Is There a Role for Antibiotics in the Treatment of Asthma?

Emerging evidence suggests an association between some asthma and pulmonary infection by the atypical organisms Chlamydia pneumoniae and Mycoplasma pneumoniae, but a causal role for infection remains unproven and controversial. Most acute exacerbations of asthma are triggered by acute infections that are due to viral respiratory pathogens, not to bacteria or atypical organisms. Administration of antibiotics for acute exacerbations of asthma has been shown to be ineffective. Most evidence linking atypical infections to asthma is consistent with a promoting role for chronic infection in producing persistent asthma symptoms. Preliminary studies suggest that prolonged (>/=6 weeks) administration of doxycycline or macrolides may eradicate C. pneumoniae from respiratory secretions and improve long term, not acute, asthma symptoms. Randomised, controlled trials are currently under way to investigate the effectiveness of these prolonged courses of macrolides and azalides (roxithromycin, clarithromycin and azithromycin) in adults with stable persistent asthma. Traditional courses (7 to 10 days) of any antibiotic are incapable of eradicating chronic C. pneumoniae or M. pneumoniae infection; furthermore, beta-lactam and sulphonamide-based antibiotics that are commonly prescribed in acute respiratory syndromes are ineffective against these atypical organisms. Unless the goal is to treat documented sinusitis associated with asthma, it is inappropriate to prescribe traditional courses of any antibiotic for acute asthma exacerbations; whether longer courses of antibiotics should be prescribed to eradicate chronic atypical infections and decrease persistent asthma severity remains to be established.     

Anaplastic Carcinoma of the Pancreas: Is There a Role for Palliative Surgical Procedure?

Anaplastic carcinoma (AC) or undifferentiated carcinoma of the pancreas is a rare variant among the malignant pancreatic neoplasms. These tumors have a poor prognosis with survival measured in months. The role of surgical palliation to improve the quality of life is not well defined in these patients. We report a case of AC of pancreas in a 65-year-old male patient. Patient had upper abdominal pain with frequent bilious vomiting. Computed tomography scan of the abdomen showed a mass in the body of pancreas with possible infiltration of duodenojejunal flexure (DJF). Laparotomy revealed an inoperable mass with posterior fixity and involvement of the DJF. Patient underwent a palliative duodenojejunostomy. Tissue biopsy from the tumor showed pleomorphic type AC with giant cells. Patient had good symptomatic relief from profuse vomiting and progressed well at follow up. AC of pancreas is a rare and aggressive malignancy with dismal outlook. If obstructive symptoms are present due to duodenal involvement, a palliative bypass may be a worthwhile surgical option in selected cases.     

Should Core Needle Biopsy be Used in the Evaluation of Thyroid Nodules?

Fine needle aspiration (FNA) is the first choice in thyroid nodules suspected of harboring malignancy on sonography in routine practice. However, sampling with core needle biopsy (CNB) is also being used, especially in cases with repeated nondiagnostic/indeterminate diagnoses. The aim of this study was the retrospective evaluation of CNB samples. A total of 604 thyroid CNB samples registered in the Department of Pathology at Bezmialem Foundation University Medical Faculty within the 1-year period between June 2014 and June 2015 were re-evaluated by correlation with previous FNA and later resection results. CNB was divided into diagnostic groups of insufficient, malignant, suspicious for malignancy, no evidence of malignancy/benign, atypia of uncertain significance (AUS)/follicular lesions of uncertain significance (FLUS), and follicular neoplasm (FN)/suspicious for follicular neoplasm (SFN). Among the 604 cases, 15 cases (2.48 %) were classified as malignant and 9 cases (1.49 %) as suspicious for malignancy. No evidence of malignancy was seen in 512 cases (84.76 %). There were 26 (4.3 %) cases in the AUS/FLUS-FN/SFN group, and the sample was inadequate in 42 cases (6.95 %). Resection was performed for 17 of the cases classified as malignant or suspicious for malignancy, and all were found to be malignant. There were also 10 resected cases with a diagnosis of no evidence of malignancy, and all were found to be benign. We think that sampling with CNB may be useful especially in repeating inadequate biopsies or cases diagnosed with AUS/FLUS that have hesitations regarding clinical management. Larger series including comparisons with FNA and resection results are required.     

Is There a Future for Neural Transplantation?

