The value of honey dressings in pilonidal cyst healing: a prospective randomized single-center trial.

BACKGROUND: Honey is described as a wound healing agent. Many virtues have been attributed to it, in particular, antibacterial properties. The aim of our study was to evaluate its value in healing of wounds after wide excision on pilonidal cyst healing. METHODS: A prospective randomized trial was conducted from March 2016 to February 2022 which included patients with a persistent non healed wound which required packing 6 weeks after pilonidal cyst excision. Patients were randomly allocated to simple alginate wick dressings or the same design plus honey. RESULTS: Fifty patients were included in each arm. There were 57 men and 43 women. The median age was 22 years (range 19-28 years). The mean healing time was 61 (± 44) days in the wick + honey group compared to 78 (± 55) days in the simple alginate wick group (p = 0.094). There was no significant difference between the two groups in terms of time off work and time without physical activity The VQ-Dermato quality of life score was equivalent in both groups. CONCLUSIONS: Tolerability for honey dressings is good and is equivalent to that of alginate dressings in cavity wound care. This trial did not reach a significant difference in its primary endpoint but it shows the value of honey in this indication, although its use requires further study. TRIAL REGISTRATION NUMBER: CLINICAL TRIALS: NCT02485860 and EUDRACT: 2015-A00452-47 (10/03/2015).

Effect of empagliflozin on ectopic fat stores and myocardial energetics in type 2 diabetes: the EMPACEF study.

BACKGROUND: Empagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that has demonstrated cardiovascular and renal protection in patients with type 2 diabetes (T2D). We hypothesized that empaglifozin (EMPA) could modulate ectopic fat stores and myocardial energetics in high-fat-high-sucrose (HFHS) diet mice and in type 2 diabetics (T2D). METHODS: C57BL/6 HFHS mice (n = 24) and T2D subjects (n = 56) were randomly assigned to 12 weeks of treatment with EMPA (30 mg/kg in mice, 10 mg/day in humans) or with placebo. A 4.7 T or 3 T MRI with 1H-MRS evaluation-myocardial fat (primary endpoint) and liver fat content (LFC)-were performed at baseline and at 12 weeks. In humans, standard cardiac MRI was coupled with myocardial energetics (PCr/ATP) measured with 31P-MRS. Subcutaneous (SAT) abdominal, visceral (VAT), epicardial and pancreatic fat were also evaluated. The primary efficacy endpoint was the change in epicardial fat volume between EMPA and placebo from baseline to 12 weeks. Secondary endpoints were the differences in PCr/ATP ratio, myocardial, liver and pancreatic fat content, SAT and VAT between groups at 12 weeks. RESULTS: In mice fed HFHS, EMPA significantly improved glucose tolerance and increased blood ketone bodies (KB) and ß-hydroxybutyrate levels (p < 0.05) compared to placebo. Mice fed HFHS had increased myocardial and liver fat content compared to standard diet mice. EMPA significantly attenuated liver fat content by 55%, (p < 0.001) but had no effect on myocardial fat. In the human study, all the 56 patients had normal LV function with mean LVEF = 63.4 ± 7.9%. Compared to placebo, T2D patients treated with EMPA significantly lost weight (- 2.6 kg [- 1.2; - 3.7]) and improved their HbA1c by 0.88 ± 0.74%. Hematocrit and EPO levels were significantly increased in the EMPA group compared to placebo (p < 0.0001, p = 0.041). EMPA significantly increased glycosuria and plasma KB levels compared to placebo (p < 0.0001, p = 0.012, respectively), and significantly reduced liver fat content (- 27 ± 23 vs. - 2 ± 24%, p = 0.0005) and visceral fat (- 7.8% [- 15.3; - 5.6] vs. - 0.1% [- 1.1;6.5], p = 0.043), but had no effect on myocardial or epicardial fat. At 12 weeks, no significant change was observed in the myocardial PCr/ATP (p = 0.57 between groups). CONCLUSIONS: EMPA effectively reduced liver fat in mice and humans without changing epicardial, myocardial fat or myocardial energetics, rebutting the thrifty substrate hypothesis for cardiovascular protection of SGLT2 inhibitors. Trial registration NCT, NCT03118336. Registered 18 April 2017, https://clinicaltrials.gov/ct2/show/NCT03118336.

