bluuebunny/crossref_metadata_2025 huggingface dataset:
Lipodermatosclerosis: a postphiebitic syndrome
Authors: Sheth Rekha , Poonevala Vera
Published: August 2010

A 30‐year‐old businessman, weighing 94 kg, presented with pigmentation and skin changes extending from the calf to the dorsum of the left foot. One year ago, the patient noticed erythema around the medial malleolus and edema of the ankle, following trauma while starting a bike. The patient was afebrile during the event. He gave no history suggestive of muscle weakness, cramping calf pains at rest, intermittent claudication while walking, paresthesia, or increased sensitivity to cold. No history suggestive of systemic involvement was obtained.

On examination, the affected part showed pigmentary color changes varying from brown to bluish black (diffuse around the ankle and mottled towards the knee). The overlying skin was warm, indurated, brawny, and stony hard. Along with patchy hair loss, there was a painless decrease in the mobility of the left ankle. The circumference of the left calf and ankle measured approximately 2.5 cm less than the corresponding right side. The skin on the thigh above was hypertrophied and pachydermatous. There was no evidence of varicose veins.

The blood count, urine analysis, erythrocyte sedimentation rate, bleeding, clotting, and prothrombin time were all within normal limits. Blood sugar levels were moderately elevated. Antinuclear‐antibodies were absent.

Histopathology of the skin biopsy showed uniform thinning of the epidermis, with focal areas of increased pigmentation in the stratum basale. A sparse perivascular lymphocytic infiltrate was seen around the superficial and deep vessels of the retioular dermis. The collagen bundles were closely packed, homogeneous, thickened, and deeply stained. The subcutaneous tissue was replaced with collagen fibers, thus resembling a scleroderma‐like picture.

Color Doppler showed evidence of segmental thrombosis in the left posterior tibial and peroneal veins.

Before the dermatologic referral, the patient had been treated with intravenous heparin followed by tablet aspirin. We advised dietary restrictions for weight reduction and control of diabetes. In addition, we recommended vitamin supplements and compression stockings. The patient was taught limb care with special emphasis on leg elevation and exercise (to hasten the development of collaterals).
Papular umbilicated granuloma annulare in association with Alagille syndrome
Authors: Kibarian Maral A. , Mallory Susan B. , Keating James , Shitabata Paul
Published: August 2010

A 10‐year‐old white boy with Alagille syndrome was referred to the dermatology clinic for evaluation of an eruption on the lower extremities. The lesions were mildly pruritic, gradual in onset, and increased in number over several months. The patient reported no insect bites, no unusual contacts, no history of chronic dermatologic disorders, and no recent febrile illness or systemic complaints. He had Alagille syndrome with cholestatic liver disease, hyperlipidemia, pulmonary artery stenosis, retinal pigment abnormalities, and myopia. His medications included rifampin and phenobarbital. There was no family history of Alagille syndrome; however, the patient's father had retinal cone abnormalities and a half‐sister had died of Aicardi syndrome.

Physical examination revealed typical facies with hypertelorism, deep set eyes, and a sharply pointed chin. Dermatologic examination showed firm umbilicated papules symmetrically distributed on the dorsa of both feet and ankles (Fig. 1).

The differential diagnosis included xanthomas, prurigo papules, and molluscum contagiosum. A skin biopsy revealed palisading necrobiotic granulomas consistent with granuloma annulare (Fig. 2).
Cytochrome P450 polymorphisms in patients with Behcet's disease
Authors: Tursen Umit , Tamer Lulufer , Api Hale , Yildirim Hatice , Baz Kiymet , İkizoglu Guliz , Atik Ugur
Published: August 2010

Objectives Although the etiopathogenesis of Behcet's disease (BD) remains unknown, increased neutrophil functions such as chemotaxis, phagocytosis and excessive production of reactive oxygen species, including superoxide anion, may be responsible for the oxidative tissue damage observed in BD. Cytochrome P‐450 are a multigene family of enzymes involved in the detoxification and occasional activation of a wide variety of chemicals. Our aim was to investigate CYP2C9 and CYP2C19 polymorphisms in patients with BD.

Methods Sixty‐two subjects with BD and 107 healthy control subjects were enrolled in the study. Polymorphisms of CYP2C9 and CYP2C19 were performed by real‐time PCR with a LightCycler instrument. We researched associations between CYP polymorphisms and BD.

Results The frequencies of wild‐type and heterozygous CYP2C19*2 genotypes were 66.1% and 33.9% in the patients and 83.2% and 16.8% in the controls, respectively. There was a 2.53‐fold increased risk of Behcet's disease in individuals with the CYP2C19*2 heterozygous genotype (OR = 2.53; 95% CI, 1.22–5.25) when compared with the control group. But the CYP2C9*2, CYP2C9*3 and CYP2C19*3 gene polymorphisms were not related to an increased risk of developing BD.