Traditionally neural transplantation has had as its central tenet the replacement of missing neurons that have been lost because of neurodegenerative processes, as exemplified by diseases such as Parkinson disease (PD). However, the effectiveness and widespread application of this approach clinically has been limited, primarily because of the poor donor supply of human fetal neural tissue and the incomplete neurobiological understanding of the circuit reconstruction required to normalize function in these diseases. So, in PD the progress from promising neural transplantation in animal models to proof-of-principle, open-labeled clinical transplants, to randomized, placebo-controlled studies of neural transplantation has not been straightforward. The emergence of previously undescribed adverse effects and lack of significant functional advantage in recent clinical studies has been disappointing and has served to cast a new, and perhaps more realistic, perspective on this treatment approach. In fact, there have been calls by some involved in neural transplantation to return to the drawing board before pressing on with further clinical trials, and the return to basic experimentation. This therefore precipitates the question — is there a future for neural transplantation? It is important to remember that there are a number of possible explanations for the disappointing results from the recent clinical trials in PD, ranging from the mode of transplantation to patient selection. Nevertheless, almost irrespective of these reasons for the current trial results, there have always been significant practical and ethical problems with using human fetal tissue, and so a number of alternative cell sources have been investigated. These alternative sources include stem cells, which are attractive for cell-based therapies because of their potential ease of isolation, propagation and manipulation, and their ability in some cases to migrate to areas of pathology and differentiate into specific and appropriate cell types. Furthermore, the availability of stem cells derived from non-embryonic sources (e.g. adult stem cells derived from the sub-ventricular zone) has removed some of the ethical limitations associated with the use of embryonic human tissue. These potentially beneficial aspects of stem cells means that there is a future for neural transplantation as a means of treating patients with a range of neurological disorders, although whether this will ever translate into a truly effective, widely available therapy remains unknown.     

Cytomorphological Analysis of Thyroid Nodules Diagnosed as Follicular Variant of Papillary Thyroid Carcinoma: a Fine Needle Aspiration Study of Diagnostic Clues in 42 Cases and the Impact of Using Bethesda System in Reporting—an Institutional Experience

Follicular variant of papillary thyroid carcinoma (FVPTC) is the second most common subtype of papillary thyroid carcinoma (PTC) after classical PTC (cPTC). Follicular thyroid lesions such as follicular adenomas/carcinomas, FVPTC, and noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) pose some diagnostic challenges for FNAC. In this study, we aimed to explore whether FNAC can demonstrate diagnostic clues by re-evaluating cytology slides from histopathologically diagnosed FVPTC cases. A total of 42 patients were enrolled in this study: patients were diagnosed with FVPTC via surgical resection between 2006 and 2016, and all patients were subjected to preoperative FNAC, which was conducted at either a private center or at the teaching hospital of Kocaeli University and reported by the same cytopathologist (NP). Clinical and cytomorphological characteristics were reviewed by both authors .Most cases (76.2%) are diagnosed either Bethesda IV or V. The majority of cases had a high cellularity (38/42; 90.5%), and the most frequent observations were monolayer and large syncytial groups of cells (95.2%). While microfollicular structures were observed in 30 (71.4%) cases, nuclear crowding and large naked nuclei were observed in all cases. Nuclear grooves were sparsely detected in 23 (54.8%) cases, and nuclear pseudoinclusions were detected in only six (14.3%) cases. Because thyrocytes often have a mixed architecture in FVPTC, despite a distinct follicular morphology, we believe that nuclear overcrowding, enlargement, and hyperchromasia in cases presenting with increased cellularity are notable clues for the cytodiagnosis of FVPTC. We believe that the primary aim of FNAC in such cases is to give preoperative diagnosis as either category IV or V. Nuclear crowding, monolayered clusters with large syncytial formations, nuclear enlargement, and hyperchromasia are notable cytomorphologic clues for the diagnosis of FVPTC on FNAC.     

Is There a Weekly Pattern for Health Searches on Wikipedia and Is the Pattern Unique to Health Topics?

Background

Online health information–seeking behaviors have been reported to be more common at the beginning of the workweek. This behavior pattern has been interpreted as a kind of “healthy new start” or “fresh start” due to regrets or attempts to compensate for unhealthy behavior or poor choices made during the weekend. However, the observations regarding the most common health information–seeking day were based only on the analyses of users’ behaviors with websites on health or on online health-related searches. We wanted to confirm if this pattern could be found in searches of Wikipedia on health-related topics and also if this search pattern was unique to health-related topics or if it could represent a more general pattern of online information searching—which could be of relevance even beyond the health sector.

Objective

The aim was to examine the degree to which the search pattern described previously was specific to health-related information seeking or whether similar patterns could be found in other types of information-seeking behavior.

