Challenges in Perioperative Cerebral Oximetry Monitoring: A Case of Clofazimine-Induced Skin Pigmentation Interference.

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac surgery. The most consistent risk factor associated with the condition is a history of a prior stroke. Cerebral oximetry is a simple, non-invasive, and continuous monitoring device that uses near-infrared spectroscopy (NIRS) to monitor cerebral oxygenation. However, like other monitoring devices, cerebral oximetry has certain limitations, and it must be interpreted cautiously and by taking into account all available clinical information related to the patient. We present a case of a 62-year-old Caucasian woman with a past medical history of a transient ischemic attack (TIA), who had been advised to undergo a right pneumectomy by video-assisted thoracoscopic surgery for treating chronic infection of bronchiectasis. Before administering any drug and while the patient was still alert, we monitored NIRS, and the values recorded were 15 on the left side and 26 on the right side. Despite being Caucasian, she had a darker brownish skin color due to chronic clofazimine use, which is known to cause skin pigmentation. Skin pigmentation is known to attenuate the transmission of near-infrared (NIR) light, potentially affecting the estimation of cerebral oxygen saturation. Thus, our patient suffered from clofazimine-induced skin pigmentation, which may have interfered with the NIR light transmission, which explains the extremely low values observed. Regional intracerebral oxygen saturation should be interpreted in the context of all available clinical information since NIRS transmission can be influenced by several factors and skin pigment has been found to independently influence regional intracerebral oxygen saturation. Apart from race or high serum bilirubin concentration, we should also consider other causes of skin pigmentation alterations, such as pharmacological therapy.

Innovative actions in oceans and human health for Europe.

Innovative actions are local initiatives which leverage the interactions between the ocean and human health to reduce the risks and enhance the benefits for the stakeholders and the natural environment. These initiatives can have strong positive effects on human health and wellbeing as well as on the marine environment. We analysed 150 such innovative actions in Europe. Using a combined case study and survey approach, innovative actions were identified using interviews and content analysis of websites and compiled into a database. Quantitative data were analysed according to the Drivers, Pressures, State, Impact and Response (DPSIR) framework, guided by selected in-depth interviews. Overall, the innovative actions provided a positive impact on the health of both the ocean and humans through increasing food provision, water quality and tourism opportunities; and addressing environmental issues such as commercial fish stock depletion, pollution and climate change. Innovative actions contributed to meeting various targets of the Sustainable Development Goals (SDGs) 3, 13 and 14. These actions played a potential role ahead of and alongside policy. Some of the innovative actions may have potential to be put in place elsewhere. Such up-scaling would need to be adapted to local circumstances and could be facilitated by an innovative action exchange platform.

This study presents 150 innovative actions taken by citizens and organizations in Europe to promote the health of both the ocean and humans. These were analysed and categorized according to the environmental issues they responded to, the Sustainable Development Goals (SDGs) addressed, and the ecosystem services provided. Plastic pollution and loss of biodiversity were the most targeted environmental issues, while tourism, recreation and wellbeing were the services most addressed by the innovative actions. These innovative actions tended to target those SDGs that currently show a lack of progress. Such actions, with both an environmental and health promotion agenda, may have the potential to complement regular policymaking in achieving these SDGs. The impact could be further enhanced by sharing best practices among an international network of local stakeholder action innovators. An interactive map shows the locations and websites of the European innovative actions identified. The map can serve as a first step in providing a platform for the network to connect and inspire people interested in creating their own interventions.

Management of an Anticipated Difficult Airway in a Pediatric Patient With Stickler Syndrome.

Stickler syndrome (SS) is a congenital autosomal dominant condition that affects the formation of collagen. Of primary importance to the anesthesia provider is the propensity for difficulties in managing the airway due to orofacial abnormalities associated with this syndrome. The authors present a two-year-old infant with SS who required anesthetic care for a cleft palate repair. The potential anesthetic implications of this syndrome are discussed and the importance of proper planning and preparation and the usefulness of ultrasound as an airway evaluation tool are highlighted.

Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review.

BACKGROUND: A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed. AIM: We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management. METHOD: We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group. RESULTS: There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances. CONCLUSION: It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.

Exploring public views on marine litter in Europe: Perceived causes, consequences and pathways to change.

Marine litter is a global challenge and society plays an important role via lifestyles and behaviour, including policy support. We analysed public perceptions of marine litter and contributing factors, using data from 1133 respondents across 16 European countries. People reported high levels of concern about marine litter, and the vast majority (95%) reported seeing litter when visiting the coast. The problem was attributed to product and packaging design and behaviour rather than lack of facilities or accidental loss of items. Retailers, industry and government were perceived as most responsible, but also least motivated and competent to reduce marine litter, whereas scientists and environmental groups were perceived as least responsible but most motivated and competent. Regression analyses demonstrated the importance of psychological factors such as values and social norms above sociodemographic variables. These findings are important for communications and interventions to reduce inputs of marine litter to the natural environment.