Thermal plasma activation and UV/H2O2 oxidative degradation of pharmaceutical residues.

The aquatic environment becomes increasingly contaminated by anthropogenic pollutants such as pharmaceutical residues. Due to poor biodegradation and continuous discharge of persistent compounds in sewage water samples, pharmaceutical residues might end up in surface waters when not removed. To minimize this pollution, onsite wastewater treatment techniques might complement conventional waste water treatment plants (WWTPs). Advanced oxidation processes are useful techniques, since reactive oxygen species (ROS) are used for the degradation of unwanted medicine residues. In this paper we have studied the advanced oxidation in a controlled laboratory setting using thermal plasma and UV/H2O2 treatment. Five different matrices, Milli-Q water, tap water, synthetic urine, diluted urine and synthetic sewage water were spiked with 14 pharmaceuticals with a concentration of 5 µg/L. All compounds were reduced or completely decomposed by both 150 W thermal plasma and UV/H2O2 treatment. Additionally, also hospital sewage water was tested. First the concentrations of 10 pharmaceutical residues were determined by liquid chromatography mass spectrometry (LC-MS/MS). The pharmaceutical concentration ranged from 0.08 up to 2400 µg/L. With the application of 150 W thermal plasma or UV/H2O2, it was found that overall pharmaceutical degradation in hospital sewage water were nearly equivalent to the results obtained in the synthetic sewage water. However, based on the chemical abatement kinetics it was demonstrated that the degree of degradation decreases with increasing matrix complexity. Since reactive oxygen and nitrogen species (RONS) are continuously produced, thermal plasma treatment has the advantage over UV/H2O2 treatment.

A Case of Prolonged Angioedema After Cardiac Surgery.

Angioedema (AE) is a transient capillary leak syndrome, caused by either histamine or bradykinin, that presents as an acute nonpitting swelling of the skin, subcutaneous tissues, and mucous membranes of the face, lips, tongue, upper airways, and gastrointestinal tract, with or without a rash. A lack of response to antihistamines, steroids, and epinephrine suggests a bradykinin-mediated AE. Bradykinin-AE may be inherited, acquired, or drug related. Mechanism of increased bradykinin can include decreased C1-esterase inhibitor (C1-INH) levels or activity, increased bradykinin production, or decreased bradykinin breakdown, the latter occurring during angiotensin converting enzyme inhibitor (ACEi). A 65-year-old woman had coronary artery bypass grafting, which was complicated by prolonged bradykinin-AE owing to ACEi, requiring prolonged endotracheal tube intubation. Treatment with a C1-esterase inhibitor (Berinert) on postoperative day 7 resulted in a dramatic improvement in airway edema and tongue swelling within 7 hours, and the patient was subsequently extubated. The case is unusual because of the prolonged course of AE and the benefit of late administration of C1-INH concentrate.

Posttraumatic Stress Related to Hyperglycemia: Prevalence in Adults with Type I Diabetes.

Prevalence of hyperglycemia-related posttraumatic stress (PTS) was assessed in 239 adults with type 1 diabetes using the posttraumatic stress diagnostic scale (PDS; Foa, Posttraumatic stress diagnostic scale manual, National Computer Systems, Inc., Minneapolis, 1995) by an anonymous online survey. Additionally, this study aimed to identify variables related to hyperglycemia-related PTS. Over 30 % of participants reported symptoms consistent with PTSD related to hyperglycemia with standard PDS scoring, and 10 % with more conservative scoring. Hierarchical multiple regression analyses indicated that diabetes self-management behavior and perceived helplessness about hyperglycemia predicted PTSD with standard scoring. Perceived death threat, self-management behavior, helplessness about hyperglycemia, and severity of hypoglycemia in past month predicted PTSD using more conservative scoring. Perceived helplessness, hypoglycemia severity, perceived death-threat, HbA1c, and self-management behavior predicted PTS severity. When fear, helplessness, and perceived death-threat were combined to represent an overall cognitive appraisal factor, this variable was the strongest predictor of PTSD and PTS severity. Scores for PTSD symptom clusters appeared similar to data on hypoglycemia-related PTS.

