complementary method of assessment. This estimation may greater relevance when intrauterine growth restriction or macrosomia is suspected.     

Different effects of magnesium sulfate and angiotensin II on the capacity of the fetal and maternal compartments of normal human placenta to secrete TNF-alpha and IL-6

Three different protocols were carried out to evaluate the effect of magnesium sulfate (MgSO4) on the capacity of the normal human placenta to secrete TNF-alpha and IL-6 in presence and absence of angiotensin II (AII). Ten placentas were perfused with MgSO4 (6-7 mg%) or medium in the absence or presence of AII. Perfusate samples from fetal and maternal sites were collected and examined for IL-6 and TNF-alpha by ELISA. The maternal site of placentas exposed to AII showed only basal levels of TNF-alpha. Exposure of the placentas to MgSO4 resulted in significant increase in TNF-alpha and IL-6 in the maternal site (p < 0.05). However, the effect of MgSO4 was significantly attenuated by AII injected in presence of MgSO4. TNF-alpha and IL-6 levels in the maternal site significantly decreased (p < 0.05). The fetal site of the placentas exposed to MgSO4 or AII separately showed only basal levels of TNF-alpha and IL-6. However, TNF-alpha and IL-6 levels were significantly higher after injection of AII in the presence of MgSO4 compared to TNF-alpha levels in the fetal site of placentas exposed to AII alone (p < 0.05) or MgSO4 alone (p < 0.01). MgSO4 induced the ability of the placental maternal site to secrete TNF-alpha and IL-6. In the presence of both MgSO4 and AII, the effect of MgSO4 on the maternal site was significantly reduced. However, in the fetal site, MgSO4 alone had no significant effect on TNF-alpha and IL-6 levels although, in presence of AII and MgSO4, there was a significant increase in TNF-alpha and IL-6 levels. Elevation of TNF-alpha and IL-6 in the fetal compartment, which may affect fetal brain growth and development and placental function should be considered before administration of MgSO4 during pregnancy.