Prevalence and risk factors of low bone mineral density and 25-hydroxyvitamin D status in young healthy epileptic adult patients in a tropical Asian country taking antiepileptic drug

PurposeAntiepileptic drugs have been reported to reduce bone mineral density (BMD) in several countries with varying prevalence but in studies with small sample size and inadequate assessment of confounders, and rarely including young adults. We sought to determine the prevalence, vitamin D status and risk factors for low BMD in young adult epileptic patients in a tropical setting.MethodsWe prospectively examined left femoral neck and spine with dual-energy X-ray absorption. Demographic data, basic laboratory studies, history of clinical epilepsy, parathyroid hormone and vitamin D level were obtained.ResultsOne hundred and twenty three patients were included. The mean (± SD) T-score was ? 0.31 ± 1.24 at the spine and ? 0.19 ± 1.11 at the left femoral neck. 36% had osteopenia and 4.1% had osteoporosis at either site. Four patients had vitamin D deficiency. Vitamin D levels were not correlated with BMD. Twenty-five patients had vitamin D insufficiency. Multivariate logistic regression analysis identified low body mass index (BMI) and male sex as risk factors for low BMD at the spine and low BMI and duration of treatment as risk factors for low BMD at the left femoral neck.ConclusionChronic use of antiepileptic drug (AED) in young adult patients is associated with low BMD.     

Vitamin D deficiency promotes growth of MCF-7 human breast cancer in a rodent model of osteosclerotic bone metastasis

IntroductionBreast cancer metastases to bone are common in advanced stage disease. We have recently demonstrated that vitamin D deficiency enhances breast cancer growth in an osteolytic mouse model of breast cancer metastasis. In this study, we examined the effects of vitamin D deficiency on tumor growth in an osteosclerotic model of intra-skeletal breast cancer in mice.MethodsThe effects of 1,25-dihydroxyvitamin D₃ [1,25(OH)₂D₃] on proliferation and apoptosis of MCF-7 breast cancer cells, and changes in the expression of genes within the vitamin D metabolic pathway (VDR, 1α- and 24-hydroxylase) were examined in vitro. MCF-7 breast cancer cells were injected intra-tibially into vitamin D deficient and vitamin D sufficient mice co-treated with and without osteoprotegerin (OPG). The development of tumor-related lesions was monitored via serial X-ray analysis. Tumor burden and indices of proliferation and apoptosis were determined by histology along with markers of bone turnover and serum intact PTH levels.ResultsIn vitro, MCF-7 cells expressed critical genes for vitamin D signalling and metabolism. Treatment with 1,25(OH)₂D₃ inhibited cell growth and proliferation, and increased apoptosis. In vivo, osteosclerotic lesions developed faster and were larger at endpoint in the tibiae of vitamin D deficient mice compared to vitamin D sufficient mice (1.49 ± 0.08 mm² versus 1.68 ± 0.15 mm², P < 0.05). Tumor area was increased by 55.8% in vitamin D deficient mice (0.81 ± 0.13 mm² versus 0.52 ± 0.11 mm² in vitamin D sufficient mice). OPG treatment inhibited bone turnover and caused an increase in PTH levels, while tumor burden was reduced by 90.4% in vitamin D sufficient mice and by 92.6% in vitamin D deficient mice. Tumor mitotic activity was increased in the tibiae of vitamin D deficient mice and apoptosis was decreased, consistent with faster growth.ConclusionVitamin D deficiency enhances both the growth of tumors and the tumor-induced osteosclerotic changes in the tibiae of mice following intratibial implantation of MCF-7 cells. Enhancement of tumor growth appears dependent on increased bone resorption rather than increased bone formation induced by these tumors.     

Single high-dose oral vitamin D3 (stoss) therapy — A solution to vitamin D deficiency in children with cystic fibrosis?

ObjectivesTo determine the safety and efficacy of stoss therapy on vitamin D levels over a 12 month period in children with cystic fibrosis and vitamin D deficiency (< 75 nmol/L).Study designRetrospective chart review of 142 paediatric CF patients from 2007 till 2011.ResultsThirty eight children received stoss therapy and 37 children with vitamin D deficiency were not treated and served as a control group. The stoss treated group had a significant and sustained increase in 25-hydroxyvitamin D levels measured at 1, 3, 6 and 12 months post treatment compared to controls (94.82 ± 41.0 nmol/L, p = 0.001; 81.54 ± 24.6 nmol/L, p = 0.001; 92.18 ± 36.5 nmol/L, p = 0.008 and 64.6 ± 20.0 nmol/L, p = 0.006 respectively). At 12 months post intervention, the mean difference in vitamin D levels from baseline between the stoss treated group and controls was significant at 15 nmol/L compared to 5 nmol/L (p = 0.038).ConclusionStoss therapy effectively achieves and maintains levels of 25-hydroxyvitamin D greater than 75 nmol/L over 12 months.     