Conclusions We observed that patients with BD presented with a higher prevalence of the heterozygous CYP2C19*2 genotype. Hereditary deficiencies of this enzyme activity may lead to an imbalance between pro‐ and antioxidant systems, resulting in the formation of excessive reactive oxygen species.
Clinicopathologic challenge
Authors: Bordeaux Jeremy S. , O’Brien Meghan , Mahalingam Meera , Wiss Karen
Published: August 2010

What is your diagnosis?
Indigenous leishmaniasis in Taiwan: report of a case
Authors: Wang Jia‐Ru , Lee Sho‐Tone , Juan Wei‐Hsin , Chuang Wei‐Lin , Hung Shuen‐Iu , Chung Wen‐Hung , Hong Hong‐Shang
Published: August 2010

Taiwan is not considered an endemic area of leishmaniasis. Imported cases are encountered infrequently, and only two cases of indigenous cutaneous leishmaniasis have been reported.1 We found one new case in the past 20 years. The patient presented with erythematous plaques on the nasal bridge and right thumb. Skin biopsy specimens from both sites revealed numerous Leishman–Donovan bodies in macrophages. There was no history of travel outside the country, and the diagnosis of indigenous cutaneous leishmaniasis was made. Polymerase chain reactions (PCR) identified the species as Leishmania tropica. The route of infection in this patient is unclear. Because pentavalent antimony, the drug of choice for leishmaniasis, is not available in Taiwan, the patient was treated with levamisole and potassium iodide, with an excellent response.
Solitary and multifocal oral melanoacanthoma
Authors: Yarom Noam , Hirshberg Avraham , Buchner Amos
Published: August 2010

Background  Oral melanoacanthoma is a rare pigmented lesion characterized by sudden appearance and rapid radial growth, mimicking malignant melanoma. Oral melanoacanthoma may present as a solitary or multifocal lesion; however, the characteristics of these two clinical variants have never been addressed. In this study, we present an unusual case of multifocal oral melanoacanthoma and analyze cases of oral melanoacanthoma reported in the literature, with special emphasis on multifocal lesions.

Methods  A thorough MEDLINE search of the literature for cases of oral melanoacanthoma was performed. The demographic and clinical data, histologic features, and immunohistochemical findings were extracted from the full‐text articles.

Results  The literature search yielded 52 patients with 67 lesions. The addition of our case increased this number to 53 patients with 72 lesions, 43 of whom had solitary lesions and 10 of whom had multifocal lesions. There was a female predominance amongst the patients with solitary oral melanoacanthoma (3 : 1), whereas multifocal oral melanoacanthoma showed an equal gender distribution (1 : 1). Multifocal lesions tended to occur more frequently on the palate, and solitary lesions on the buccal mucosa.

Conclusions  Multifocal oral melanoacanthoma appears to demonstrate some demographic and clinical variations from the solitary type of lesion.
Are age‐specific high serum IgE levels associated with worse symptomatology in children with atopic dermatitis?
Authors: Hon Kam‐lun Ellis , Lam Man‐ching Adrian , Leung Ting‐fan , Wong Kin‐yee , Chow Chung‐mo , Fok Tai‐fai , Ng Pak‐cheung
Published: August 2010

Background Atopic dermatitis (AD) is a distressing disease associated with excoriations, pruritus, sleep disturbance, and elevation of serum total immunoglobulin E (IgE) levels.

Objective To evaluate whether serum IgE levels correlate with the symptomatology and plasma chemokine levels in children with AD.

Methods AD patients aged younger than 18 years were recruited from the pediatric dermatology clinic of a university teaching hospital, and the AD severity was evaluated using the SCORing Atopic Dermatitis (SCORAD) index. Concentrations of serum total IgE, eosinophil count, and plasma AD‐associated chemokines [cutaneous T‐cell‐attracting cytokine (CTACK), thymus and activation‐regulated chemokine (TARC)] were measured.

Results One hundred and seventeen Chinese children with AD (64 boys and 53 girls), with an age (mean ± standard deviation) of 10.7 ± 4.4 years, were recruited. Their overall SCORAD index (mean ± standard deviation) was 51.1 ± 22.8. The total serum IgE level divided by the age‐specific upper limit (Æ) correlated well with the extent and intensity of AD, except for oozing/crusting, which was significant only in males. There was a significant correlation between Æ and pruritus or sleep loss only in females. Levels of IgE, CTACK, and TARC, and eosinophil count, differed significantly between patients with mild, moderate, and severe disease. Æ correlated well with TARC (r = 0.50,P < 0.001) and eosinophil count (r = 0.41,P < 0.001), but not with CTACK (r = 0.11,P = 0.270). The prediction of moderate to severe eczema by Æ gave an area under the receiver‐operating characteristic curve of 0.76 (95% confidence interval, 0.65–0.86;P = 0.004). An optimum positive predictive value of 94.2% was achieved with a cut‐off point of Æ of 2.95, sensitivity of 75.0%, and specificity of 66.7%.

Conclusion Æ correlates significantly with various objective clinical scores and chemokine markers of AD, and is a useful indicator for predicting moderate to severe AD in children.
Comparative efficacy of two nit combs in removing head lice (Pediculus humanus var. capitis) and their eggs
Authors: Speare Rick , Canyon Deon V. , Cahill Christine , Thomas Genelle
Published: August 2010

Background  Fine tooth lice combs fall into two classes based on the material from which their teeth are made: plastic or metal. Metal combs are further divided into those that are made from a flat sheet of metal, and hence have rectangular teeth, and those that have cylindrical teeth embedded in a plastic base.