Enhancing public awareness and promoting co-responsibility for marine litter in Europe: The challenge of MARLISCO.

Marine litter is a pervasive and complex societal problem but has no simple solution. Inadequate practices at all levels of production-use-disposal contribute to accumulation of waste on land and at sea. Enhanced societal awareness but also co-responsibility across different sectors and improved interactions between stakeholders are necessary. MARLISCO was a European initiative, which developed and implemented activities across 15 countries. It worked towards raising societal awareness and engagement on marine litter, through a combination of approaches: public exhibitions in over 80 locations; a video competition involving 2100 students; and a legacy of educational and decision-supporting tools. 12 national participatory events designed to facilitate dialogue on solutions brought together 1500 stakeholders and revealed support for cross-cutting, preventive measures. Evaluation during implementation shows that these activities are effective in improving individuals' perceptions about the problem but also commitment in being part of the solution. This paper summarises MARLISCO's approach and highlights a selection of outcomes.

Non-secretory multiple myeloma relapsing as extramedullary liver plasmacytomas.

We report a case of a 58-year-old woman with a true non secretory multiple myeloma of the producer type relapsing after many lines of therapy including the novel anti-myeloma drugs, which eventually relapsed as extramedullary liver plasmacytomas manifesting as a fatal acute cholestatic hepatitis. Due to the aggressiveness of this disease, new therapeutic modalities are necessary.

Early Diagnosis of Invasive Aspergillosis in Neutropenic Patients. Comparison between Serum Galactomannan and Polymerase Chain Reaction.

BACKGROUND: Invasive aspergillosis (IA) is a major cause of morbidity and mortality in profoundly neutropenic patients, so early diagnosis is mandatory. AIM: Consecutive patients with hematological malignancies undergoing intensive chemotherapy were screened for IA with two different methods which were compared. METHODS: From October 2000 to August 2003 we tested 1311 serum samples from 172 consecutive patients with a polymerase chain reaction assay and between April 2005 and April 2008 we tested 806 serum samples from 169 consecutive patients with a Galactomannan (GM) test. Bronchoalveolar (BAL) samples were obtained whenever the patient's condition allowed and tested with either method. RESULTS: The serum PCR assay had a sensitivity of 75.0% and a specificity of 91.9% and the serum GM assay had a sensitivity of 87.5% and a specificity of 93.1%, (P > 0.05). The presence of two or more consecutive positive serum samples was predictive of IA for both assays. BAL GM/PCR was positive in some patients without serum positivity and in patients with 2 or more positive serum GM/PCR. CONCLUSIONS: No significant differences between the 2 serum tests were found. The GM assay has the advantage of being standardized among several laboratories and is incorporated in the criteria established by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycosis Study Group (EORTC/MSG), however is much more expensive. BAL GM and PCR sampling aids in IA diagnosis but needs further validation studies to differentiate between colonization and true infection in cases where serum GM or PCR are negative.

Polymerase chain reaction screening for fungemia and/or invasive fungal infections in patients with hematologic malignancies.

INTRODUCTION: Invasive fungal infections (IFIs) are a life-threatening complication in patients with hematologic malignancies, mainly in acute leukemia patients, following chemotherapy. IFI incidence is increasing, and associated mortality remains high due to unreliable diagnosis. Antifungal drugs are often limited by inadequate antimicrobial spectrum and side effects. Thus, the detection of circulating fungal DNA has been advocated as a rapid, more sensitive diagnostic tool. PATIENTS AND METHODS: Between June 01 and January 03, weekly blood samples (1,311) were screened from 193 patients undergoing intensive myelosuppressive or immunosuppressive therapy. IFI cases were classified according to European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. Fungal DNA was extracted from whole blood and amplified using polymerase chain reaction (PCR) published primers that bind to the conserved regions of the fungal 18S rRNA gene sequence. In our study, two or more consecutive positive samples were always associated with fungal disease. RESULTS: PCR screening predicted the development of IFI to be 17 days (median). This test had a specificity of 91.1% and a sensitivity of 75%. IFI incidence was 7.8%. DISCUSSION: Therefore, our results confirm the potential usefulness of PCR serial screening and the clinical applicability in everyday routine. PCR screening offers a noninvasive repeatable aid to the diagnosis of IFI.