Effects of sinus surgery in patients with cystic fibrosis after lung transplantation: a 10-year experience

Chronic infectious rhinosinusitis with Pseudomonas aeruginosa is common in cystic fibrosis and may result in allograft infection after lung transplantation. Sinus surgery followed by nasal care may reduce these adverse effects. Sinus surgery was performed in 37 patients with cystic fibrosis after transplantation. Bacteriology of sinus aspirates (n=771) and bronchoalveolar lavage (BAL) (n=256) was correlated with clinical data. Sinus surgery was successful in 54% and partially successful in 27% of patients. A significant correlation between negative sinus aspirates and negative BAL and between positive sinus aspirates and positive BAL (P<0.0001) was found. Successful sinus management led to a lower incidence of tracheobronchitis and pneumonia (P=0.009) and a trend toward a lower incidence of bronchiolitis obliterans syndrome (P=0.23). Sinus surgery followed by daily nasal douching may control posttransplant lower airway colonization and infection. In the long term, this concept may lead to less bronchiolitis obliterans syndrome by decreasing bronchiolar inflammation.     

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway

Objective

To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management.

Methods

Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO₂ reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared.

Results

A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic = 1; range = 1-7). The overall placement success rate was virtually equal across the two groups (ETI = 80.2%, King LTS-D = 80.5%; p = 0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI = 19.5 s vs. King LTS-D = 20.0 s; z = −0.25; p = 0.80).

Conclusion

In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.     

Side effects of mandibular advancement devices for sleep apnea treatment.

Our purpose was to investigate side effects of sleep apnea treatment by removable oral appliances (OA) that advance the mandible. In 22 patients suffering from obstructive sleep apnea (OSA), questionnaire evaluations, polysomnographies, cephalographies, and dental plaster casts were obtained before initiation of treatment with OA that fully covered both dental arches. Patients were reevaluated after 3 to 12 mo (questionnaires, polysomnographies) and 12 to 30 mo (questionnaires, cephalographies, plaster casts) during continuous treatment. Polysomnographies confirmed improved breathing by OA. All patients experienced persistent alleviation of symptoms after 12 to 30 mo and wished to continue treatment. Side effects were common but only mildly disturbing: mucosal dryness (86% of patients), tooth discomfort (59%), and hypersalivation (55%). Cephalographies revealed a decrease in the mean (+/- SE) upper incisors to maxillary plane angle from 102 +/- 2 degrees at baseline, to 101 +/- 2 degrees after 12 to 30 mo (p < 0.05). Overbite and overjet were also slightly (mean reduction < 1 mm) but significantly reduced. None of these side effects required discontinuation of treatment. OA are an effective therapy of obstructive sleep apnea. Mild side effects are common but rarely require intervention. Nevertheless, close follow-up during long-term therapy by OA is advisable in order to timely detect potentially relevant orthodontic changes.     

Ipilimumab in real-world clinical practice: efficacy and safety data from a multicenter observational study

In patients with metastatic melanoma, ipilimumab has been shown to improve long-term survival. This observational multicenter study reports clinical outcomes of 418 patients treated with second-line ipilimumab from February 2013 to August 2014. Median overall survival (OS) was 6.43 months (95%CI: 5.45–7.42; n = 300), while median progression-free survival (PFS) was 3.7 months (95%CI: 3.23–4.17; n = 188). Demographic factors, such as sex or number of previous therapies did not affect OS. Survival was shorter in patients with ECOG > 0 (Eastern Cooperative Oncology Group, Performance Status) (p < 0.001), while a longer OS was found in patients who completed all four therapy cycles (p < 0.001). Adverse events of any grade were reported for 66% of patients (mainly cutaneous and gastrointestinal), but most were low grade and easily managed. Adverse events of grades 3–4 were observed in 13% of patients. This study confirmed the efficacy and safety of this treatment in real practice.     

High permeability pulmonary edema (ARDS) during tocolytic therapy--a case report

A 26 year old previously healthy woman who was treated with fenoterol for premature labor at 30 gestational weeks developed pulmonary edema requiring intubation and mechanical ventilation. Vaginal delivery was accomplished with forceps after tocolytic therapy had been stopped. Right heart catheterization with measurement of pulmonary wedge pressure did not reveal left ventricular failure. Protein determination in lung edema fluid provided evidence of increased pulmonary capillary permeability. Recovery was rapid and ventilatory support was stopped after 36 hours. It is suggested that the infusion of beta-sympathomimetic drugs may alter the permeability of the alveolar-capillary membranes which together with triggering factors such as fluid overload might lead to clinically manifest pulmonary edema.     