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice

ObjectivesTo report our experience with rituximab therapy in patients with rheumatoid arthritis (RA) and a history of severe or recurrent bacterial infections.Patients and methodsRetrospective observational study in five rheumatology departments experienced in the use of biotherapies. Patients were included if they had RA and a history of severe or recurrent bacterial infection (requiring admission and/or intravenous antimicrobial therapy) that contraindicated the introduction or continuation of TNFα antagonist therapy.ResultsOf 161 RA patients given rituximab in the five study centers, 30 met the inclusion criteria, 23 females and seven males with a mean age of 58.4 ± 11.8 years and a mean disease duration of 11.4 ± 13.9 years. Among them, 22 had rheumatoid factors and 21 had received TNFα antagonist therapy (one agent in 15 patients, two in five patients and three in one patient). Prior infections were as follows: septicemia, n = 2; lower respiratory tract infection or lung abscess, n = 12; prosthesis infection, n = 3; septic arthritis, n = 3; endocarditis, n = 1; pyelonephritis, n = 2; osteitis, n = 4; and various skin infections (erysipelas, cellulitis or skin abscess), n = 6. Of these 33 infections, 21 occurred during TNFα antagonist therapy. During rituximab therapy, all patients received concomitant glucocorticoid therapy (mean dosage, 12 ± 7.9 mg/day). The number of rituximab cycles was one in 13 patients, two in seven patients and three or more in 10 patients. Mean time from the single or last serious infection and the first rituximab infusion was 20.1 ± 18.7 months. Mean follow-up since the first rituximab infusion was 19.3 ± 7.4 months. During follow-up, six (20%) patients experienced one infection each. Immunoglobulin levels after rituximab therapy were within the normal range.ConclusionRituximab therapy was well tolerated in 24 (80%) of 30 patients with RA and a history of severe or recurrent bacterial infection. In everyday practice, rituximab therapy seems safe with regard to the recurrence of infectious episodes. However, longer follow-ups are needed.     

Effect of tramadol gargle on postoperative sore throat: A double blinded randomized placebo controlled study

BackgroundPostoperative sore throat is an undesirable complaint after general anesthesia with laryngeal mask airway. Tramadol is a synthetic codeine analogue with NMDA receptor antagonist and local anesthetic effects. We compared tramadol gargle to placebo given 5 min before surgery on attenuating postoperative sore throat for 24 postoperative hours.MethodIn a prospective randomized double blind study, fifty patients of ASA I and II, undergoing elective moderate urological surgery under general anesthesia using laryngeal mask airway were allocated into two groups (25 patients each); all patients were asked to gargle for 1 min with 30 ml apple juice containing tramadol 2 mg/kg in group (T), and nothing in group (P) 5 min before surgery. The incidence and the severity of postoperative sore throat were graded at 2, 6, 12, and 24 h after surgery using a four-point scale.ResultIncidence and severity of postoperative sore throat were significantly less in tramadol treated group compared to placebo group at 2, 6, 12, and 24 h (p < 0.05).ConclusionPreoperative gargling with tramadol reduced the incidence and severity of POST compared to placebo group in patients undergoing elective moderate urological surgery, during general anesthesia with laryngeal mask airway for up to 24 h postoperatively.     