Acute trauma and multiple injuries in the elderly population.

PURPOSE OF REVIEW: Traumatic injuries in the rapidly growing elderly population pose a significant challenge to the healthcare community. These injuries are associated with significant morbidity and mortality, and as a result cause a financial burden on the medical system. Although normal decline in physiologic reserve can provide some explanation for these poor outcomes, there is significant room for improvement. This review will summarize recent literature around the evaluation and management of elderly trauma patients with a particular focus on those with hip fractures. RECENT FINDINGS: It is becoming increasingly evident that customized evaluation and management of elderly trauma patients is a key factor in improving outcomes. Geriatric-specific triage and assessment criteria have been developed and initial results are encouraging. In particular, the use of frailty as an assessment tool in these patients has been shown to be an independent predictor of outcomes. Further, assessment of these tools in elderly trauma patients with hip fractures has provided a wealth of information about their use and limitations. SUMMARY: Differentiated, geriatric-specific triaging, assessment and treatment pathways in the care of elderly trauma patients will ultimately lead to improvements in outcomes. These improvements have already started to be seen in the realm of orthogeriatrics.

Alveolar Oral Layer Repair by Periosteal Grafts versus Maxillary Flaps and Gingivoperiosteoplasty: Techniques and Follow-up to Adolescence.

Background: Alveolar periosteoplasty during primary repair of cleft lip is still a topic of debate due to the fear exacerbating maxillary retrusion. The authors present their experience with early closure of alveolar clefts. The study aims to analyze gingivoperiosteoplasty (GPP) by comparing the use of locoregional flaps versus distant grafts for reconstruction of the lower layer of the primary palate cleft. Methods: Seventeen infants underwent 22 alveolar cleft repairs. After nasal floor repair by nasal mucoperiosteum, the oral layer was repaired by maxillary or gingival periosteal flaps in seven patients with alveolar clefts less than or equal to 6 mm wide, and tibial or pericranial periosteal grafts in 10 patients with wider clefts. At teenage years, crossbites in three flap-GPP and three graft-GPP patients were compared with nine older adolescents without primary GPP. Results: Alveolar clefts were perfectly sealed. Radiographs during the early 3 postoperative years showed new bone formation more posteriorly extended in patients who underwent graft-GPP. Teeth eruption and alveolar rigidity at the mixed dentition age eliminated the need for secondary bone grafting. The anterior crossbites in adolescent patients ranged between -2 and -14 mm; crossing was relatively smaller in patients with a younger age and without cleft palate. The mean crossbite was 7.2 mm in the six teenagers and 9.6 mm in the control cases. Conclusions: Graft-GPP may be a good alternative to flap-GPP, particularly for wide alveolar cleft repair. Maxillary retrusion is aggravated in patients with cleft palate and older age at assessment. GPP may not increase crossbite.

Unilateral acute idiopathic maculopathy. 1991.

This is a report of nine patients who experienced sudden, severe, unilateral central vision loss following a flulike illness. Each patient had an exudative detachment of the macula. All patients experienced a spontaneous resolution of the acute macular manifestations with near-complete recovery of vision. A characteristic "bull's-eye" appearance in the macula persisted. The acute manifestations of the disorder did not recur in any of the patients during the period of follow-up. The constellation of findings was suggestive of an inflammatory disease of the retinal pigment epithelium, but a specific causative agent could not be identified. The acute clinical and angiographic features, the natural course, and the residual pigment epithelial derangement were not consistent with any previously described disorder.

Drivers and distribution of global ocean heat uptake over the last half century.