Methods

We extracted the number of searches performed on Wikipedia in the Norwegian language for 911 days for the most common sexually transmitted diseases (chlamydia, gonorrhea, herpes, human immunodeficiency virus [HIV], and acquired immune deficiency syndrome [AIDS]), other health-related topics (influenza, diabetes, and menopause), and 2 nonhealth-related topics (footballer Lionel Messi and pop singer Justin Bieber). The search dates were classified according to the day of the week and ANOVA tests were used to compare the average number of hits per day of the week.

Results

The ANOVA tests showed that the sexually transmitted disease queries had their highest peaks on Tuesdays (P<.001) and the fewest searches on Saturdays. The other health topics also showed a weekly pattern, with the highest peaks early in the week and lower numbers on Saturdays (P<.001). Footballer Lionel Messi had the highest mean number of hits on Tuesdays and Wednesdays, whereas pop singer Justin Bieber had the most hits on Tuesdays. Both these tracked search queries also showed significantly lower numbers on Saturdays (P<.001).

Conclusions

Our study supports prior studies finding an increase in health information searching at the beginning of the workweek. However, we also found a similar pattern for 2 randomly chosen nonhealth-related terms, which may suggest that the search pattern is not unique to health-related searches. The results are potentially relevant beyond the field of health and our preliminary findings need to be further explored in future studies involving a broader range of nonhealth-related searches.     

Is There Any Role of Positron Emission Tomography Computed Tomography for Predicting Resectability of Gallbladder Cancer?

The role of integrated ¹⁸F-2-fluoro-2-deoxy-D-glucose positron emission tomography computed tomography (PET-CT) is uncertain in gallbladder cancer. The aim of this study was to show the role of PET-CT in gallbladder cancer patients. Fifty-three patients with gallbladder cancer underwent preoperative computed tomography (CT) and PET-CT scans. Their medical records were retrospectively reviewed. Twenty-six patients underwent resection. Based on the final outcomes, PET-CT was in good agreement (0.61 to 0.80) with resectability whereas CT was in acceptable agreement (0.41 to 0.60) with resectability. When the diagnostic accuracy of the predictions for resectability was calculated with the ROC curve, the accuracy of PET-CT was higher than that of CT in patients who underwent surgical resection (P=0.03), however, there was no difference with all patients (P=0.12). CT and PET-CT had a discrepancy in assessing curative resection in nine patients. These consisted of two false negative and four false positive CT results (11.3%) and three false negative PET-CT results (5.1%). PET-CT was in good agreement with the final outcomes compared to CT. As a complementary role of PEC-CT to CT, PET-CT tended to show better prediction about resectability than CT, especially due to unexpected distant metastasis.

Graphical Abstract

相似文献   

Custodian of Oxygen Monitoring: Is There a Winner?

How to cite this article: Praveen Kumar G, Kakar V. Custodian of Oxygen Monitoring: Is There a Winner? Indian J Crit Care Med 2021;25(9):967–968.

