Oral Squamous Cell Carcinomas Developing from Oral Lichen Planus: A 5–21 year Retrospective Study

Background and AimsThere is insufficient data regarding clinical characteristics, relapse rates, as well as lymph node metastasis of squamous cell carcinomas of the oral cavity (OSCC) developing from oral lichen planus (OLP-OSCC). The aim of this retrospective study was to evaluate clinical characteristics, as well as relapse, recurrence and survival rates of OLP-OSCC. MethodsIn a retrospective monocenter analysis, all consecutive patients with an OSCC treated in the time period 1st January 2000–December 31 2016 were reviewed. All patients with OSCC developing from OLP/OLL (oral lichenoid lesions) were identified and analyzed for epidemiological data, risk profile, location of primary tumor, pTNM classification, lymph node metastasis, primary therapy, recurrence, and outcome.ResultsA total of 103 patients (45%♂/ 55%♀) with an average age of 62 ± 14 year were included in this study. At the time of initial diagnosis, 17% (n = 18) of patients had cervical metastases (CM) whereas only 11% (11 patients) displayed advanced tumor sizes (T > 2). T-status (p = 0.003) and histopathological grading (p = 0.001) had an impact on the incidence of CM. 39.6% of the patients developed a relapse after an average of 24 months with a mean of two recurrences per patient. Advanced tumor size had a significant impact on the 5 year overall survival and was associated with disease-free survival of the patients (p < 0.001, respectively p = 0.004).ConclusionAlthough initial lymph node metastases were not more frequent, more aggressive recurrence patterns compared to OSCC were seen for OLP-OSCC. Therefore, based on the study results, a modified recall for these patients is suggested.     

The safety of synthetic colloid in critically ill patients with severe traumatic brain injuries

Purpose

Although 4% albumin is associated with increased mortality in patients with traumatic brain injury (TBI), evidence concerning the safety of synthetic colloids is lacking. We aimed to determine if there is an association between synthetic colloids and mortality in patients with severe TBI.

Materials and Methods

A retrospective cohort study of patients with severe TBI was conducted. Data were collected on all intravenous fluids administered during the first 14 days of admission. Multivariable Cox proportional hazards regression was used to model the association between daily cumulative pentastarch quintiles and mortality.

Results

Patients receiving pentastarch had higher Acute Physiology and Chronic Health II scores (23.9 vs 21.6, P < .01), frequency of craniotomy (42.5% vs 21.6%, P = .02), longer duration of intensive care unit stay (12 vs 4 days, P < .01), and mechanical ventilation (10 vs 3 days, P < .01). On unadjusted Cox regression, patients in the highest quintile of cumulative pentastarch administration had a higher rate of mortality compared with those receiving no colloid (hazard ratio, 3.8; 95% confidence interval, 1.2-12.4; P = .03). However, this relationship did not persist in the final multivariable model (hazard ratio 1.0; 95% confidence interval, 0.25-4.1; P = .98).

Conclusion

There was no association between cumulative exposure to pentastarch and mortality in patients with severe TBI.     

Markedly disturbed sleep in medically refractory compared to controlled epilepsy - a clinical and polysomnography study

PurposeTo evaluate sleep disturbances or sleep related events and their characteristics among patients with medically refractory epilepsy, compared to those with controlled epilepsy.MethodsIn a prospective case-controlled study, patients of medically refractory and controlled epilepsy were recruited and history pertaining to epilepsy and sleep related events and Epworth sleepiness scores were recorded and all patients underwent over night polysomnography.ResultsAmong 40 patients, 20 with medically refractory (Group 1) and 20 with controlled epilepsy (Group 2) (median age 18, range 10–35 years), the self reported sleep parameters in Group 1 patients were found to be significantly different as compared to Group 2, in terms of the duration of night time sleep, day time sleep, day time nap frequency, total sleep hours per day, excessive daytime sleepiness (EDS)(45% vs. 15%) and average sleep hours over the week prior to polysomnography. On PSG, Group 1 patients showed significantly less total sleep time [340.4 min (147–673) vs. 450.3 min (330–570)] with delayed sleep latency and REM latency, poor sleep efficiency [80.45 (40.5–98.0) vs. 95.45 (88.4–99.7)] and frequent arousals and wake after sleep onset (WASO) compared to Group 2 patients. Four patients (20%) in Group 1 compared to none in Group 2 were found to have mild obstructive sleep apnea.ConclusionsOur results indicate that medically refractory epilepsy patients believe that they spend more time sleeping, in contrast to the documented shorter sleep duration on polysomnography. This difference between perceived and actual sleep seems, by their data, to arise mainly from sleep fragmentation, disturbed architecture and the interesting finding of associated sleep apnea among the medically refractory epilepsy patients.     

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait

Aim Information on the timing and long‐term outcome of single‐event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single‐event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. Method We performed a retrospective analysis of the long‐term outcomes of single‐event multilevel surgery. Thirty‐two children (17 males, 15 females) who had received single‐event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo–15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single‐event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow‐up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow‐up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman’s rank correlation coefficient were used to prove the hypothesis. Results The older the child was at the time of the surgery, the better the long‐term result (_Age,Time=0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft‐tissue procedures performed initially as well as during the 10 years of follow‐up. Interpretation Children with CP who require single‐event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.     

First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children

Aim

The objective of this study is to report, for the first time, quantitative data on CPR quality during the resuscitation of children under 8 years of age. We hypothesized that the CPR performed would often not achieve 2010 Pediatric Basic Life Support (BLS) Guidelines, but would improve with the addition of audiovisual feedback.

