Dexamethasone and perioperative blood glucose in patients undergoing total joint arthroplasty: A retrospective study

Study objectivePerioperative dexamethasone is commonly used to prevent nausea. It can also increase blood glucose levels, and recent concern about its blood glucose-elevating effect in humans has been raised. This study aimed to demonstrate relationships between dexamethasone administration and elevated perioperative blood glucose in patients undergoing total joint arthroplasty.DesignRetrospective study.SettingAcademic, orthopedic hospital.PatientsA total of 625 patients (18–99 years) who underwent total hip or total knee arthroplasty with an ASA ≤ 3 were included in the study.InterventionsPatients who received dexamethasone perioperatively were compared to those who did not receive dexamethasone.MeasurementsThe primary outcome, which was any postoperative glucose > 200 mg/dl, was compared between groups using multiple logistic regression. Demographic information, intraoperative information, incidence of postoperative nausea and vomiting, white blood cell count, medication use, and length of stay were also collected.Main resultsPerioperative dexamethasone (median [1st quartile, 3rd quartile] dose = 4 [4, 8] mg) was administered to 76% of patients. Only 5.6% (95% CI: 3.8–7.5) of patients had postoperative glucose levels > 200 mg/dl. After covariate adjustment, there was no evidence of a difference in odds of experiencing postoperative glucose levels > 200 mg/dl (odds ratio [95% CI]: 0.76 [0.28–2.07]; P = 0.594) and maximum glucose levels (P = 0.518) between groups. Dexamethasone-treated patients had greater changes in white blood cell count between baseline and postoperative days 0–1. There was no evidence of a difference in wound healing and length of stay between groups.ConclusionsThere was no evidence of an association between perioperative dexamethasone administration and the odds of having postoperative glucose levels > 200 mg/dl or higher maximum glucose levels. However, these findings may not be generalizable to patients having different baseline characteristics or procedures.     

Environmental factors and incidence of dengue fever and dengue haemorrhagic fever in an urban area, Southern Thailand

Using the enumeration district (ED) block level this study looked at the incidence of dengue fever and dengue haemorrhagic fever (DF/DHF) within the Songkhla municipality in Thailand. Each of the 146 blocks in this area were considered as study units and surveyed for their environmental characteristics. A total of 287 cases of DH/DHF occurring in the year 1998 were selected for this study and the location of their homes mapped. Clustering analysis showed point clustering of the homes (P<0.0001) which was probably due to high density habitation, without any actual prevalence of case clustering. There was no evidence of clustering of the ED blocks with an incidence of DF/DHF (P=0.32). DF/DHF incidence for each block was strongly associated with the percentages of shop-houses, brick-made houses and houses with poor garbage disposal (all P<0.01). DF/DHF control should be emphasized for the areas which have a predominance of these housing types.     

Prognostic significance of Bax, Bcl-2, and p53 expressions in cervical squamous cell carcinoma treated by radiotherapy

OBJECTIVE: The objective was to determine the prognostic significance of the immunohistochemical expressions of Bax, Bcl-2, and p53 in squamous cell carcinoma of the uterine cervix treated by radiotherapy alone. METHODS: One hundred and seventy-four cases of squamous cell carcinoma of the cervix (stage Ib-IVa) diagnosed between January 1996 and December 1998 were investigated for Bax, Bcl-2, and p53 expressions and were correlated to the patients' survival. RESULTS: The mean age of the patients was 54.1 with a range of 29-82 years. There were 23 cases with stage I (13.2%), 99 stage II (56.9%), 51 stage III (29.3%), and 1 case with stage IV (0.6%). The 5-year disease-free survival (DFS) was 70.50% and overall survival (OS) was 65.95%. Bax, Bcl-2, and p53 expressions were seen in 68.4%, 25.9%, and 77.6% of cases, respectively. In multivariate analysis by Cox's regression, age, stage, Bax, and Bcl-2 expressions appeared to be independent prognostic predictors of DFS. Bax expression was associated with good survival (hazard ratio, 0.47) while Bcl-2 expression was associated with poor survival (HR, 2.51). In addition, a combination of Bcl-2+/Bax+ was significantly associated with poorer DFS compared to Bcl-2-/Bax+ (HR 3.55). However, none of the markers or combinations was associated with OS. CONCLUSIONS: Evaluation of Bax and Bcl-2 expressions and their co-expression provide independent prognostic information for the clinical course of the disease and therefore could be developed as a prognostic indicator for cervical cancer.     