Absence of CD4CD25 regulatory T cell expansion in renal transplanted patients treated in vivo with Belatacept mediated CD28–CD80/86 blockade

AimsBelatacept is a new recombinant molecule (CTLA4-Ig) that interferes with the second activation signal of T lymphocytes. CTLA4-Ig induced T cell allograft tolerance in rodents but not in primates. We examined the changes in peripheral lymphocyte subsets, including regulatory T cells, in renal transplant patients treated with Belatacept.MethodsA cross-sectional immunological study was carried out 6 months after transplantation in 28 patients enrolled in the Belatacept phase II study. Eighteen patients received Belatacept, mycophenolate mofetil and steroids (Belatacept group), while the control group of 10 patients received cyclosporine, mycophenolate mofetil and steroids (CsA group). Lymphocyte subsets were examined by flow cytometry. Foxp3 mRNA expression was measured by quantitative PCR.ResultsThe number of T lymphocytes and the percentage of CD3+ T cells were similar in both groups. However, the percentage of CD3+ CD4+ T cells was lower in the Belatacept group than in the control CsA group (B = 42.5% ± 13.7 vs CsA = 52.9% ± 9, p < 0.005), and the percentage of CD3+ CD8+ cells was higher in the Belatacept group than in the control (B = 32.9% ± 6.7 vs CsA = 19.5% ± 8.2, p < 0.0002). The percentage of CD19+ cells was similar in both groups. Among CD56+cells, only the percentage of CD16+ cells was significantly higher in the Belatacept group than in the control (B = 82% ± 12 vs CsA = 59.7% ± 25, p = 0.01). Among CD4 and CD8 T cells the percentage of activated lymphocytes expressing CTLA4, HLA-DR or CD40L was similar in both groups. The percentage of CD4+CD25+ T cells was higher in the CsA group. The percentage of regulatory CD4+CD25+ cells with bright CD25 staining was similar in both groups (B = 3.6 ± 2.3% vs CsA = 4.7 ± 1.9%, ns) as was the expression of FoxP3.ConclusionOur results indicated that Belatacept did not induce regulatory T cell expansion in vivo. We suggest that Belatacept treatment should be maintained after transplantation to allow graft acceptance.     

Prognostic relevance of dynamic hyperinflation during cardiopulmonary exercise testing in adult patients with cystic fibrosis

BackgroundDynamic hyperinflation during cardiopulmonary exercise testing (CPET) in cystic fibrosis (CF) has not been well characterized, and little is known regarding its prevalence, risk factors and clinical associations.MethodsCPET data from 109 adult patients with mild-to-moderate CF was used, in this retrospective study, to characterize and determine the prevalence of dynamic hyperinflation, and evaluate its relationship with lung function and exercise tolerance, clinical symptoms, and prognosis over a two-year period.Results58% of patients responded to CPET with dynamic hyperinflation. These patients had significantly lower lung function (FEV₁ 66 ± 19 versus 79 ± 18%pred., p < 0.01) and exercise tolerance (peak oxygen uptake 28.7 ± 8.1 versus 32.9 ± 6.1 mL·kg^? 1·min^? 1, p = 0.02), and experienced greater shortness of breath at peak exercise (7 ± 3 versus 5 ± 2 Modified Borg scale, p = 0.04) compared to patients who responded without dynamic hyperinflation. Significant relationships between FEV₁, FVC, FEV₁/FVC, FEF_25–75 and dynamic hyperinflation were shown (p < 0.01; p = 0.02; p < 0.01; p < 0.01, respectively). Dynamic hyperinflation was also significantly correlated with oxygen uptake, tidal volume, work-rate and shortness of breath at peak exercise (p = 0.03; p < 0.01; p < 0.01; p = 0.04, respectively). Responding to CPET with or without dynamic hyperinflation did not significantly predict FEV₁ at 2 years beyond the FEV₁ at baseline (p = 0.06), or increase the likelihood of experiencing a pulmonary exacerbation over a two-year period (p = 0.24).ConclusionThe prevalence of dynamic hyperinflation during CPET in adult patients with mild-to-moderate CF is high, and is associated with reduced lung function and exercise tolerance, and increased exertional dyspnea. However, identifying dynamic hyperinflation during CPET had limited prognostic value for lung function and pulmonary exacerbation.     

Transient effectiveness of vitamin D2 therapy in pediatric cystic fibrosis patients

BackgroundThe effectiveness of current treatment recommendations for vitamin D insufficiency in children with CF is unknown. Therefore, we assessed the effectiveness of vitamin D₂ 50,000 IU once daily for 28 days for vitamin D insufficiency.MethodsRetrospective chart review of pediatric CF patients from 2006–2008. Vitamin D₂ 50,000 IU daily for 28 days was given to patients with 25-OHD < 30 ng/mL and repeat 25-OHD levels were obtained after completion of therapy.ResultsOne hundred forty-seven levels from 97 individuals were assessed. Success of treatment was 54% (n = 80/147). Seventeen of 39 patients (43%) followed for an additional 6–18 months were able to maintain levels of ≥ 30 ng/mL.ConclusionsVitamin D₂ 50,000 IU daily for 28 days was effective in correcting vitamin D insufficiency in approximately 50% of subjects. However, almost half of successfully treated patients were unable to maintain normal 25-OHD levels > 6 months after completion of therapy, implying that this effect is transient.     

