The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia

During upper gastrointestinal endoscopy, topical oropharyngeal anesthesia with lidocaine and/or benzocaine is used routinely by many endodscopists. Although such a practice is usually safe, there have been a number of reports of methemoglobinemia induced by topical anesthesia. Early treatment is extremely important as the development of methemoglobinemia is potentially fatal. Methemoglobinemia should be considered when oxygen desaturation occurs without another explanation. In this case series, we report 4 cases of methemoglobinemia that followed the liberal application of Cetacaine for ERCP. All patients recovered after appropriate treatment but these cases serve to highlight the potential problem, the importance of early recognition and treatment, and the most appropriate treatment options.     

Fatty acid composition of liver triglycerides in various stages of fat deposition in the parenchyma

Summary In 30 diabetic inpatients the fatty acid pattern of triglycerides in parenchymal liver cells was studied by gas-liquid chromatography. With increasing size of fat droplets, a significant increase in the proportion of palmitic and oleic acid was observed as well as a significant fall of arachidonic (C 20: 4) and eicosapentaenoic acid (C 20: 5).     

PD-L1 – inhibitors in neuroendocrine neoplasia: Results from a real-life study

Immune check-point inhibitors (ICIs) have changed our view on how to treat cancer. Despite their approval in treatment of many different cancers, efficacy of immune check-point inhibitors (ICI) in neuroendocrine neoplasia is limited and poorly understood. Established treatment options of neuroendocrine tumors (NET) and neuroendocrine carcinomas (NECs) are based on surgery, tumor-targeted medical treatments, Peptide Receptor Radionuclide Therapy (PRRT), and locoregional therapies. However, in many patients these treatments lose efficacy over time, and novel therapies are urgently needed. We report on 8 patients diagnosed with neuroendocrine neoplasms (NEN) that were treated with ICI (pembrolizumab, avelumab, nivolumab plus ipilimumab) as salvage therapy. In this cohort, we observed tumor response with partial remission in 3 patients and stable disease in 1 patient. Four patients showed progressive disease. Of note, responses were observed both in PD-L1 positive and PD-L1 negative patients. Here, we discuss clinical courses of these patients in the context of available literature to highlight limitations and drawbacks currently preventing the use of ICI in routine management of patients with NEN.     

Platelet-rich plasma in the foot and ankle

Purpose of review

Platelet-rich plasma has become an increasingly popular treatment option within the orthopedic community to biologically enhance and stimulate difficult-to-heal musculoskeletal tissues. This review evaluates the recent literature on platelet-rich plasma use in the treatment of foot and ankle pathologies.

Recent findings

Recent literature has demonstrated platelet-rich plasma to have a possible benefit in the treatment of Achilles pathology, chronic plantar fasciitis, osteochondral lesions of the talus, ankle osteoarthritis, and diabetic foot ulcers. However, given the lack of standardization of platelet-rich plasma preparations and protocols and the predominance of low-quality studies, no definitive treatment indications exist.

Summary

Platelet-rich plasma is a promising treatment option, but at present, there is only limited clinical evidence supporting its use in foot and ankle applications.

     

Phytomedicines in Acute Rhinosinusitis: A Prospective,Non-interventional Parallel-Group Trial

Introduction

The objective of this prospective, multicenter, parallel-group, non-interventional clinical trial (NIT) was to characterize the effectiveness of a treatment with the phytomedicines ELOM-080 and BNO 1016 in patients with acute rhinosinusitis (ARS).

Methods

A total of 228 patients suffering from ARS took part in this NIT and were treated for a maximum of 14 days with either BNO 1016 or ELOM-080. Focus was on improvement of rhinosinusitis-associated pain/discomfort and nasal congestion in real-life conditions of primary care setting, as assessed by numeric and verbal rating scale, and five-point Likert scale.

Results

The course of the key ARS symptom facial pain demonstrated a faster recovery in patients with ELOM-080, when compared to BNO 1016. ELOM-080 tended to be superior for several ancillary criteria and induced significantly higher patient satisfaction with regard to the improvement of feeling of general illness. Physicians assessed both products to be very effective and well tolerated. Adverse drug reactions classified as gastrointestinal disorders occurred in both groups to a comparable extent.