Update on endoscopic enteral access

Enteral access is a common procedure in managing patients in need of enteral nutrition and decompression. Enhancements of technology and improvements in operator skills have resulted in the development of several techniques of enteral access including endoscopic-guided, imaging-guided, laparoscopic-assisted, or combined techniques. Endoscopic enteral access techniques are the most commonly used and preferred method. These include endoscopy-guided nasoenteric tube placement and percutaneous endoscopic enterostomy. These techniques can be safely performed even in challenging conditions such as prior operative intervention, ascites, and head and neck obstructions. However, each type of procedure has its unique set of indication as well as complications. The decision to use endoscopic enteral access should be carefully considered and individualized based on the patient's specific anatomical limitations, preference, overall health status, and disease. In this article, we review current knowledge focusing on endoscopic enteral feeding access including indications, contraindications, preprocedural preparation, procedure technique, enteral access in specific conditions, postprocedural care, and prevention and management of associated complications.     

Future directions in endoscopic ultrasound-guided tissue acquisition

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is safe and has a high diagnostic yield. Multiple factors affect the outcome of EUS-TA such as operator experience, procedure technique, needle-type, and cytopathologist training and experience. There have been numerous advances aiming to increase the diagnostic yield of EUS-TA. These include novel devices, modified tissue acquisition techniques, enhancements in EUS imaging, improved tissue processing methods, and increasingly frequent molecular and genetic testing of acquired tissue. Importantly, recent advances in personalized medicine may require greater amounts of tissue to be acquired to guide subsequent oncotherapy. As a result of all these new developments, several additional questions have arisen including defining the precise role of EUS-guided fine-needle biopsy, the optimal technique for EUS-TA, and standardization of tissue processing protocols. This review discusses recent advances and future directions regarding EUS-TA.     

Successful treatment of persistent pulmonary hypertension of the newborn with bosentan

The sophisticated and expensive treatment modalities of persistent pulmonary hypertension of the newborn (PPHN), such as nitric oxide, are limited in developing countries. Alternative (less expensive) treatments are being sought and bosentan, an oral dual endothelin-1 receptor antagonist, may be an option for the treatment of PPHN. We report our experience of using bosentan in a neonate with severe PPHN.
Conclusion:  Bosentan may be a useful adjuvant therapy in neonates with PPHN, providing significant improvement in oxygenation, and thus may be particularly useful in the treatment of PPHN in countries with limited resources.     

Community capacity for sustainable community-based dengue prevention and control: study of a sub–district in Southern Thailand

ObjectiveTo assess the level of community capacity for dengue prevention and control and to study household environments and larval indices in southern Thailand.MethodsA cross-sectional survey was designed for the study, enrolling two communities with higher dengue incidence rate than the standard over the past five years. Data gathering was conducted by the dengue leader group (DLG), including 15 leaders and 15 non-leaders trained by the research team. The dengue community capacity assessment tool (DCCAT) for leaders (115 items, 14 domains) and non-leaders (83 items, 11 domains). Participants were selected by the DLG based on their communities' dengue risk. In the low-dengue incidence (LDI) community, 32 leaders and 177 non-leaders were selected; while in the high-dengue incidence (HDI) community, 31 leaders and 199 non-leaders were chosen.ResultsThe leaders from the LDI and the HDI communities demonstrated high levels of dengue community-capacity (360.47±58.82, 416.22±57.72). Non-leaders in the LDI community demonstrated a moderate level of dengue community capacity competence (205.90±60.76), while the non-leaders in the HDI community had a high level (254.78±50.34).ConclusionsThese initial levels of dengue community capacity serves as a baseline for diagnosing each community. For a community that needed to improve its capacity, the DCCAT is essential tool to conduct a pre-post intervention assessment or a serial assessment. A participatory approach is taken to enable local communities to carry out anti-dengue efforts on their own, rather than have intervention by an outsider.     

Clinical features and molecular analysis in Thai patients with HbH disease

We studied the α-globin gene abnormalities, the clinical features, hematologic values, growth assessment, transfusion therapy, and serum ferritin levels of patients with hemoglobin H (HbH) disease in southern Thailand. HbH disease in 83 of the 147 patients was the deletional type of HbH. The remaining 64 patients was the nondeletional type of HbH disease. All 83 patients with the deletional type were double heterozygotes of α⁰-thalassemia and α⁺-thalassemia. The Southeast Asian type of α⁰-thalassemia accounted for 98% of the Thai patients with HbH disease and the Thai type of α⁰-thalassemia made up the rest. A 3.7-kb deletion accounted for 91% of α⁺-thalassemia, and a 4.2-kb deletion made up the rest of the deletional type. In patients with nondeletional type of HbH disease, the Constant Spring variant was the majority of the disease. Newborns with a nondeletional genotype had higher mean corpuscular volume, had higher mean corpuscular hemoglobin, had higher red blood cell distribution width, had lower mean corpuscular hemoglobin concentration, and had higher proportions of Hb Bart's than those with a deletional genotype. Twenty-one percent of children with HbH disease had growth deficiency. A genotype–phenotype correlation was found; patients with the nondeletional type of HbH disease had more symptoms at a younger age, more severe hemolytic anemia, more growth deficiency, more dysmorphic facial features, larger spleens, larger livers, and higher serum ferritin levels and required more transfusions than patients with deletional HbH disease.