Peak Oxygen Uptake During the Six-minute Walk Test in Diffuse Interstitial Lung Disease and Pulmonary Hypertension

IntroductionThe six-minute walk test (6MWT) is widely used in evaluating diffuse interstitial lung disease (ILD) and pulmonary hypertension (PH). However, their physiological determining factors have not been well defined.ObjectiveTo evaluate the physiological changes that occur in ILD and PH during the 6MWT, and compare them with the cardiopulmonary exercise test (CPET).Material and MethodsThirteen patients with ILD and 14 with PH were studied using the 6MWT and CPET on an ergometer cycle. The respiratory variables were recorded by means of telemetry during the 6MWT.ResultsOxygen consumption (VO₂), respiratory and heart rate reached a plateau from minute 3 of the 6MWT in both diseases. The VO₂ did not differ from the peak value in the CPET (14 ± 2 and 15 ± 2ml/kg/min, respectively, in ILD; 16 ± 6 and 16 ± 6ml/kg/min, in PH). The arterial oxygen saturation decreased in both diseases, although it was more marked in ILD (?12 ± 5%, P<.01). The ventilatory equivalent for CO₂ (VE/VCO₂) in PH during the 6MWT was strongly associated with functional class (FC) (85 ± 14 in FC III-IV, 44 ± 6 in FC I-II; P<.001).ConclusionsThe 6MWT in ILD and PH behaves like a maximal effort test, with similar VO₂ to the CPET, demonstrating a limit in oxygen transport capacity. Monitoring using telemetry during the 6MWT may be useful for the clinical evaluation of patients with ILD or PH.     

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction,a prospective randomized controlled study

PurposeAdult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.Patient and methods42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43–55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.ResultsAt 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊ ± 2.8 versus 13.95̊ ± 2.2 (p = 0.001) and 13.70̊ ± 2.2 versus 19.05̊ ± 3.2 (p < 0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.ConclusionLCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Hemodynamic changes occurring with tracheal intubation by direct laryngoscopy compared with intubating laryngeal mask airway in adults: A randomized comparison trial

BackgroundHemodynamic changes are major problems due to general anesthesia. We designed a prospective randomized study to compare the hemodynamic responses due to direct laryngoscopy (DL) and intubating laryngeal mask airway (ILMA).MethodsSeventy adult ASA-I and ASA-II patients referred to anesthesia department were randomly divided into two groups: direct laryngoscopy (Macintosh laryngoscope) and ILMA. Systolic, diastolic and mean arterial blood pressure and heart rate were recorded at baseline, preintubation, 1, 3 and 5 min after intubation following intubation. Also some complications including sore throat, laryngospasm, hoarseness and cough were evaluated.ResultsMean age of studied patients in DL group (including 11 (31.4%) male) was 35.5 ± 12.2 and 35.5 ± 9 years old in ILMA group (including 16 (45.7%) male). There was no significant difference between two studied groups about measured hemodynamic indices (P < 0.05, CI = 95%). The results showed that the just difference between increment of diastolic blood pressure and mean arterial pressure after 5 min interval of two studied groups was significant (P = 0.04; P = 0.034). There was no significant difference between the number of patients with positive complications and those without them (P < 0.05).ConclusionLaryngoscoy through the intubating laryngeal mask airway was associated with lesser mean arterial pressure and diastolic blood pressure when compared to intubation by direct laryngoscope. Thus this technique seems to reduce hemodynamic response to tracheal intubation.     