Methods

Prospective observational cohort evaluating CPR quality during chest compression (CC) events in children between 1 and 8 years of age. CPR recording defibrillators collected CPR data (rate (CC/min), depth (mm), CC fraction (CCF), leaning (%> 2.5 kg.)). Audiovisual feedback was according to 2010 Guidelines in a subset of patients. The primary outcome, “excellent CPR” was defined as a CC rate ≥100 and ≤120 CC/min, depth ≥50 mm, CCF >0.80, and <20% of CC with leaning.

Results

8 CC events resulted in 285 thirty-second epochs of CPR (15,960 CCs). Percentage of epochs achieving targets was 54% (153/285) for rate, 19% (54/285) for depth, 88% (250/285) for CCF, 79% (226/285) for leaning, and 8% (24/285) for excellent CPR. The median percentage of epochs per event achieving targets increased with audiovisual feedback for rate [88 (IQR: 79, 94) vs. 39 (IQR 18, 62) %; p = 0.043] and excellent CPR [28 (IQR: 7.2, 52) vs. 0 (IQR: 0, 1) %; p = 0.018].

Conclusions

In-hospital pediatric CPR often does not meet 2010 Pediatric BLS Guidelines, but compliance is better when audiovisual feedback is provided to rescuers.     

Human Immunodeficiency Virus and Leprosy Coinfection in Pune,India

We report eight cases and the incidence of leprosy in human immunodeficiency virus (HIV)-infected individuals after initiation of antiretroviral treatment (ART). The incidence of leprosy in patients on ART was 5.22 per 1,000 person-years (95% confidence interval, 2.25 to 10.28). This high incidence suggests that there should be regular examination of HIV-infected individuals for clinical signs of leprosy.Although there is a declining trend in the global burden of leprosy, there are 15 countries in Asia and Africa which account for 94% of the global total of the new-case detection rate. India is one of the countries where ≥1,000 new cases of leprosy were reported during 2006 (14). Human immunodeficiency virus (HIV) and leprosy both are feared due to the associated social stigma, and leprosy can manifest as immune reconstitution inflammatory syndrome (IRIS) in HIV-infected individuals (9). The first case of leprosy-associated immune reconstitution disease was reported in 2003 for a Ugandan living in London, United Kingdom (5). Later leprosy was described as a manifestation of IRIS in many instances (8, 10).Antiretroviral treatment (ART) for HIV infection is now available in resource-poor regions where leprosy is still endemic, such as South America, Africa, and Asia, including India. India accounts for half of the world''s leprosy cases due to its population of more than 1 billion, even though a nationwide prevalence of less than 1 case/10,000 population was reported in 2005 (4). In addition, India also has the third largest burden of HIV-infected individuals (12). In spite of having a large burden of both leprosy and HIV, there are very few published reports of HIV-leprosy coinfection from India. We report eight cases of incident leprosy in HIV-infected patients who were on ART and the incidence of leprosy in HIV-infected individuals on ART.This report is from the Amrita Clinic of PRAYAS, a nongovernmental organization working on HIV/AIDS in Pune, in the state of Maharashtra, India. We retrospectively analyzed data on HIV-infected patients who initiated ART between January 2003 and December 2006 and we studied their follow-up till December 2007 to evaluate the incident cases of leprosy. ART was provided following the national guidelines for treatment of HIV infection (7).Diagnosis of leprosy was based on the clinical signs and symptoms and demonstration of acid-fast bacilli in the slit skin smears by Ziehl-Neelsen staining. All patients with leprosy received multidrug treatment per the WHO guidelines (15).Several definitions of IRIS have been utilized, each incorporating the general concept that cases of IRIS need to have an inflammatory component occurring in the setting of immune reconstitution that cannot be explained by drug toxicity or a new opportunistic infection (1, 6). We have considered leprosy manifestation after starting ART with increase in CD4⁺ cell count, inflammatory response as seen by neuritis, type I or type II leprosy reaction, or need for the use of steroids for the control of inflammation as a criterion for defining leprosy manifestation as IRIS. Statistical analysis was done using STATA (version 8.0).Between January 2003 and December 2006, among the 1,002 HIV-infected patients who started ART for HIV infection and were followed up till December 2007, eight incident cases of leprosy were detected. None of them had clinical evidence of leprosy at the time of initiation of ART. Table ​Table11 describes the details of these eight patients. All the patients except for one were males, and the mean age of the patients with leprosy was 33.8 years (standard deviation [SD], 5.1 years; range, 27 to 42 years). Four patients had paucibacillary leprosy, and four patients had multibacillary leprosy. The mean CD4⁺ cell count of incident leprosy cases was 326 (median, 245; SD, 255.5; range, 99 to 892). Of these eight patients, three had other opportunistic infections such as pulmonary tuberculosis, abdominal tuberculosis, and herpes zoster. The mean number of months to develop leprosy after starting ART was 13.8 months (SD, 14.3 months; range, 2 to 43 months). All eight patients completed their leprosy treatment and recovered completely. Although eight patients developed incident leprosy, six of them developed leprosy within 2 years of starting ART and two patients had delayed manifestations, with one patient developing leprosy after 28 months and the other after 43 months. These 1,002 patients on ART contributed to 1,532.5 person-years, and hence, the overall incidence of leprosy after starting ART was 5.22 per 1,000 person-years (95% confidence interval, 2.25 to 10.28).

TABLE 1.

Details of HIV-infected patients on ART with incident leprosy^a