Methods  The efficacy of two fine tooth combs [Lice Meister comb (metal) and Lady Jayne comb (plastic)] in removing head lice (Pediculus humanus var. capitis) and their eggs from the hair of children was evaluated after treatment with a viscous head lice product (Lice Blaster; Emerald Forest Pharmaceuticals Pty Ltd, Currumbin, Qld, Australia). The hair of 27 children was divided into two sections sagitally, and each comb was randomly assigned to one half of the hair, and the lice and eggs removed by the combs were counted.

Results  In 96% of subjects, the Lice Meister comb removed more eggs than the Lady Jayne comb, with an average of three to four times more hatched, dead, and live eggs removed. The Lice Meister comb removed more lice than the Lady Jayne comb in 10 subjects, the same in eight subjects, and less in nine subjects.

Conclusion  Overall, the Lice Meister comb is recommended as a more effective comb for use in controlling head lice infestations, whether employed with conditioner or with insecticide treatment. This appears to be the first study investigating the efficacy of nit combs in vivo. Further research is needed to determine which characteristics of fine tooth combs are the most important in removing head lice eggs.
Pheohyphomycosis caused by Exophiala spinifera: a rare occurrence
Authors: Singal Archana , Pandhi Deepika , Bhattacharya Sambit N. , Das Shukla , Aggarwal Sarla , Mishra Kiran
Published: August 2010

A 10‐year‐old immunocompetent boy presented with multiple, verrucous, disseminated pheohyphomycotic lesions caused by Exophiala spinifera. The patient was not responsive to combination antifungal therapy (itraconazole, terbinafine, fluconazole) and cryotherapy. As antifungal susceptibility is known to be variable for Exophiala spinifera, in vitro sensitivity testing is recommended before medical treatment. This article reviews, in brief, all cases documented so far in the English literature.
Current status of HIV infection: a review for non‐HIV‐treating physicians
Authors: Knoll Bettina , Lassmann Britta , Temesgen Zelalem
Published: August 2010

An estimated 40 million people live with human immunodeficiency virus (HIV) globally, and over four million people were newly diagnosed with HIV infection in 2006. Twenty‐five million people have died as a result of HIV since its recognition in 1981. Where available, highly active antiretroviral therapy has resulted in significant decreases in HIV‐associated morbidity and mortality. Nevertheless, opportunistic infections and conditions continue to occur, and their recognition and management continue to be an important component of HIV care.
Herpes zoster‐associated voiding dysfunction in hematopoietic malignancy patients
Authors: Imafuku Shinichi , Takahara Masakazu , Uenotsuchi Takeshi , Iwato Koji , Furue Masutaka
Published: August 2010

Background  Voiding dysfunction is a rare but important complication of lumbo‐sacral herpes zoster. Although the symptoms are transient, the clinical impact on immunocompromised patients cannot be overlooked.

Methods  To clarify the time course of voiding dysfunction in herpes zoster, 13 herpes zoster patients with voiding dysfunction were retrospectively analyzed.

Results  Of 13 patients, 12 had background disease, and six of these were hematopoietic malignancies; four of these patients were hematopoietic stem cell transplant (HSCT) recipients. Ten patients had sacral lesions, two had lumbar, and one had thoracic lesions. Interestingly, patients with severe rash, or with hematopoietic malignancy had later onset of urinary retention than did patients with mild skin symptoms (Mann–Whitney U analysis, P = 0.053) or with other background disease (P = 0.0082). Patients with severe skin rash also had longer durations (P = 0.035). In one case, acute urinary retention occurred as late as 19 days after the onset of skin rash.

Conclusions  In immune compromised subjects, attention should be paid to patients with herpes zoster in the lumbo‐sacral area for late onset of acute urinary retention even after the resolution of skin symptoms.
Increased insulin‐like growth factor binding protein‐3 expression level in psoriatic tissue before and after systemic treatment with cyclosporine A and methotrexate
Authors: Özden Müge Güler , İlter Nilsel , Suer Özlem Erdem , Solaktekin Nilgün , Gürer Mehmet Ali
Published: August 2010

Insulin‐like growth factor (IGF) and its binding proteins (BPs) are candidates to play a role in the pathogenesis of psoriasis. IGF‐I and ‐II and their binding proteins (IGFBPs) have both growth inhibitory and mitogenic effects on a multitude of cell types. Current studies have explored the potential role of IGFBP‐3 in keratinocyte growth and differentiation. To gain more insight into the role of IGFBP‐3 in the pathogenesis of psoriasis, we investigated the changes in IGFBP‐3 expression levels in psoriatic plaque and compared these expressions with levels in other inflammatory skin diseases. In particular, we investigated whether or not the changes in IGFBP‐3 were affected by systemic treatment with cyclosporine A (CsA) or methotrexate (Mtx). We found significantly increased IGFBP‐3 expression levels in the psoriatic group compared with levels in patients with other, nonproliferative inflammatory skin diseases, and we demonstrated differences in distribution pattern before and after systemic treatment with Mtx or CsA. Mtx and CsA had no effect on tissue IGFBP‐3 expression levels. Before treatment with Mtx or CsA, IGFBP‐3 expression was limited to the basal layer and suprapapillary region. Unlike with Mtx, CsA significantly changed the IGFBP‐3 distribution pattern.
Anticonvulsant hypersensitivity syndrome: clinical and laboratory features
Authors: Mansur Ayşe Tülin , Pekcan Yaşar Şirin , Göktay Fatih
Published: August 2010

Background  Anticonvulsant hypersensitivity syndrome (AHS) is a severe adverse drug reaction with multiorgan involvement. Aromatic anticonvulsants are the most frequently involved drugs. This study was aimed to highlight the clinical and laboratory findings of AHS.

