Clinical characteristics,pathophysiology, and management of noncentral nervous system cancer‐related cognitive impairment in adults

Answer questions and earn CME/CNE Over the past few decades, a body of research has emerged confirming what many adult patients with noncentral nervous system cancer have long reported—that cancer and its treatment are frequently associated with cancer‐related cognitive impairment (CRCI). The severity of CRCI varies, and symptoms can emerge early or late in the disease course. Nonetheless, CRCI is typically mild to moderate in nature and primarily involves the domains of memory, attention, executive functioning, and processing speed. Animal models and novel neuroimaging techniques have begun to unravel the pathophysiologic mechanisms underlying CRCI, including the role of inflammatory cascades, direct neurotoxic effects, damage to progenitor cells, white matter abnormalities, and reduced functional connectivity, among others. Given the paucity of research on CRCI with other cancer populations, this review synthesizes the current literature with a deliberate focus on CRCI within the context of breast cancer. A hypothetical case‐study approach is used to illustrate how CRCI often presents clinically and how current science can inform practice. While the literature regarding intervention for CRCI is nascent, behavioral and pharmacologic approaches are discussed. CA Cancer J Clin 2015;65: 123–138. © 2014 American Cancer Society.     

Human saliva stimulates skin and oral wound healing in vitro

Despite continuous exposure to environmental pathogens, injured mucosa within the oral cavity heals faster and almost scar free compared with skin. Saliva is thought to be one of the main contributing factors. Saliva may possibly also stimulate skin wound healing. If so, it would provide a novel therapy for treating skin wounds, for example, burns. This study aims to investigate the therapeutic wound healing potential of human saliva in vitro. Human saliva from healthy volunteers was filter sterilized before use. Two different in vitro wound models were investigated: (a) open wounds represented by 2D skin and gingiva cultures were used to assess fibroblast and keratinocyte migration and proliferation and (b) blister wounds represented by introducing freeze blisters into organotypic reconstructed human skin and gingiva. Re‐epithelialization and differentiation (keratin K10, K13, K17 expression) under the blister and inflammatory wound healing mediator secretion was assessed. Saliva‐stimulated migration of skin and oral mucosa fibroblasts and keratinocytes, but only fibroblast proliferation. Topical saliva application to the blister wound on reconstructed skin did not stimulate re‐epithelization because the blister wound contained a dense impenetrable dead epidermal layer. Saliva did promote an innate inflammatory response (increased CCL20, IL‐6, and CXCL‐8 secretion) when applied topically to the flanking viable areas of both wounded reconstructed human skin and oral mucosa without altering the skin specific keratin differentiation profile. Our results show that human saliva can stimulate oral and skin wound closure and an inflammatory response. Saliva is therefore a potential novel therapeutic for treating open skin wounds.     

Evaluating asymmetry in prosthetic gait with step-length asymmetry alone is flawed

Prosthetic gait is often asymmetric in step length, but the direction of this asymmetry varies inconsistently across amputees. This situation is akin to that seen in stroke patients, where step-length asymmetry has been shown to be the additive result of asymmetries in trunk progression and asymmetries in forward foot placement relative to the trunk. The present study examined the validity of this notion in three trans-tibial and seven trans-femoral amputees wearing a unilateral prosthesis while walking over a walkway at a comfortable and slower-than-comfortable speed. The latter manipulation was added to examine the expectation that the magnitude of the trunk-progression asymmetry - attributable to a weaker propulsion generating capacity on the prosthetic side - would be smaller when walking slower because of the diminished propulsion demands. Step length, forward foot placement relative to the trunk, and trunk progression of prosthetic and non-prosthetic steps, as well as asymmetries therein, were quantified. The direction of step-length and forward foot placement asymmetries varied inconsistently across (but consistently within) participants. As expected, step-length asymmetry depended on the combination of asymmetries in forward foot placement and trunk progression, with a smaller contribution of trunk-progression asymmetry at slow speed. These results extend our previous finding for hemiplegic patients that an analysis of gait asymmetry in terms of step length alone is flawed to prosthetic gait, implying that knowledge of asymmetries in trunk progression and forward foot placement relative to the trunk is required to help elucidate the contribution of underlying impairments (viz. propulsion generating capacity) and adopted compensations on prosthetic gait asymmetry.     

Less adhesiolysis and hernia repair during completion proctocolectomy after laparoscopic emergency colectomy for ulcerative colitis

Background  

The aim of this study was to determine whether the need for adhesiolysis during completion proctectomy (CP) with ileopouch anal anastomosis (IPAA) is influenced by the surgical approach of the initial emergency colectomy for ulcerative colitis and the hospital setting.     

Incidence,risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis: a systematic review

Introduction

Critically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly atrial fibrillation (AF). Systemic inflammation, circulating stress hormones, autonomic dysfunction, and volume shifts are all possible triggers for AF in this setting. We conducted a systematic review to describe the incidence, risk factors and outcomes of new-onset AF in patients with sepsis.

Methods

MEDLINE, EMBASE and Web Of Science were searched for studies reporting the incidence of new-onset AF, atrial flutter or supraventricular tachycardia in patients with sepsis admitted to an intensive care unit, excluding studies that primarily focused on postcardiotomy patients. Studies were assessed for methodological quality using the GRADE system. Risk factors were considered to have a high level of evidence if they were reported in ≥2 studies using multivariable analyses at a P value <0.05. Subsequently, the strength of association was classified as strong, moderate or weak, based on the reported odds ratios.