Conclusion

This trial demonstrated comparable effectiveness of a therapy of ARS with the phytomedicines ELOM-080 and BNO 1016, although the treatment with ELOM-080 resulted in a more rapid and more complete recovery in ARS key symptoms and tended to be superior for several ancillary criteria. Both treatments were well tolerated.

Trial registration number

NIS-6471.

Funding

G. Pohl-Boskamp GmbH & Co. KG.

     

Bacterial contamination of urine, collected in fractions from different phases of micturition. A study in healthy women.

With a special technique 4-13 consecutive fractions of urine were collected during micturition from 4 female volunteers at together 12 occasions. Quantitative bacterial cultures were performed in 78 urine fractions. Most fractions contained one or several different bacterial strains-generally in small amounts, wheras only 14% were sterile. Fractions from the end of micturition showed on average less bacterial contamination than the earlier portions. No difference was observed between the bacterial counts after cleaning the area around the urethra as compared with the counts without preparation before sampling.     

Effect of afterload reduction on plasma volume during acute heart failure

Previous investigations in our unit indicated that acute cardiogenic pulmonary edema is associated not only with an increase in left ventricular end-diastolic pressure and pulmonary arterial wedge pressure but also with a relative increase in colloid osmotic (oncotic) pressure and peripheral hemoglobin concentration. This combination of changes suggested that acute congestive heart failure with pulmonary edema, unlike chronic congestive heart failure, is associated with a contraction of intravascular blood volume. In this study, plasma volume changes were measured before and during the treatment of acute cardiogenic pulmonary edema in 14 patients with arteriosclerotic heart disease. The plasma volume measurement in all 14 patients before the initiation of treatment was either normal or decreased. After treatment with the alpha adrenergic blocking agent phentolamine, the plasma volume increased rather than decreased when measured 4 and 12 hours after the initiation of treatment. During this time colloid osmotic pressure and peripheral hemoglobin concentration progressively decreased. These findings suggest that acute cardiogenic pulmonary edema is associated with the extravasation of large quantities of plasma water from the intravascular compartment into the interstitial compartment and contraction of the intravascular plasma volume. The treatment of acute cardiogenic pulmonary edema is associated with the return of hypo-oncotic fluid from the interstitial compartment back into the intravascular compartment with expansion of plasma volume and reduction of colloid osmotic pressure and hemoglobin concentration.     

Difference in development of medullary thyroid carcinoma among carriers of RET mutations in codons 790 and 791

Objectives Hereditary medullary thyroid carcinoma (MTC) is caused by germ‐line mutations in the RET proto‐oncogene. Our study addresses the difference in development of MTC between rare mutations in RET codons 790, 791 and 804. Design We evaluated tumour stage, calcitonin levels, biochemical cure rates and associated endocrinopathies in 153 German/Austrian patients with RET 790 (n = 47), 791 (n = 56) and 804 mutations (n = 50), divided into index‐ and screening groups. Results Age at diagnosis in index‐patients did not differ significantly among the three codon groups (medians of 57, 61 and 53 years). Tumour stage at diagnosis was significantly less advanced with codon 791 (n = 22) than 790 (n = 16) and 804 (n = 16) mutations (P = 0·001). In screening patients, age at diagnosis did not differ significantly among the three groups (medians 19, 24 and 32 years). Tumour stage at diagnosis was also significantly less advanced with codon 791 (n = 34) than 790 (n = 31) and 804 (n = 34) (P = 0·032). Preoperative basal calcitonin levels were significantly lower in codon 791 carriers compared to codon 790 carriers, and cure rates were significantly higher in both index (75%vs. 31%; P = 0·03) and screening patients (100%vs. 75%; P = 0·015). Additional endocrinopathies were observed only with codon 791 carriers (four pheochromocytomas and two hyperparathyroidism). Conclusion There is a significant difference in MTC development with less extensive C‐cell disease, higher cure rate and more frequent additional endocrinopathies in carriers of RET codon 791 mutations compared with carriers of codons 790 and 804 mutations. This information should be considered when age of prophylactic thyroidectomy is discussed.