Methods  The medical records of 31 patients diagnosed as AHS in a 12‐year period were evaluated retrospectively.

Results  The syndrome was related to carbamazepine in 48.38%, phenytoin in 35.48%, lamotrigine in 9.6% and cotreatment with lamotrigine and valproic acid in 6.45% of cases. Symptoms appeared 2–86 (mean: 35.96) days after ingestion of the offending agent. The type of skin rash was maculopapular and/or erythrodermic in 77.42% of patients, bullous in 19.35%, and erythematopustular in 3.22%. Fever and peripheral lymphadenopathy were detected in 61.29% and 54.82% of cases, respectively. Laboratory investigations revealed elevation of hepatic enzymes in 70.96%, leucocytosis in 43.3%, and peripheral eosinophilia in 64.3% of patients.

Conclusions  Our analysis showed that carbamazepine and phenytoin are still the major causes of AHS, with lamotrigine being the third etiologic agent. Valproic acid and benzodiazepines are safe alternatives of the causative anticonvulsants. As there are yet no strict diagnostic criteria, the constellation of clinical and laboratory features that occur within 3 months of the associated anticonvulsant agents helps to recognize the disorder. The risk of seizure due to withdrawal or changing of the anticonvulsant drug and the potentially serious clinical features often necessitates providing care and treatment in an inpatient setting.
Psychological stress, endocrine and immune response in patients with lichen planus
Authors: Krasowska Dorota , Pietrzak Aldona , Surdacka Agata , Tuszyńska‐Bogucka Violetta , Janowski Konrad , Roliński Jacek
Published: August 2010

Background  Lichen planus still remains a disease of unclear etiology. Inconclusive reports exist on the role of stress the pathophysiological mechanisms involved in this disease. The objective of this study was to find associations between levels of stress and indices of the endocrine and immune response in patients with lichen planus.

Methods  A total of 57 patients with lichen planus and 27 healthy control volunteers took part in the study. All participants completed questionnaires measuring the frequency of stressful life events. Blood samples were collected and analyzed for levels of endocrine and immune parameters: neopterin, cortisol, interleukin (IL)‐2, IL‐6, IL‐18, soluble IL‐2 receptor (sIL‐2R), sIL‐6R, sFasL, T lymphocyte antigens CD3, CD4, CD8, CD25, CD69, HLA‐DR, CD16/56, CD45RO and CD45RA.

Results  Patients differed significantly from the controls in the levels of neopterin (but not cortisol), expression of CD25, CD16, CD8, and CD45RA antigens on T lymphocytes. Patients had also significantly higher levels of sIL‐2R, sFasL, sIL‐6R and IL‐18 than healthy controls. Patients and controls did not differ in the overall frequency of stressful life events experienced over 1 year prior to the study. However, two subgroups of patients with various stress levels differed significantly in the expression of CD25, HLA‐DR, CD45RO, and CD45RA on T lymphocytes.

Conclusions  Our findings suggest that stress may alter numerous parameters of endocrine and immune response in lichen planus, which provides support for its role in the etiopathogenesis of this disease.
No pain relief from codeine…?
Authors: Fagerlund T. H. , Braaten Ø.
Published: August 2010

Drug treatment remains a mainstay of medicine. In some situations a drug unexpectedly has no effect, or unforeseen serious side effects occur. For the patient this represents a dangerous and potentially life‐threatening situation. It certainly is a distressing experience for the doctor. At the societal level, adverse drug reactions represent a leading cause of disease and death. Genetic variation often underlies these unexpected situations. Pharmacogenetics is the term used about genetically determined variability in the metabolism of drugs. Pharmacogenomics usually refers to drug discovery based on knowledge of genes, but it is a discipline that offers insight into aetiologic mechanisms, and possible prevention and treatment. There is a trend towards a definition of pharmacogenomics that includes both pharmacogenetics and pharmacogenomics as defined above. Our article is an introduction to pharmacogenomics, using the broader definition. Biotechnological methods cannot be understood without a grasp of basic medical genetics, and we provide a brush‐up on the fundamentals. We then outline pharmacogenetics, giving examples of genetically based variation in drug metabolising enzymes, drug receptors and drug transporting proteins. Modern biotechnology would be unthinkable without the aid of computers, and we briefly touch upon the field of bioinformatics. Finally, we give an overview of pharmacogenomics in the narrower sense. The rapidly growing field of pharmacogenomics is going to influence our everyday practice of medicine in the immediate future.
Bronchial blocker compared to double‐lumen tube for one‐lung ventilation during thoracoscopy
Authors: Bauer C. , Winter C. , Hentz J. G. , Ducrocq X. , Steib A. , Dupeyron J. P.
Published: August 2010

Background: Video‐assisted thoracoscopic surgery (VATS) requires one‐lung ventilation with a properly collapsed lung. This study compared the Broncho‐Cath double‐lumen endotracheal tube with the Wiruthan bronchial blocker to determine the advantages of one device over the other during anaesthesia with one‐lung ventilation for thoracoscopy.