Hypoxemia is extremely common in critically ill patients. In a multicenter study, over 50% of the patients evaluated had some degree of hypoxemia and close to 27% of the patients with hypoxemia died in the hospital.¹ This makes a point for close and continuous monitoring of patients with hypoxemia. Measuring peripheral oxygen saturation (SpO₂) by pulse oximetry and dissolved oxygen in the arterial blood (SaO₂) remains the most validated and common method for evaluating the degree of hypoxemia. Both the modalities have been used interchangeably for monitoring oxygen saturation, but PaO₂ measurements have been more widely accepted as a method to quantify the degree of hypoxemia and to titrate inspired oxygen levels.In a retrospective analysis, involving 300 patients, Sheetal Babu et al. showed that SF ratio can be used as an alternative to PF ratio in critically ill patients with hypoxic respiratory failure. Notably, a significant number of patients were on vasopressor and inotropic support when the measurements were made, highlighting the functionality of SpO₂ in patients with good peripheral perfusion. Rice and his colleagues described the relationship between the P/F and S/F ratios with a simple equation and showed that SF and PF ratios can be interchanged across varying degrees of hypoxemia with near accuracy.² Likewise, multiple researchers have tried to answer the same question, if SpO₂ can replace PaO₂ in critical care settings, and the answer is an overwhelming YES.^3–5Another part of the study was to establish cutoffs of SF ratio for various PF ratios. Even if the cutoffs were established, they had a lower sensitivity and specificity. SF ratio of 285 correlated with PF of 200, and SF ratio of 323 correlated with PF ratio of 300. The cutoffs though different when compared to other studies, they were definitely not disparate. The reason for varying values in different studies could be explained by the fact that SpO₂ remains the same for a wide range of PaO₂.In the study published in this edition of IJCCM, Sheetal Babu and his colleagues also tried to answer another pertinent question. If PF ratio can be replaced by SF ratio or SpO₂ unambiguously with different methods of oxygen supplementation. The answer again is an overwhelming YES. The answer remained YES for both invasive and noninvasive methods of oxygen supplementation.In the middle of the raging pandemic with thousands of patients on some form of oxygen supplementation, this study asks critical care physicians a cardinal question, and it questions the utility of arterial blood gases in measuring oxygenation and quantifying hypoxemia. The study and already existing literature are a testament to the fact that SpO₂ is a reliable indicator for tissue oxygenation. Restoring the utility and benefits of SpO₂ has limitless advantages. First, PaO₂ is a finer indicator of oxygen content in the blood, but SpO₂ also reflects upon tissue perfusion and oxygen delivery. Second, SpO₂ gives a continuous measure of tissue oxygen levels and thereby precludes the delays in decision-making based on PaO₂. Thirdly, in comparison to SpO₂, the use of arterial blood gases is invasive, expensive, and of limited utility in measuring oxygenation. Also, PaO₂-based interventions preludes to additional blood gas testing, thereby squandering resources. Fourth, albeit not yet validated, to quantify the degrees of hypoxemia and acute respiratory distress syndrome, SF ratio can be reliably used for therapeutic targets and clinical decision-making in intensive care settings. A worsening SF ratio can be reliably interchanged with the PF ratio for escalation of care in the pyramid for the treatment of hypoxic patients. Fifth, SpO₂ and SF ratio can be more appropriate in the middle of the pandemic when scores of patients need repeated assessments of oxygenation and the resources are scarce and limited.Since SpO₂ remains more than 90 for a very wide range of PaO₂, accepting a lower PaO₂ or late diagnosis of worsening hypoxemia is a concern while using SF ratios, and the concern is not without a merit. Thus, though SF ratio can be used as a surrogate for PF ratio in wide settings, when in doubt PaO₂ measurements using arterial blood gases should be considered. Also, multiple other drawbacks of pulse oximetry should be worth remembering.So, to answer the question in the title: Is there a custodian of oxygen monitoring? The answer can definitely not be a plain sailing. We would rather reframe the question and ask which modality among the two is more beneficial? And the answer is clearer and it is definitely SpO₂. Through the quotidian traffic of monitoring equipment available for intensive care physicians, SpO₂ remains the simplest way of measuring hypoxemia and still remains the only continuous monitoring device ubiquitously present. We would conclude by saying that taking the road not taken might be challenging and rewarding, but one should not forget that the road not taken is not taken for a reason, and knowing the reason before can prevent adversities. Measuring SF ratio is the road not taken, and the critical care physicians should know the reasons before driving down the road.     

What Is the Current Role of Algorithmic Approaches for Diagnosis of Clostridium difficile Infection?

With the recognition of several serious outbreaks of Clostridium difficile infection in the industrialized world coupled with the development of new testing technologies for detection of this organism, there has been renewed interest in the laboratory diagnosis of C. difficile infection. Two factors seem to have driven much of this interest. First, the recognition that immunoassays for detection of C. difficile toxins A and B, for many years the most widely used tests for C. difficile infection diagnosis, were perhaps not as sensitive as previously believed at a time when attributed deaths to C. difficile infections were showing a remarkable rise. Second, the availability of FDA-approved commercial and laboratory-developed PCR assays which could detect toxigenic strains of C. difficile provided a novel and promising testing approach for diagnosing this infection. In this point-counterpoint on the laboratory diagnosis of C. difficile infection, we have asked two experts in C. difficile infection diagnosis, Ferric Fang, who has recently published two articles in the Journal of Clinical Microbiology advocating the use of PCR as a standalone test (see this author''s references 12 and 28), and Mark Wilcox, who played a key role in developing the IDSA/SHEA guidelines on Clostridium difficile infection (see Wilcox and Planche''s reference 1), along with his colleague, Tim Planche, to address the following question: what is the current role of algorithmic approaches to the diagnosis of C. difficile infection?     

Is Anyone There? Use of the Telephone and Use of the Couch

Many therapists have been using the telephone for analytic sessions during the Covid 19 pandemic. This paper considers the ways in which the use of the telephone resembles the use of the couch and revisits the value of the couch in order to assess the value of the telephone. The questions raised are whether analytic therapists still find the use of the couch helpful, and if so why. This is then linked to the experience of using only the telephone. The paper considers the ways in which the two techniques increase or diminish shame and the willingness to disclose difficult material. An anonymized clinical illustration is used of a woman who began in face-to-face work with a purely practical problem, but in telephone sessions was able to acknowledge her need to understand her own mental state in order to be able to change at a deeper level. Conclusions are drawn about the positive usefulness of the telephone in contrast with the view that it is just the best that we can do in some circumstances.     