Since the 1970s, the ocean has absorbed almost all of the additional energy in the Earth system due to greenhouse warming. However, sparse observations limit our knowledge of where ocean heat uptake (OHU) has occurred and where this heat is stored today. Here, we equilibrate a reanalysis-forced ocean-sea ice model, using a spin-up that improves on earlier approaches, to investigate recent OHU trends basin-by-basin and associated separately with surface wind trends, thermodynamic properties (temperature, humidity and radiation) or both. Wind and thermodynamic changes each explain ~ 50% of global OHU, while Southern Ocean forcing trends can account for almost all of the global OHU. This OHU is enabled by cool sea surface temperatures and sensible heat gain when atmospheric thermodynamic properties are held fixed, while downward longwave radiation dominates when winds are fixed. These results address long-standing limitations in multidecadal ocean-sea ice model simulations to reconcile estimates of OHU, transport and storage.

Determination of cytotoxicity following oxidative treatment of pharmaceutical residues in wastewater.

Pharmaceutical residues are released in the aquatic environment due to incomplete removal from wastewater. With the presence of multiple chemicals in sewage waters, contaminants may adversely affect the effectiveness of a wastewater treatment plant (WWTP). In certain cases, discharged metabolites are transformed back into their pristine structure and become bioactive again. Other compounds are persistent and can withstand conventional wastewater treatment. When WWTP effluents are released in surface waters, pristine and persistent chemicals can affect the aquatic environment. To complement WWTPs and circumvent incomplete removal of unwanted chemicals or pharmaceuticals, on-site wastewater treatment can contribute to their removal. Advanced oxidation processes (AOPs) are very powerful techniques for the abatement of pharmaceuticals, however, under certain circumstances reactive toxic by-products can be produced. We studied the application of on-site AOPs in a laboratory setting. It is expected that treatment at the contamination source can eliminate the worst polluters. Thermal plasma and UV/H2O2 oxidation were applied on simulation matrices, Milli-Q and synthetic sewage water spiked with 10 different pharmaceuticals in a range of 0.1 up to 2400 µg/L. In addition, untreated end-of-pipe hospital effluent was also subjected to oxidative treatment. The matrices were activated for 180 min and added to cultured HeLa cells. The cells were 24 h and 48 h exposed at 37 °C and subsequently markers for oxidative stress and viability were measured. During the UV/H2O2 treatment periods no toxicity was observed. After thermal plasma activation of Milli-Q water (150 and 180 min) toxicity was observed. Direct application of thermal plasma treatment in hospital sewage water caused elimination of toxic substances. The low cytotoxicity of treated pharmaceutical residues is likely to become negligible if plasma pre-treated on-site wastewater is further diluted with other sewage water streams, before reaching the WWTP. Our study suggests that AOPs may be promising technologies to remove a substantial portion of pharmaceutical components by degradation at the source. Further studies will have to be performed to verify the feasibility of upscaling this technology from the benchtop to practice.

Drugs Commonly Applied to Kidney Patients May Compromise Renal Tubular Uremic Toxins Excretion.

In chronic kidney disease (CKD), the secretion of uremic toxins is compromised leading to their accumulation in blood, which contributes to uremic complications, in particular cardiovascular disease. Organic anion transporters (OATs) are involved in the tubular secretion of protein-bound uremic toxins (PBUTs). However, OATs also handle a wide range of drugs, including those used for treatment of cardiovascular complications and their interaction with PBUTs is unknown. The aim of this study was to investigate the interaction between commonly prescribed drugs in CKD and endogenous PBUTs with respect to OAT1-mediated uptake. We exposed a unique conditionally immortalized proximal tubule cell line (ciPTEC) equipped with OAT1 to a panel of selected drugs, including angiotensin-converting enzyme inhibitors (ACEIs: captopril, enalaprilate, lisinopril), angiotensin receptor blockers (ARBs: losartan and valsartan), furosemide and statins (pravastatin and simvastatin), and evaluated the drug-interactions using an OAT1-mediated fluorescein assay. We show that selected ARBs and furosemide significantly reduced fluorescein uptake, with the highest potency for ARBs. This was exaggerated in presence of some PBUTs. Selected ACEIs and statins had either no or a slight effect at supratherapeutic concentrations on OAT1-mediated fluorescein uptake. In conclusion, we demonstrate that PBUTs may compete with co-administrated drugs commonly used in CKD management for renal OAT1 mediated secretion, thus potentially compromising the residual renal function.