Methods: Thirty‐five patients undergoing VATS were randomly assigned to one of two groups. Sixteen patients received a left‐sided double‐lumen tube (DLT) and nineteen a Wiruthan bronchial blocker (BB). The BB group was subdivided in two: BB in the right mainstem bronchus (BBR) for right‐sided VATS (9 patients), BB in the left mainstem bronchus (BBL) for left‐sided VATS (10 patients). The position of the devices was checked using a fibreoptic bronchoscope. The following variables were measured: 1) number of unsuccessful placement attempts; 2) number of malpositions of the devices; 3) time required to place the device in the correct position; 4) number of secondary dislodgements of the devices after turning the patient into the lateral decubitus position. The quality of lung deflation was evaluated by the surgeons who were blinded to the type of tube being used.

Results: The number of unsuccessful placement attempts was one in the DLT group (1/16), three in the BBL group (3/10) and none in the BBR group (0/9). The number of malpositions was significantly greater in the BBL group (10/10) compared to the DLT group (2/16) and to the BBR group (1/9) (P<0.001). The time (mean±SD) required to place a BBL was 4.21 min±1.28, significantly longer than the time required to place a DLT (2.26 min±0.55, P<0.0006) or a BBR (2.41 min±0.53, P<0.008). The difference in placement time between DLT and BBR was not significant. The number of secondary dislodgements was one in the DLT group, one in the BBR group and none in the BBL group (NS). The quality of lung deflation was judged excellent or fair in all patients in the DLT and the BBL groups and poor in 44% of the patients in the BBR group.

Conclusion: It took significantly longer to place a left BB than a DLT (P<0.0006) or a right BB (P<0.008). The number of initial malpositionings of the left BB was significantly greater than in the other groups (P<0.001). The quality of lung deflation was better in the BBL and in the DLT groups than in the BBR group. We conclude that for routine use during left‐sided VATS, the use of a DLT is preferable to a left BB because of its greater ease of placement. For right‐sided VATS, DLT and right BB showed the same facility of placement but the DLT provided a better quality of lung deflation.
Dextrose 5% in water: fluid medium for maintaining electrical stimulation of peripheral nerves during stimulating catheter placement
Authors: Tsui B. C. H. , Kropelin B. , Ganapathy S. , Finucane B.
Published: August 2010

It is well documented that a higher electrical current is required to elicit a motor response following a normal saline (NS) injection during the placement of stimulating catheters for peripheral nerve block. We present three cases of continuous brachial plexus catheter placement in which Dextrose 5% in water (D5W) was used to dilate the perineural space instead of NS. Three brachial plexus blocks (two interscalene and one axillary) were performed in three different patients for pain relief. In each case, an insulated needle was advanced towards the brachial plexus. A corresponding motor response was elicited with a current less than 0.5 mA after needle repositioning. A stimulating catheter was advanced with ease after 3–5 ml of D5W was injected to dilate the perineural space. A corresponding motor response was maintained when the current applied to the stimulating catheter was less than 0.5 mA. Local anesthetic was then injected and the motor response immediately ceased. All blocks were successful and provided excellent pain relief with the continuous infusion of local anesthetics.
Plasma lidocaine levels and risks after liposuction with tumescent anaesthesia
Authors: Nordström H. , Stånge K.
Published: August 2010

Background:  It is common today to use tumescent anaesthesia with large doses of lidocaine for liposuction. The purpose of the present study was to evaluate lidocaine plasma levels and objective and subjective symptoms during 20 h after tumescent anaesthesia with approximately 35 mg per kg bodyweight of lidocaine for abdominal liposuction.

Methods:  Three litres of buffered solution of 0.08% lidocaine with epinephrine was infiltrated subcutaneously over the abdomen in eight female patients during monitored intravenous (i.v.) light sedation. Plasma levels of lidocaine and signs of subjective and objective symptoms were recorded every 3 h for 20 h after liposuction.

Results:  Lidocaine 33.2 ± 1.8 mg/kg was given at a rate of 116 ± 11 ml/min. Peak plasma levels (2.3 ± 0.63 µg/ml) of lidocaine occurred after 5–17 h. No correlation was found between peak levels and dose per kg bodyweight or total amount of lidocaine infiltrated. One patient experienced tinnitus after 14 h when a plasma level of 3.3 µg/ml was recorded.