Does Fine-Needle Aspiration Cytology Optimize the Surgical Management of Thyroid Disorders in Endemic Goiter Region?

Aim The aim of this study was to determine the diagnostic value of fine-needle aspiration cytology (FNAC) before thyroidectomy in an endemic goiter region. Methods One hundred patients with preoperative FNAC of thyroid nodules who underwent thyroidectomy were recruited. FNAC were classified into five groups. 0, no thyroid cells; 1, normal thyroid cells; 2, degenerative thyroid cells without evidence of malignacy; 3, follicular or oncocytary neoplasia; and 4, malignant thyroid cells. FNAC was compared with postoperative histopathological diagnoses. Results Only 76% of the FNAC allowed an adequate cytological examination. In 15 patients (15%), carcinomas were found in the postoperative histopathological diagnosis (including four follicular carcinomas). In the 48 patients of FNAC groups 3 and 4, nine carcinomas (18.7%) were found (including four follicular carcinomas). In the 28 patients of groups 1 and 2, there was only one papillary carcinoma (3.5%). In the 24 patients of group 0, there were two papillary, two follicular, and one anaplastic carcinomas (total of 20.8%). The sensitivity, specificity, and likelihood ratio (LR) of the FNAC for benign nodules were 90%, 40.9%, 0.24, respectively. The LR for malignant nodules was 13.2, and that for follicular neoplasia was 0.55. Conclusions Despite the high prevalence of carcinoma in an endemic goiter region, FNAC disappointed its diagnostic expectation. The lower specificity of FNAC may be caused by a higher prevalence of thyroid nodules in an endemic goiter region or by the absence of a specialized cytopathologist. T. Osei-Agyemang and I. Hassan contributed equally to this work. Presented in part to Second Biennial Congress of the European Society for Endocrine Surgeons (ESES), May 18–20, 2006, Krakow (Poland)     

Is there a way for pathologists to decrease interobserver variability in the diagnosis of dysplasia?

Many obstacles interfere with our efforts to screen patients with Barrett esophagus. Probably the largest is choosing the appropriate patient group for screening. Beyond this problem, sampling error on the part of endoscopists is probably more serious a problem than observer variation among pathologists reviewing patient samples. Pathologists agree well on lesions that merit close follow-up or other intervention (high-grade dysplasia and invasive carcinoma), although interobserver agreement between pathologists interpreting lesser lesions is not good. This lack of agreement is not likely to improve substantially, and many adjunct markers are being sought in an attempt to identify patients with lesions of lower grades that are most likely to progress, allowing doctors to identify patients who would benefit from upgraded surveillance.     

Is the mouse a good model for the human with respect to the development of the preimplantation embryo in vitro?

A comparison has been made of various aspects of preimplantation development of mouse and human embryos in vitro. Changes in substrate utilization follow similar patterns in both species. This similarity in metabolic parameters between the two species has facilitated the use of the mouse as a model to study the formulation of culture media to be used at different stages over the preimplantation period from fertilization to the fully expanded blastocyst stage. It has also prescribed the mouse embryo as a practical tool for quality control testing of the laboratory system in human in-vitro fertilization. Aspects of the physiology of both species that require further study are the physiological levels of endogenous inorganic phosphate in the female reproductive tract, the requirement for inorganic phosphate in culture medium, the specificity of the amino acid requirements for optimal development before and after compaction and the importance of including EDTA in culture medium.     

Is there a role for palmitoylethanolamide in the treatment of depression?

Depression is a common brain disorder affecting about 350 million people worldwide. Although the pharmacological treatment currently available can produce benefits in the majority of cases, residual depressive symptoms, cognitive deficits, functional impairment, and increase in frequency of relapses are frequently present in unipolar and bipolar depressed patients correctly treated. In the last years, numerous evidences have demonstrated the involvement of endocannabinoid system in the pathophysiology of mood disorders. Considering the recent findings about the antidepressant effect of palmitoylethanolamide in animal model, we have hypothesized the potential antidepressant effect of this fatty acid amide in unipolar and bipolar depressed patients.     

Is there a critical period for the acquisition of segmental analysis?

Twelve Portuguese illiterate adults were required to delete the initial consonant of a spoken pseudoword and were provided with both explicit instructions and continuous corrective feedback. Nine of them displayed rapid improvements in performance. This suggests that there is no critical period for acquiring the ability of segmental analysis of speech.