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review.

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.

Growth hormone (GH1) gene variation and the growth hormone receptor (GHR) exon 3 deletion polymorphism in a West-African population.

Among Europeans, functionally significant GH1 gene variants occur not only in individuals with idiopathic growth hormone (GH) deficiency and/or short stature but also fairly frequently in the general population. To assess the generality of these findings, 163 individuals from Benin, West Africa were screened for mutations and polymorphisms in their GH1 genes. A total of 37 different sequence variants were identified in the GH1 gene region, 24 of which occurred with a frequency of >1%. Although four of these variants were novel missense substitutions (Ala13Val, Arg19His, Phe25Tyr and Ser95Arg), none of these had any measurable effect on either GH function or secretion in vitro. Some 37 different GH1 promoter haplotypes were identified, 23 of which are as yet unreported in Europeans. The mean in vitro expression level of the GH1 promoter haplotypes observed in the African population was significantly higher than that previously measured in Britons (p<0.001). A gene conversion in the GH1 promoter, previously reported in a single individual of British origin, was found to occur at polymorphic frequency (5%) in the West-African population and was associated with a 1.7-fold increase in promoter activity relative to the wild-type. The d3 allele of the GHR exon 3 deletion polymorphism, known to be associated with increased GH responsiveness, was also found to occur at an elevated frequency in these individuals from Benin. We speculate that both elevated GH1 gene expression and increased GHR-mediated GH responsiveness may constitute adaptive responses to the effects of scarce food supply in this West-African population since increased circulating GH appears to form part of a physiological response to nutritional deprivation.

Active cushing syndrome patients have increased ectopic fat deposition and bone marrow fat content compared to cured patients and healthy subjects: a pilot 1H-MRS study.

OBJECTIVE: Glucocorticoid excess is one of the most important causes of bone disorders. Bone marrow fat (BMF) has been identified as a l new mediator of bone metabolism. Cushing syndrome (CS), is a main regulator of adipose tissue distribution but its impact on BMF is unknown. The objective of the study was to evaluate the effect of chronic hypercortisolism on BMF. DESIGN: This was a cross-sectional study. Seventeen active and seventeen cured ACTH-dependent CS patients along with seventeen controls (matched with the active group for age and sex) were included. METHODS: the BMF content of the femoral neck and L3 vertebrae were measured by 1H-MRS on a 3-Tesla wide-bore magnet. BMD was evaluated in patients using dual-energy X-ray absorptiometry. RESULTS: Active CS patients had higher BMF content both in the femur (82.5±2.6%) and vertebrae (70.1±5.1%) compared to the controls (70.8±3.6%, p=0.013 and 49.0±3.7% p=0.005, respectively). In cured CS patients (average remission time of 43 months), BMF content was not different from controls at both sites (72.3±2.9% (femur) and 46.7%±5.3% (L3)). BMF content was positively correlated with age, fasting plasma glucose, HbA1c, triglycerides and visceral adipose tissue in the whole cohort and negatively correlated with BMD values in the CS patients . CONCLUSIONS: Accumulation of BMF is induced by hypercortisolism. In remission patients BMF reached values of controls. Further studies are needed to determine whether this increase in marrow adiposity in CS is associated with bone loss.

Practical strategies for increasing efficiency and effectiveness in critical care education.

Technological advances and evolving demands in medical care have led to challenges in ensuring adequate training for providers of critical care. Reliance on the traditional experience-based training model alone is insufficient for ensuring quality and safety in patient care. This article provides a brief overview of the existing educational practice within the critical care environment. Challenges to education within common daily activities of critical care practice are reviewed. Some practical evidence-based educational approaches are then described which can be incorporated into the daily practice of critical care without disrupting workflow or compromising the quality of patient care. It is hoped that such approaches for improving the efficiency and efficacy of critical care education will be integrated into training programs.