Cytotoxicity of ketoconazole in malignant cell lines

Summary The cytotoxic effects of ketoconazole, an antifungal agent known to have some activity against human prostate cancer, adrenal cancer, and male metastatic breast cancer, were evaluated using colony-growth and clonogenic assays in eight malignant cell lines. The cytotoxicity of ketoconazole showed a dose-and time-dependent pattern, with the following concentrations, inhibiting 90% of the growing colonies (IC₉₀): MCF 7 (human breast cancer) 7.25 g/ml, T 47 D (human breast cancer) 9.0 g/ml, MiaPaCa (human pancreatic carcinoma) 10.0 g/ml, COLO 357 (human pancreatic carcinoma) 9.5 g/ml, HCT 8 (human colonic adenocarcinoma) 27.1 g/ml, DU 145 (human prostatic cancer) 40.0 g/ml, AR 42 J (rat pancreatic carcinoma) 9.0 g/ml, and L1210 (murine leukemia) 8.6 g/ml. Since a concentration of 10 g/ml can be achieved in humans, the use of ketoconazole in human malignancies might be worthy of clinical evaluation.This investigation was supported in part by a grant from the German Volkswagen Foundation, Hannover, Federal Republic of Germany and by a gift from Dr Virgil Gianelli, Stockton, California     

Association between pre-treatment perfusion profile and cerebral edema after reperfusion therapies in ischemic stroke

The relationship between reperfusion and edema is unclear, with experimental and clinical data yielding conflicting results. We investigated whether the extent of salvageable and irreversibly-injured tissue at baseline influenced the effect of therapeutic reperfusion on cerebral edema. In a pooled analysis of 415 patients with anterior circulation large vessel occlusion from the Tenecteplase-versus-Alteplase-before-Endovascular-Therapy-for-Ischemic-Stroke (EXTEND-IA TNK) part 1 and 2 trials, associations between core and mismatch volume on pre-treatment CT-Perfusion with cerebral edema at 24-hours, and their interactions with reperfusion were tested. Core volume was associated with increased edema (p < 0.001) with no significant interaction with reperfusion (p = 0.82). In comparison, a significant interaction between reperfusion and mismatch volume (p = 0.03) was observed: Mismatch volume was associated with increased edema in the absence of reperfusion (p = 0.009) but not with reperfusion (p = 0.27). When mismatch volume was dichotomized at the median (102 ml), reperfusion was associated with reduced edema in patients with large mismatch volume (p < 0.001) but not with smaller mismatch volume (p = 0.35). The effect of reperfusion on edema may be variable and dependent on the physiological state of the cerebral tissue. In patients with small to moderate ischemic core volume, the benefit of reperfusion in reducing edema is related to penumbral salvage.     

German version of the Epworth Sleepiness Scale.

BACKGROUND: The Epworth Sleepiness Scale (ESS) is a questionnaire widely used in English speaking countries for assessment of subjective daytime sleepiness. OBJECTIVE: Our purpose was to translate and validate the ESS for use in German-speaking countries. METHODS: A German translation of the ESS was administered to 159 healthy German-speaking Swiss and to 174 patients with various sleep disorders. RESULTS: The mean +/- SD of ESS scores in normals was 5.7+/-3.0, in patients it was 13.0+/-5.1 (p<0.001). Scores were not correlated with age or gender but with the percentage of time spent at an oxygen saturation <90% (R = 0.35, p<0.001), and the respiratory disturbance index (R = 0.26, p<0.001) in primary snorers and sleep apnea patients. Item analysis confirmed internal consistency of the scale (Cronbach alpha = 0.60 in normals, and 0.83 in patients). Follow-up scores in 25 sleep apnea patients on treatment showed a reduction by 7+/-5 points (p<0.05). CONCLUSIONS: Our data validate the ESS for application in German-speaking populations. The simplicity, reliability and the apparent lack of relevant influences of language and cultural background on performance of the ESS makes it a valuable tool for clinical management and research.     

Detection of inspiratory flow limitation during sleep by computer assisted respiratory inductive plethysmography.

The potential of respiratory inductive plethysmography (RIP) to detect inspiratory flow limitation during sleep was investigated. Sixteen sleep apnoea patients underwent polysomnography. Airflow by a flowmeter attached to a nasal mask, oesophageal and mask pressure were recorded along with calibrated RIP. Presence of inspiratory flow limitation was defined by constant or decreasing flow without pressure dependence throughout significant portions of inspiration, its absence by a linear or mildly alinear pressure:airflow relationship. Based on this standard, three of various computerized RIP derived parameters, with highest performance to detect flow limitation, were identified. They were combined to an inspiratory flow limitation, (IFL)-Index(RIP), which was validated prospectively in another 10 sleep apnoea patients. RIP derived fractional inspiratory time, peak to mean inspiratory flow ratio, and ribcage contribution to tidal volume had the highest accuracy to detect flow limitation (area under the receiver operating characteristic (ROC) curves 0.81, 0.76, 0.76, respectively, 160 comparisons). Prospective validation revealed an area under the ROC curve for the IFL-Index(RIP) to detect flow limitation of 0.89 (95% confidence interval 0.85 to 0.93, 200 comparisons) with sensitivity and specificity at the point of equality of 80%. It is concluded that inspiratory flow limitation may be assessed by computer assisted analysis of respiratory inductive plethysmography derived breathing patterns with clinically acceptable accuracy.