Conclusion:  Doses of lidocaine up to 35 mg/kg were sufficient for abdominal liposuction using the tumescent technique and gave no fluid overload or toxic symptoms in eight patients, but with this dose there is still a risk of subjective symptoms in association with the peak level of lidocaine that may appear after discharge.
Effect of levosimendan on ventriculo‐arterial coupling in patients with ischemic cardiomyopathy
Authors: Guarracino F , Cariello C , Danella A , Doroni L , Lapolla F , Stefani M , Baldassarri R , Vullo C
Published: August 2010

Background:  Levosimendan, a novel calcium sensitizer, enhances myocardial contractility without affecting intracellular calcium concentration. It also dilates peripheral arterial vessels by acting on ATP‐dependent K+ channels. Ventriculo‐arterial coupling, the relationship between myocardial contractility and the arterial system, describes the efficiency of the cardiovascular system by analysing the relationship between myocardial contractility expressed by ventricular elastance (Ees) and arterial elastance (Ea). The aim of this prospective clinical investigation was to evaluate the effects of levosimendan on ventriculo‐arterial coupling in patients with ischemic cardiomyopathy.

Methods:  Fifteen patients with stable angina and left ventricular dysfunction underwent elective coronary surgery. Before surgery started, ventriculo‐arterial coupling and several variables of cardiovascular performance were assessed by invasive monitoring and transoesophageal echocardiography before and after administration of levosimendan (12 μg/kg bolus) in coronary patients under general anesthesia.

Results:  The cardiac index and ejection fraction increased significantly [from 1.92 ± 0.4 to 2.1 ± 0.4 l/min/m2 (P = 0.0004) and from 31% ± 6 to 40% ± 9 (P = 0.001), respectively], while mean arterial pressure and systemic vascular resistances decreased significantly [from 83 ± 10 to 72 ± 5 mmHg (P = 0.0016) and from 997 ± 341 to 855 ± 324 dyne s/cm5 (P = 0.0002), respectively]. After administration of levosimendan, Ea decreased significantly (from 4.3 ± 1.8 to 3.2 ± 1.3 mmHg/ml/m2, P= 0.005), while Ees significantly increased (from 2.8 ± 1.6 to 4.4 ± 2.3 mmHg/ml/m2, P= 0.05); as a result, Ea/Ees decreased significantly (from 1.76 ± 1 to 0.83 ± 0.2, P= 0.002).

Conclusion:  Levosimendan improves ventriculo‐arterial coupling and cardiovascular performance in coronary patients with left ventricular dysfunction by enhancing myocardial contractility and reducing arterial elastance.
Tracheostomy: current practice on timing, correction of coagulation disorders and peri‐operative management – a postal survey in the Netherlands
Authors: Veelo D. P. , Dongelmans D. A. , Phoa K. N. , Spronk P. E. , Schultz M. J.
Published: August 2010

Background:  Several factors may delay tracheostomy. As many critically ill patients either suffer from coagulation abnormalities or are being treated with anticoagulants, fear of bleeding complications during the procedure may also delay tracheostomy. It is unknown whether such (usually mild) coagulation abnormalities are corrected first and to what extent. The purpose of this study was to ascertain current practice of tracheostomy in the Netherlands with regard to timing, pre‐operative correction of coagulation disorders and peri‐/intra‐operative measures.

Methods:  In October 2005, a questionnaire was sent to the medical directors of all non‐pediatric ICUs with ≥5 beds suitable for mechanical ventilation in the Netherlands.

Results:  A response was obtained from 44 (64%) out of 69 ICUs included in the survey. Seventy‐five percent of patients receive tracheostomy within 2 days after the decision to proceed with a tracheostomy. Reasons indicated as frequent causes for delay were most often logistical factors. A heterogeneous attitude exists regarding values of coagulation parameters acceptable to perform tracheostomy. Fifty percent of the respondents have no guideline on correction of coagulation disorders or anticoagulant therapy before tracheostomy. Antimicrobial prophylaxis is almost never administered before tracheostomy. Forty‐eight percent mentioned always using endoscopic guidance and 66% of ICUs only perform chest radiography on indication.

Conclusions:  There is a high variation in peri‐ and intra‐operative practice of tracheostomy in the Netherlands. Especially on the subject of coagulation and tracheostomy there are different opinions and protocols are often lacking.
The effects of vasoactive agents, platelet agonists and anticoagulation on thrombelastography
Authors: Kawasaki J. , Katori N. , Taketomi T. , Terui K. , Tanaka K. A.
Published: August 2010

Background:  Platelet activation is a critical step in primary hemostasis and clot formation. We tested a hypothesis that platelet stimulating effects of vasoactive agents or platelet agonists could be shown using thrombelastography (TEG®) as faster onset or increased clot strength. We further examined if TEG® could be modified to evaluate activated platelets as a reversal of anticoagulation in the presence of partial thrombin inhibition.

Methods:  Blood samples were obtained from 126 non‐cardiac surgical patients. Effects of vasoactive agents on TEG® and aggregometry were examined using epinephrine, norepinephrine, vasopressin, desmopressin acetate, milrinone and olprinone (Experiment I). Platelet agonists (epinephrine, ADP and collagen) were separately tested on TEG® (Experiment II). Effects of platelet agonists (ADP and collagen) on TEG® under anticoagulation in the absence or presence of abciximab were studied (Experiment III). We also tested antiplatelet effects of milrinone and olprinone in the presence of anticoagulants on TEG® (Experiment IV).

Results:  Neither vasoactive agents nor platelet agonists affected TEG® or aggregometry results except for milrinone and olprinone on aggregometry (Experiment I, II). Platelet agonists facilitated clotting in the presence of anticoagulants (Experiment III). Abciximab‐treated platelets still exhibited procoagulant effects in the presence of heparin, while not in the presence of argatroban (Experiment III). Platelet inhibition on the modified TEG® was more extensive with milrinone than olprinone, and it was dose dependent (Experiment IV).