Results

Eleven studies were included. Overall quality was low to moderate. The weighted mean incidence of new-onset AF was 8% (range 0 to 14%), 10% (4 to 23%) and 23% (6 to 46%) in critically ill patients with sepsis, severe sepsis and septic shock, respectively. Independent risk factors with a high level of evidence included advanced age (weak strength of association), white race (moderate association), presence of a respiratory tract infection (weak association), organ failure (moderate association), and pulmonary artery catheter use (moderate association). Protective factors were a history of diabetes mellitus (weak association) and the presence of a urinary tract infection (weak association). New-onset AF was associated with increased short-term mortality in five studies (crude relative effect estimates ranging from 1.96 to 3.32; adjusted effects 1.07 to 3.28). Three studies reported a significantly increased length of stay in the ICU (weighted mean difference 9 days, range 5 to 13 days), whereas an increased risk of ischemic stroke was reported in the single study that looked at this outcome.

Conclusions

New-onset AF is a common consequence of sepsis and is independently associated with poor outcome. Early risk stratification of patients may allow for pharmacological interventions to prevent this complication.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0688-5) contains supplementary material, which is available to authorized users.     

Histological characteristics and prognosis in patients with fatty liver

OBJECTIVE: The clinical-pathological spectrum of fatty liver ranges from simple steatosis to end-stage fibrotic liver disease. However, no histological characteristics have been identified that can predict progression from pure steatosis to fibrotic liver disease in non-alcoholic fatty liver disease. The objective of this study was to investigate whether histological characteristics in patients with fatty liver without inflammation could predict mortality or development of cirrhosis. MATERIAL AND METHODS: A total of 417 patients had a liver biopsy performed, which showed fatty liver without inflammation. The population consisted of 170 non-alcoholic and 247 alcoholic fatty liver patients. The study cohort was linked through their unique personal identification number to The National Registry of Patients and the nationwide Registry of Causes of Death. RESULTS: Median follow-up time was 19.9 years in the non-alcoholic group and 12.8 years in the alcoholic group. Overall mortality in the non-alcoholic group was not related to morphological findings in the index liver biopsy. Mortality was significantly (p < 0.05) higher in alcoholic patients with severe steatosis. One non-alcoholic patient (0.6%) developed cirrhosis versus 54 alcoholic patients (22%) during the follow-up period. CONCLUSIONS: In patients with non-alcoholic fatty liver without inflammation, patients at risk for premature death cannot be identified by histological characteristics in the index liver biopsy. Patients with alcoholic fatty liver have a high risk for development of cirrhosis and increased mortality with the severity of steatosis in the index liver biopsy.     

Bleomycin-induced changes in the carbon monoxide transfer factor of the lungs and its components

To study subclinical pulmonary toxicity of bleomycin we measured the single-breath carbon monoxide transfer factor (TLCO) and its components, pulmonary capillary blood volume (Vc), diffusing capacity of the alveolar-capillary membrane (Dm), and vital capacity (VC) in a homogenous group of 18 patients with testicular nonseminomatous germ cell tumor treated with bleomycin, vinblastine, and cis-diammine-dichloroplatinum (DDP). The most prominent finding was a substantial decrease in Vc (p less than 0.001) with only minor, though significant, changes in the other parameters. No recovery of pulmonary function had taken place 4 months after the last dose of bleomycin. The importance of correcting TLCO for hemoglobin concentration is shown. We conclude that vascular damage may be an important feature of subclinical pulmonary injury caused by bleomycin given in combination with vinblastine and DDP. In the postbleomycin phase, other forms of potentially lung-toxic treatment should be instituted with care.     

Single versus multimodality training basic laparoscopic skills

Introduction

Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills.

Methods

Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S) (n?=?18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M) (n?=?18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks?+?one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test.

Results

Both groups improved their performance significantly (Wilcoxon signed-rank, P?U test, P?>?0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P?≤?0.05), which can be explained by the fact that they were much more familiar with these tasks.

Conclusions

Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.     

The availability,condition and employability of automated external defibrillators in large city centres in the Netherlands

Background

In the Netherlands there are, at the time of writing, no clear guidelines about the implementation of automated external defibrillators (AEDs). An observational study was conducted to investigate the current status of AEDs in city centres in the Netherlands looking specifically at the availability, condition and employability of the AEDs.

Methods and results

The shopping areas in the old city centres of the six largest cities in the Netherlands were included in the study. After the AEDs had been identified, a questionnaire was used to determine the availability, condition and employability of the AED. In total 130 AEDs were found and 122 included in the study. The following results were found: 40% of the AEDs were not visible (range 21–64), 29% were not indicated with a sign (range 19–41), 7% had an empty battery (range 0–23), 16% of the defipads had expired (range 0–31) and in 98% of the AEDs a trained employee was present (range 96–100). After combining these results, 71% of the AEDs were available for use (range 61–93), 70% were in a good condition (range 46–82) and 70% were employable (range 58–93). The results show a major variability between cities.

Conclusion

Our study demonstrates that although national guidelines have not been implemented, a reasonable amount of AEDs can be found. However there is certainly room for improvement in the current availability, condition and employability of AEDs in city centres in the Netherlands.