Strong relationship between vitamin D status and bone mineral density in anorexia nervosa

BackgroundAnorexia nervosa (AN) is associated with impaired bone health and low bone mineral density (BMD) as a consequence of an inadequate peak bone mass in adolescence and bone loss in young adulthood. The vitamin D status with its implications for bone health in patients affected by AN has only been examined previously in small studies.ObjectiveTo evaluate the prevalence of vitamin D deficiency and test the hypothesis that patients with AN and vitamin D deficiency might have worse bone metabolism and lower bone density as compared with AN with adequate vitamin D repletion.DesignWe analysed the vitamin D status and bone metabolism in a large cohort (n = 89) of untreated patients affected by AN, with amenorrhoea.ResultsVitamin D deficiency is widespread in untreated patients with AN: 16.9% had 25OH vitamin D levels below 12 ng/ml, 36% below 20 ng/ml and 58.4% below 30 ng/ml. PTH values were higher and BMD at both femoral sites were lower in patients with vitamin D < 20 ng/ml. Progressively higher values of BMD were observed by 4 ranks of 25 OH vitamin D values (severe deficiency: < 12 ng/ml, deficiency: ≥ 12 ng/ml and < 20 ng/ml, insufficiency: ≥ 20 and < 30 ng/ml and normal: ≥ 30 ng/ml). In patients with severe vitamin D deficiency BMD at the hip were significantly lower than that measured in groups with values over 20 ng/ml (p < 0.001 for trend). The level of significance did not change for values adjusted for BMI or body weight.ConclusionWe found a strong relationship between vitamin D status and hip BMD values with additional benefits for those with 25OHD levels above 20 ng/ml. Our results support the design of a randomized placebo-controlled clinical trial on the effect of vitamin D on BMD in patients with AN. The second point, whether 25OHD should be above 20 or 30 ng/ml remains a discussion point.     

Early results of minimally invasive,reverse-oblique,distal metaphyseal metatarsal osteotomy (R-DMMO) for arthritis of the lesser tarsometatarsal joints — A retrospective case series

BackgroundArthrodesis is the gold standard for operative management of osteoarthritis of the lesser tarsometatarsal joints (TMTJs) but is not without complications. Our early results of a minimally invasive alternative treatment – the reverse-oblique distal metaphyseal metatarsal osteotomy (R-DMMO) are described.MethodsThis is a single-centre, single-surgeon, retrospective series of patients with isolated, symptomatic lesser TMTJ arthrosis who underwent R-DMMO.ResultsSixteen feet in 15 patients were included. The mean age was 64.7 ± 9.7 years and mean duration of follow-up was 109.4 ± 27.4 weeks. There were no non-unions, infections or wound complications. Two patients developed transfer symptoms to their first metatarsal, one of these patients improved after three months. There was one delayed union which united at 12 months. Two patients developed recurrence of symptoms but felt that they were still improved compared to preoperatively and no patient has required arthrodesis thus far. The mean preoperative VAS was 8.3 ± 1.3 and the mean postoperative VAS was 2.4 ± 2.2 (P < 0.001). The mean postoperative MOxFQ-Walking was 25.2 ± 25.6, MOxFQ-Pain was 24.8 ± 20.5, MOxFQ-Social was 18.4 ± 19.1, and MOxFQ-Index was 23.4 ± 20.6. Eight patients were ‘very satisfied’ and seven were ‘satisfied’ with the procedure.ConclusionsR-DMMO is a minimally invasive and safe procedure for lesser TMTJ arthrosis which can produce good results and prevent, or at least delay, the need for arthrodesis without compromising future operative options. Good to excellent outcomes have been shown with few significant complications in the short term in selected patients.     

Middle cerebral artery blood flow velocity during beach chair position for shoulder surgery under general anesthesia

ObjectivesThe goal of the present study was to examine changes of middle cerebral artery (V_MCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position.DesignProspective observational study.SettingOperating room, shoulder surgery.PatientsFifty-three consecutive patients scheduled for shoulder surgery in beach chair position.InterventionsTranscranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20 minutes (BC2), and after back to supine position before stopping anesthesia (supine).MeasurementsMean arterial pressure (MAP), end-tidal CO₂, and volatile anesthetic concentration and V_MCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched.Main ResultsBeach chair position induced decrease in MAP (baseline: 73 ± 10 mm Hg vs lower MAP recorded: 61 ± 10 mm Hg; P < .0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in V_MCA after beach chair positioning (BC1: 33 ± 10 cm/s vs baseline: 39 ± 14 cm/s; P = .001). The V_MCA at baseline (39 ± 2 cm/s), BC2 (35 ± 14 cm/s), and supine (39 ± 14 cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO₂, SpO₂, and MAP were not different at baseline, BC1, BC2, and supine.ConclusionBeach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in V_MCA.     

Comparative study between Air-Q and Intubating Laryngeal Mask Airway when used as conduit for fiber-optic

This study compared Air-Q and Intubating LMA when used as a conduit for endotracheal intubation.MethodsOne hundred patients scheduled for surgical operations under general anesthesia were randomly allocated into two equal groups (n = 50). Group I: Air-Q and group II: Intubating Laryngeal Mask Airway (ILMA) in both groups intubation was done by Fiberoptic bronchoscope (FOB) through study device. After induction of anesthesia, patients were ventilated with Air-Q or ILMA. Then, endotracheal tube (ETT) was inserted through study device. Recorded measurements were as follows: number of attempts and duration of insertion of device, peak airway pressure and fiberoptic grading of laryngeal view. Also, we recorded number of attempts and duration of insertion of ETT and the incidence of blood stain on device and sore throat grading.ResultsDuration of insertion of Air-Q was 13.300 ± 3.471 s, whilst that of ILMA was 19.640 ± 4.737 s (p < 0.001). In group I, peak airway pressure was 26.400 ± 2.176 cmH₂O, whilst, in group II, it was 25.260 ± 1.468 cmH₂O (p < 0.01). Full view of vocal cords amounted to 78% and 26% of Groups I and II patients, respectively (p < 0.001). Time of insertion of ETT was 33.5 ± 6.795 s in group I, whilst in group II, it was 39.5 ± 6.566 s (p < 0.001). Blood stain was found on supraglottic device in 46% and 22% of cases in Groups I and II, respectively (p < 0.01).ConclusionAir-Q proved to be an excellent conduit for endotracheal intubation compared to the ILMA.     

Erythromycin improves gastric emptying half-time in adult cystic fibrosis patients with gastroparesis

BackgroundGastrointestinal manifestations are frequently encountered in cystic fibrosis patients. Gastroparesis evidenced by a variety of diagnostic methods has been described in patients with cystic fibrosis, predominantly in children and in individuals with advanced lung disease. The presence of gastroparesis in adult patients with different degrees of lung involvement and its response to the acute and chronic administration of macrolides have not been reported.MethodsUsing the University of Florida Cystic Fibrosis database we identified symptomatic patients who had gastroparesis confirmed by a prolonged half-time during gastric emptying scintigraphy.ResultsOf 86 cystic fibrosis patients, periodically followed in our institution, we found five who had classical symptoms and prolonged gastric emptying half-time. Age 25.2 ± 8 years, 80% females, BMI 22 ± 9 kg/m², HbA1c 5.8 ± 0.6 g/dl, FEV1 53.2 ± 15% of predicted. Gastric emptying half-time was 191.4 ± 91.4 min (range 100–300 min) and decreased to 12.2 ± 6 min (range 5–20 min) after IV administration of erythromycin (p = 0.043). Patients were followed up for 3 ± 2.1 years. All patients but one, who was taking opiods, had good clinical response to PO macrolides.ConclusionsGastroparesis occurs in patients with cystic fibrosis, even in patients with relatively preserved lung function and in those without cystic-fibrosis related diabetes. Macrolides may be an effective therapy in cystic fibrosis patients with gastroparesis when administered acutely or chronically.     

Effect of vitamin D3 treatment on bone density in neurofibromatosis 1 patients: A retrospective clinical study

ObjectivesWe have previously demonstrated reduced bone density and an increased incidence of 25-hydroxy vitamin D₃ (25-OH D₃) deficiency in adults with neurofibromatosis 1 (NF1) compared to healthy controls. Vitamin D₃ is a cheap, safe, and effective supplement in the general population, but its value in NF1 patients has not been demonstrated. This study investigates the therapeutic potential of oral vitamin D₃ on bone mineral density (BMD) in NF1 patients with vitamin D₃ deficiency.MethodsWe measured serum 25-OH D₃, parathyroid hormone, calcium, and bone alkaline phosphatase concentrations, urinary deoxypyridinoline concentrations, and BMD in 35 adults with NF1. Nineteen patients received vitamin D₃ supplementation for 2 years, six patients received supplementation for 1 year and 10 patients received no supplementation. Supplementation was administered in a dose that maintained the serum 25-OH D₃ level above 30 μg/l. BMD was measured again at 1 and 2 years, and biochemical assessments of bone metabolism were measured at least every half year during therapy.ResultsTreated subjects had significantly reduced loss of BMD, as measured by T score at the hip (p = 0.011) and lumbar spine (p = 0.022). The effect on hip BMD was apparent at 1 year in comparison to baseline (p = 0.02) and was greater at 2 years in comparison to measurements at 1 year (p = 0.02).ConclusionsVitamin D₃ supplementation improves BMD in adult NF1 patients. Further studies are needed to elucidate the mechanisms responsible for reduced BMD in NF1 patients.     

Preliminary evaluation of ketofol-based sedation for awake craniotomy procedures

BackgroundThe study aimed at evaluating the clinical efficiency of a ketofol-based sedation procedure during awake craniotomy for varied surgical indications.MethodsThe study included 28 patients; 19 males and 9 females with mean age of 33.4 ± 9.3 years. All patients received propofol (0.5 mg/kg/h) and ketamine (0.5 mg/kg/h) infusion mixture in 1:1 ratio. Conscious level was evaluated using the Modified Observer's Assessment of Alertness/Sedation scale and patients were maintained at level 3, at which the patients will respond after their name is called loudly or repeatedly; otherwise patient was considered over-sedated. Intraoperative (IO) monitoring included intracranial pressure (ICP), hemodynamic and respiratory changes, brain status, whether slack or tense, the frequency of over-sedations and adverse events. Duration of surgery, time till PACU transfer, total anesthesia time, postoperative (PO) complications and duration of hospital stay were reported. Patients’ satisfaction, on 0–10 score, about the procedure used for awake sedation was inquired.ResultsMean duration of surgery was 168.8 ± 19.4 min; mean time till PACU transfer after stoppage of infusion was 11.1 ± 1.7 min for a mean anesthesia time of 179.9 ± 19.2 min. Three patients had blood pressure changes, 4 had heart rate variability, 2 had respiratory depression and one had SpO₂ <90%. Two patients developed focal seizures, one had nausea and 2 patients were over-sedated. Brain was tense in only 3 patients (10.7%). Four patients had PO transient neurological deficits, 3 patients had PO seizures and only 2 patients had recurrent attacks of nausea and vomiting; however, these complications responded to treatment. Mean hospital stay was 3.1 ± 1.1 days. Mean satisfaction score was 9.1 ± 1.2; range: 6–10 with a satisfaction rate of 78.6%.ConclusionConscious sedation during awake craniotomy using ketofol infusion mixture in 1:1 ratio was safe and efficient with minor hemodynamic and respiratory events and rapid smooth recovery profile.     

A report of 21 cases of rheumatoid arthritis following Chikungunya fever. A mean follow-up of two years

ObjectiveIn 2005, after an epidemic infection of Chikungunya fever in islands in the Indian Ocean, infected patients exhibited severe musculoskeletal disorders. We report 21 cases of rheumatoid arthritis (RA) after Chikungunya infection that were diagnosed at a rheumatological centre in Reunion Island.MethodsPatients were examined by the same rheumatologist from February 2006 to July 2007. Inclusion criteria were (1) Chikungunya infection confirmed by IgM and IgG antibodies, (2) RA according to ACR criteria, (3) no other definite diagnosis of arthritis and (4) persistent arthritis symptoms from the onset of viral infection to RA diagnosis.ResultsTwenty-one patients (13 females; mean age, 57 ± 12 years) fulfilled the inclusion criteria. Eighteen patients (85.7%) had symmetric polyarthritis and three had oligoarthritis. The mean symptom duration was 10 months (range 4–18). The mean ESR was 40.7 ± 28.1 mm/hr and C-reactive protein level 37 ± 41 mg/l; 12 patients were positive for rheumatoid factor (57.1%), and six had anti-CCP antibodies (28.6%) and 14 HLA DRB1*04 or 01 alleles (66.6%). Radiographs of hands and feet of 12 patients showed erosions and/or joint space narrowing (JSN). During a mean follow-up of 27.6 ± 6.4 months, all patients were treated with DMARDs including methotrexate (n = 19) and TNF blockers (n = 6). Structural damage progressed, with 17 cases of erosion and/or JSN at follow-up.ConclusionWe diagnosed RA in 21 patients with Chikungunya fever. The first symptoms occurred at the time of viral infection. Outcome was severe in most of the cases despite low rate of anti-CCP antibodies. These cases suggest a role of viral infection in RA initiation.