Conclusion:  Modified TEG® using heparin or argatroban might delineate the procoagulant effects of platelets by adding platelet specific agonist.
Prospective randomized comparison of the new Laryngeal Tube Suction LTS II and the LMA‐ProSeal for elective surgical interventions
Authors: Genzwuerker H. V. , Altmayer S. , Hinkelbein J. , Gernoth C. , Viergutz T. , Ocker H.
Published: August 2010

Background and aim:  The Laryngeal Tube Suction (LTS) has recently undergone considerable changes in design. The new LTS II was compared with the LMA‐ProSeal to determine device performance during general anaesthesia and controlled ventilation.

Methods:  After Institutional Review Board approval, 100 elective surgical patients were randomized to be ventilated with LTS II or LMA‐ProSeal. The number of attempts (maximum of two, and then other device tested) and time until first tidal volume were recorded. Ventilation was standardized (tidal volume, 7 ml/kg; respiratory rate, 12 breaths/min) and the resulting end‐tidal CO2 was recorded. The airway leak pressure (maximum of 40 cmH2O) was measured at cuff pressures of 60 cmH2O. The ease of gastric tube insertion was evaluated. The devices were inspected for traces of blood after removal. Patients were questioned regarding post‐operative complaints. The Mann–Whitney U‐test was used to compare the groups.

Results:  The demographic data, American Society of Anesthesiologists’ group, Mallampati score, and haemodynamic and respiratory variables were comparable for both groups of 50 patients. Insertion was successful in the first/second attempts in 44/4 patients for LTS II and in 43/6 patients for LMA‐ProSeal. After two failed attempts, the other device was successfully used in one patient for LMA‐ProSeal and in two patients for LTS II. The times until first tidal volume for LTS II and LMA‐ProSeal were 25.0 ± 10.1 and 25.5 ± 11.5 s, respectively. The airway leak pressures were comparable: 33.1 (15–40) and 32.0 cmH2O (18–40 cmH2O) for LTS II and LMA‐ProSeal, respectively. Gastric tube insertion failed in two patients in each group. Traces of blood were found in two patients with LTS II and in three patients with LMA‐ProSeal. In both groups, post‐operative complaints were mild and infrequent.

Conclusion:  In this prospective randomized trial, LMA‐ProSeal and LTS II were comparable in all respects.
Brain damage following severe acute normovolemic hemodilution in combination with controlled hypotension in rats
Authors: Ge Y. L. , Lv R. , Zhou W. , Ma X. X. , Zhong T. D. , Duan M. L.
Published: August 2010

Background and aim:  The reduced oxygen content and perfusion pressure during acute normovolemic hemodilution (ANH) and controlled hypotension (CH) raise concerns about hypoperfusion and ischemic injury to the brain. In this study on rats, we examined the brain damage following four different degrees of ANH combined with CH.

Methods:  Forty rats were randomly assigned to receive a sham operation or CH and ANH [with a hematocrit (Hct) of 30, 25, 20 or 15%]. ANH was performed after baseline physiological parameters had been monitored for 20 min; 30 min later, CH was induced using sodium nitroprusside, and the mean arterial blood pressure was maintained at 50–60 mmHg for 1 h. Rats were killed 3.5 h after hemodilution. Ultrastructural alterations in the CA1 region of the rat hippocampus were observed, and serum concentrations of S100B and neuron‐specific enolase (NSE) were measured before and after ANH.

Results:  The serum S100B concentration increased significantly in the Hct 20% + CH and Hct 15% + CH groups. However, there were no significant differences in the serum levels of NSE between the groups. In the CA1 region of the rat hippocampus, marked ultrastructural alterations, such as mitochondrial denaturalization and nucleus distortion, were observed in the Hct 20% + CH and Hct 15% + CH groups.

Conclusion:  Severe ANH (Hct ≤ 20%) combined with CH may induce cerebral damage, as confirmed by marked ultrastructural alterations in the CA1 region of the rat hippocampus and significantly increased serum levels of S100B, and should be avoided.
Evaluation of the Airway Scope, a new video laryngoscope, in tracheal intubation by naive operators: a manikin study
Authors: Miki T , Inagawa G. , Kikuchi T. , Koyama Y. , Goto T.
Published: August 2010

Background and aim:  The Airway Scope (AWS) is a new video laryngoscope. The purpose of this study was to compare the AWS and Macintosh laryngoscopes with regard to their usefulness for beginners in tracheal intubation.

Methods:  Thirty‐one nurses with no previous experience of tracheal intubation used each device 10 times to intubate the trachea of a manikin (Laerdal Airway Managemant Trainer, Laerdal, Stavanger, Norway). Intubation correctly completed within 30 s was regarded as successful. The intubation time, success rate, number of esophageal intubations and dental clicks, and subjective evaluation of difficulty of intubation [rated from 1 (extremely easy) to 5 (extremely difficult)] were recorded.

Results:  The average intubation time was significantly shorter for AWS than for the Macintosh laryngoscope (16.7 ± 11.0 s vs. 23.2 ± 24.9 s; mean ± standard deviation; P = 0.0297), and the success rate with AWS was significantly greater (91.3% vs. 79.4%; P < 0.001). In the total of 310 intubation attempts for each device, the number of esophageal intubations (0/310 with AWS vs. 20/310 with the Macintosh laryngoscope) and dental clicks (0/310 with AWS vs. 40/310 with the Macintosh laryngoscope) differed significantly (P < 0.001). AWS was rated as easier to use than the Macintosh laryngoscope (P < 0.001).

Conclusion:  AWS is more useful for beginners as it provides quicker and easier tracheal intubation.
Thoracic epidural anesthesia for laparoscopic cholecystectomy in an elderly patient with severely impaired pulmonary function tests
Authors: Kim Y. I. , Lee J. S. , Jin H. C. , Chae W. S. , Kim S. H.
Published: August 2010

Regional anesthesia for laparoscopic cholecystectomy has been reported in patients with severe respiratory disease and is a safe alternative to general anesthesia. Hemodynamic instability can occur on initiating pneumoperitoneum and the respiratory acidosis can last into the post‐operative period without careful monitoring and management. This case report describes such an episode in an elderly patient with severely impaired respiratory function who was given thoracic epidural anesthesia for laparoscopic cholecystectomy.
Medical futility in asystolic out‐of‐hospital cardiac arrest
Authors: VÄYRYNEN T. , KUISMA M. , MÄÄTTÄ T. , BOYD J.
Published: August 2010

Objectives: To study the factors associated with short‐ and long‐term survival after asystolic out‐of‐hospital cardiac arrest, with a reference to medical futility.

Methods: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out‐of‐hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population.

Results: A short time interval to the initiation of advanced life support (ALS) was associated with a long‐term benefit, but a short first responding unit (FRU) response time had only a short‐term benefit. Conversion of asystole into a shockable rhythm provided only a short‐term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander‐witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)‐witnessed arrests. Bystander‐CPR was associated with increased 30‐day mortality. The 30‐day survival rate after an unwitnessed arrest (n=548) was 0.5%. All survivors in this group were either hypothermic or were victims of near‐drowning.

Conclusions: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near‐drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10–15 min in bystander‐witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander‐CPR. Early initiation of ALS should be prioritised in the treatment of out‐of‐hospital asystole.
Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients
Authors: BURGOS E. , GÓMEZ‐ARNAU J. I. , DÍEZ R. , MUÑOZ L. , FERNÁNDEZ‐GUISASOLA J. , GARCIA DEL VALLE S.
Published: August 2010

Background:Hip fracture surgery is associated with high post‐operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly.

Methods:We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre‐operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK‐VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3‐month period and 90‐day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve.

Results:The RISK‐VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post‐operative complications. The Barthel index and the RISK‐VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90‐day mortality.

Conclusions:A simple index such as the RISK‐VAS scale was the best predictor of serious post‐operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.
Lidocaine abolishes the myocardial protective effect of sevoflurane post‐conditioning
Authors: YAN M. , CHEN C. , ZHANG F. , CHEN G.
Published: August 2010

Background: Post‐ischemic administration of volatile anesthetics activates ischemia–reperfusion injury salvage process and decreases myocardial damage. However, the mechanisms underlying anesthetic post‐conditioning and effects of lidocaine on it remain unclear. Here we report the cardioprotection of sevoflurane‐induced post‐conditioning and the effects of lidocaine on it.

Methods: Isolated perfused rat hearts were exposed to 40 min of ischemia followed by 1 h of reperfusion. Volatile anesthetic post‐conditioning was induced by 15 min of 3 vol% sevourane (1.5 minimum alveolar concentration) administered at the onset of reperfusion. In some experiments, lidocaine was coadministered with sevoflurane in different concentrations (2, 10 and 20 μg/ml). Infarct size was determined by dividing the total necrotic area of the left ventricle by the total left ventricular slice area (percent necrotic area).

Results: Sevoflurane‐induced post‐conditioning signicantly improved post‐ischemia functional recovery and decreased infarct size (47.3±5.6% in unprotected hearts vs. 18.6±3.1% in anesthetic post‐conditioning, P<0.05). Sevourane‐mediated cardioprotection was abolished by 20 μg/ml lidocaine.

Conclusions: Sevourane‐induced post‐conditioning effectively protected myocardium against reperfusion damage and its cytoprotection was reversed by 20 μg/ml lidocaine.
Echocardiographic features, mortality, and adrenal function in patients with cirrhosis and septic shock
Authors: THIERRY S. , GIROUX LEPRIEUR E. , LECUYER L. , BROCAS E. , VAN DE LOUW A.
Published: August 2010

Objectives: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock.

Design: Prospective single‐center cohort study.

Patients and methods: Thirty‐four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed.

Results: Patients with cirrhosis had higher values for the CI (3.69±1.0 vs. 2.86±0.8 l/min/m2; P=0.02), SI (37.5±8 vs. 32.4±7 ml/m2; P=0.04), and LVEF (67±7 vs. 55.9±12%; P=0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis (P=0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis (P=0.18).

Conclusion: In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis.