Effects of Head and Neck Cancer Radiotherapy on Cricothyroid Membrane Related Dimensions.

Background: Radiation treatment can modify soft tissue dynamics depending on the extent and location of irradiation. We hypothesized that head and neck radiotherapy caused alterations in cricothyroid membrane (CTM) related dimensions. Objectives: Primary objective was to evaluate changes in the cricothyroid membrane height (CTMH) and skin-to-CTM distance (STCD) in patients who underwent radiation treatment for head and neck cancers. Methods: Pre- and post-head-and-neck cancer-radiated computed tomography (CT) scans were analyzed retrospectively. The patients' demographics (age, sex, body mass index, cancer location), radiation dose and laterality, time from radiation initiation to CT scan assessments were summarized. CTMH and STCD were measured from pre-and post-radiation CT scans. Pre- and post-radiation comparisons were conducted using a paired t-test, or Wilcoxon signed-rank test if more appropriate. Chi-squared or Fisher's Exact test were used for categorical variables. Results: Among 231 study patients, who underwent head and neck radiotherapy in our institution 73.2% were males, and the median age of total population was 66 years (31-93). The median BMI was 25.2 kg/m2 (13.8-47.2). The median time from first radiation dose to CT scan assessment was 29.5 months (2-115).The median pre- and post-radiation CTMH were 8.7 mm (3-16.2) and 7.5 mm (3.1-14.3) respectively. The median pre- and post-radiation STCD were 11.7 mm (2.9-71.1) and 10.2 mm (3.9-38) respectively. Conclusion: In summary our patient population had significant reduction of cricothyroid membrane related dimensions following head-and-neck radiotherapy, which can limit the localization of the cricothyroid membrane. Level of evidence III: Retrospective cohort study.

Management of respiratory failure in immune checkpoint inhibitors-induced overlap syndrome: a case series and review of the literature.

BACKGROUND: Checkpoint inhibitor-induced overlap syndrome ([OS] myocarditis, and myositis with or without myasthenia gravis) is rare but life-threatening. CASES PRESENTATION: Here we present a case series of four cancer patients that developed OS. High troponinemia raised the concern for myocarditis in all the cases. However, the predominant clinical feature differed among the cases. Two patients showed marked myocarditis with a shorter hospital stay. The other two patients had a prolonged ICU stay due to severe neuromuscular involvement secondary to myositis and myasthenia gravis. Treatment was based on steroids, plasmapheresis, intravenous immunoglobulin, and immunosuppressive biological agents. CONCLUSION: The management of respiratory failure is challenging, particularly in those patients with predominant MG. Along with intensive clinical monitoring, bedside respiratory mechanics can guide the decision-making process of selecting a respiratory support method, the timing of elective intubation and extubation.

Clinical Characteristics and Cause of Death Among Hospitalized Decedents With Cancer and COVID-19.

There is scant information on the clinical progression, end-of-life decisions, and cause of death of patients with cancer diagnosed with COVID-19. Therefore, we conducted a case series of patients admitted to a comprehensive cancer center who did not survive their hospitalization. To determine the cause of death, 3 board-certified intensivists reviewed the electronic medical records. Concordance regarding cause of death was calculated. Discrepancies were resolved through a joint case-by-case review and discussion among the 3 reviewers. During the study period, 551 patients with cancer and COVID-19 were admitted to a dedicated specialty unit; among them, 61 (11.6%) were nonsurvivors. Among nonsurvivors, 31 (51%) patients had hematologic cancers, and 29 (48%) had undergone cancer-directed chemotherapy within 3 months before admission. The median time to death was 15 days (95% confidence interval [CI], 11.8 to 18.2). There were no differences in time to death by cancer category or cancer treatment intent. The majority of decedents (84%) had full code status at admission; however, 53 (87%) had do-not-resuscitate orders at the time of death. Most deaths were deemed to be COVID-19 related (88.5%). The concordance between the reviewers for the cause of death was 78.7%. In contrast to the belief that COVID-19 decedents die because of their comorbidities, in our study only 1 of every 10 patients died of cancer-related causes. Full-scale interventions were offered to all patients irrespective of oncologic treatment intent. However, most decedents in this population preferred care with nonresuscitative measures rather than full support at the end of life.

Intraoperative Anesthesiology Management and Patient Outcomes for Surgical Revascularization for Moyamoya Disease: A Review and Clinical Experience.

BACKGROUND: Moyamoya disease (MMD) is a rare cerebrovascular condition, often presenting as a headache or stroke in adults. Anesthetic management of this illness may challenge providers because it can affect the long-term neurologic outcome and hospital length of stay (LOS) in patients with MMD. MATERIALS AND METHODS: A literature search was conducted to assess etiology and epidemiology, as well as existing reports of intraoperative management of MMD. Due to sparse findings, the search was expanded to include studies of the use of intraoperative anesthetic agents during other neurosurgical procedures. We also retrospectively reviewed all MMD cases from January 1, 2009, to December 31, 2015, at Memorial Hermann Hospital-Texas Medical Center, where intraoperative management involved craniotomy and surgical revascularization. Data were collected primarily on the use of several anesthetic agents. The LOS and any adverse events were also recorded for each case. The data were divided into two equivalent case cohorts: (1) January 1, 2009, to February 18, 2013, and (2) February 19, 2013, to December 31, 2015. RESULTS: Remifentanil use notably increased between the first and second time periods while fentanyl use decreased. Desflurane usage also demonstrated an observed increase when our two cohorts were compared. Additionally, there was a decrease in the mean LOS between the first and second periods of 3.9 and 3.3 days, respectively. CONCLUSION: Increasing use of remifentanil in MMD cases could be attributed to its ability to provide more stable hemodynamics during induction, maintenance, and emergence of anesthesia when compared with fentanyl. Lower systolic pressures, diastolic pressures, and heart rates were reported in patients receiving remifentanil over fentanyl.

Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: Retrospective analysis of patient outcomes.

STUDY OBJECTIVE: To investigate the impact of utilizing a multimodal analgesia protocol to allow the implementation of Enhanced Recovery after Cardiac Surgery (ERACS) in patients requiring cardio-pulmonary bypass. DESIGN: Retrospective analysis of patients treated with the proposed ERACS bundle in comparison to matched controls. SETTING: Single-center study. PATIENTS: A total of 50 patients undergoing elective cardiac surgery limited to on pump coronary artery bypass graft. MEASUREMENTS: Perioperative outcomes of 25 patients that underwent ERACS protocol and 25 controls were measured. In-operating room (OR) extubation, total intubation time, total intra-OP fentanyl given, total post-OP morphine equivalent given, intensive care unit (ICU) length of stay (LOS), hospital LOS and post-OP complications were examined. MAIN RESULTS: The ERACS group and control group were equivalent with regards to age, gender, comorbidities, ASA classification and type of surgery. Mean cardiac bypass time and mean aortic clamp time were similar. Extubation in the OR was achieved for 12 patients in the ERACS group compared to 1 in the control group. Post-operative opioid consumption was lower in ERACS group (27.3 vs. 51.7 morphine equivalents, p = 0.006). Although ICU LOS and hospital LOS were shorter in the ERACS group, this did not reach significance. CONCLUSIONS: The ERACS group showed a significant decrease in opioid use and increased incidence of successful in OR extubation.

Incidence and Outcomes of Heparin-Induced Thrombocytopenia in Patients Undergoing Vascular Surgery.

OBJECTIVE: The National Inpatient Sample (NIS) from years 2010 through 2012 was utilized to determine the incidence, predictive risk factors, and outcomes of heparin-induced thrombocytopenia (HIT) in patients undergoing vascular surgery. DESIGN: Retrospective population-based study. SETTING: Data from the National Inpatient Sample (NIS) (2011 through 2013) using specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes corresponding with vascular surgery. PARTICIPANTS: 425,379 hospital admissions in patients which underwent vascular surgery. Among these, 1,290 (0.31%) were diagnosed with HIT, and 17,765 (4.18%) were diagnosed with secondary thrombocytopenia. MEASUREMENTS AND RESULTS: The incidence of HIT is 0.3% in the vascular surgery population. The highest incidence is observed in thoraco-subclavian and vein reconstruction procedures. This study indicated that liver disease, endocarditis, chronic renal failure, congestive heart failure, atrial fibrillation, obesity, and female sex are associated with a higher incidence of HIT in this population. In vascular surgery patients, HIT can increase mortality by 3-fold and lead to severe complications such as acute renal failure, venous embolism, pulmonary embolism, and respiratory failure. CONCLUSION: The incidence of HIT in the vascular surgery population is similar to previously reported incidence in cardiac surgery patients. In the vascular surgery population, mortality increases 3-fold in patients with HIT versus those without any thrombocytopenia. Understanding the associated risk factors and complications will allow clinicians to make informed decisions and anticipate HIT and associated complications in certain high-risk populations.

Gastrointestinal Complications After Cardiac Surgery: A Nationwide Population-Based Analysis of Morbidity and Mortality Predictors.

OBJECTIVE: The authors aimed to evaluate the incidence, risk factors, and outcomes of gastrointestinal (GI) complications in cardiac and aortic surgery using recent versions of the National (Nationwide) Inpatient Sample (NIS) to provide clinicians with a better understanding of these uncommon but potentially serious complications. DESIGN: Population-based study. SETTING: NIS database 2010-2012. PARTICIPANTS: Patients undergoing cardiac and aortic aneurysm repair surgeries. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: The most common GI complication was postoperative ileus, which also had the lowest mortality, followed by GI hemorrhage. Mesenteric ischemia demonstrated the highest mortality, followed by intestinal perforation. Mortality was highest in those with infective endocarditis (16.02%), followed by myocardial infarction (12.48%). GI complications were highest in patients undergoing repair of abdominal aortic aneurysm, followed by off-pump coronary artery bypass grafting. CONCLUSION: In conclusion, this study demonstrated that GI complications after cardiac surgery occurred at a rate of 4.17%, which is similar to that reported in the NIS database from 1998 to 2002 in coronary artery bypass grafting patients, but higher than that previously described in single-center studies. GI complications after cardiac surgery increased inpatient mortality 3-fold and more than doubled length of stay. Improved recognition and understanding of the predisposing risk factors and complications elucidated in this study could serve to increase the necessity for timely diagnosis and treatment of patients at high risk for GI complications after cardiac surgery.

Evaluating the Adjuvant Effect of Dexamethasone to Ropivacaine in Transversus Abdominis Plane Block for Inguinal Hernia Repair and Spermatocelectomy: A Randomized Controlled Trial.

BACKGROUND: The transversus abdominis plane (TAP) block is a relatively straightforward regional technique used for postoperative analgesia in patients undergoing abdominal surgeries. Various adjuvants have been used in past to prolong the duration of action of analgesia in peripheral nerve blocks. Several studies investigating the analgesic efficacy of dexamethasone added to local anesthetic agents, such as bupivacaine, have shown promising results. However, there are few studies comparing the efficacy of dexamethasone with ropivacaine. OBJECTIVES: To determine if the addition of dexamethasone 8 mg to ropivacaine 0.2% in a TAP block would prolong the analgesic effect when compared with ropivacaine 0.2% alone after inguinal hernia repair and spermatocelectomy. STUDY DESIGN: A randomized, double blinded, placebo-controlled, prospective study. SETTING: Teaching hospital. METHODS: A total of 82 patients undergoing inguinal hernia repair or spermatocelectomy were enrolled in the study, of which 41 patients received TAP block with ropivacaine with saline, and the other 41 received ropivacaine with dexamethasone immediately following surgery. Both the proceduralist (resident) and the patient were blinded to the solution used. Visual analog pain scores (0 - 10) were obtained pre-block and immediately post block. Our primary endpoint was visual analog pain score at 12 hours, with 24 and 48-hour pain scores as the secondary endpoints. RESULTS: The averaged pre-block pain score was 7.6 ± 1.7 in the saline group and 7.7 ± 2.2 in the dexamethasone group. There was an improvement in the pain scores from the baseline, at 12 hours after the administration of the block in both the groups. Although the dexamethasone group had a greater change in pain score (-3.2) than the saline group (-2.2), the difference between the 2 groups was not statistically significant (0.08). We did not observe significant differences in change from baseline at 24 hours and 48 hours between the 2 groups (P value = 0.74 and 0.44, respectively). LIMITATIONS: We did not assess the total dose of analgesics used during the surgery with the assumption that the effect of intraoperative analgesics should wear off by the time we collect the 12-hour pain score. We did not control for the expertise of the provider that performed the block, as some of the providers may have been junior residents with limited experience and expertise in the area. Additionally, we were unable to include postoperative opioid consumption due to concerns of inconsistencies during patient reporting and data quality. CONCLUSIONS: In conclusion, we could not show a statistically significant prolongation of analgesia for TAP blocks with ropivacaine when dexamethasone was added, though there was a one point drop in pain score at 12 hours post block when dexamethasone was added to the block solution. This decrease in pain scores at 12 hours may still be beneficial to patient satisfaction given the low side effect profile of dexamethasone. As ropivacaine has a lower pH than other local anesthetic agents, further well designed studies are needed to investigate the combination of this drug with more alkaline drugs like corticosteroids. KEY WORDS: Regional anesthesia, transversus abdominis plane, dexamethasone, ropivacaine.

In-Hospital Mortality with Use of Percutaneous Endoscopic Gastrostomy in Traumatic Brain Injury Patients: Results of a Nationwide Population-Based Study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive procedure that has been associated with high short-term mortality. Its use of special interest in traumatic brain injury (TBI) patients as nutrition support constitutes important issues in intensive care of this group. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among TBI patients undergoing PEG. METHODS: We conducted a retrospective study using the US nationwide inpatient sample to analyze data from all hospitalizations in 2008 with International Classification of Diseases, Ninth Revision, diagnostic and procedure codes identifying patients with TBI and hemorrhagic stroke who received PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality in this patient population. Patients who did not undergo PEG were used as control. RESULTS: In-hospital mortality after PEG was 6% (95% CI, 0.05-0.76%) among the TBI population with 0.2% occurring in the first 7 days and 2% occurring in the first 14 days. These patients had a higher incidence of other trauma-related comorbidities and were classified as high-risk stratification based on SRRi score compared to the non-PEG group. Factors strongly predictive of in-hospital mortality were age >51 years, not receiving a PEG, and having a high comorbidity burden of >2. CONCLUSION: Understanding the rate of mortality associated with PEG in this patient population and identifying factors that increase and decrease the risk of death will improve patient selection for those most likely to benefit from this procedure.

Eugenia 'negativa', psiquiatria e catolicismo: embates em torno da esterilização eugênica no Brasil / 'Negative' eugenics, psychiatry, and Catholicism: clashes over eugenic sterilization in Brazil

Analisa o diálogo do eugenista Renato Kehl com um grupo de psiquiatras brasileiros que, no início da década de 1930, aproximaram-se da chamada eugenia negativa. Entusiasmados com as pesquisas e a aplicação de medidas eugênicas em países como os EUA e a Alemanha, autores como Ernani Lopes, Ignácio da Cunha Lopes, Alberto Farani e Antonio Carlos Pacheco e Silva elegeram a religião católica como empecilho para que o Brasil pudesse seguir caminho semelhante, especialmente quanto à resistência à implantação da esterilização dos ditos 'degenerados' que passara a vigorar na Alemanha em 1934. O artigo mapeia as diferentes estratégias propostas pelos autores para dialogar com a Igreja católica.

The article analyzes the dialogue between eugenicist Renato Kehl and a group of Brazilian psychiatrists who turned their interest to so-called negative eugenics in the early 1930s. Enthused about research into eugenics and the application of eugenic methods in countries such as the United States and Germany, authors like Ernani Lopes, Ignácio da Cunha Lopes, Alberto Farani, and Antonio Carlos Pacheco e Silva blamed Catholicism for impeding Brazil from moving in a similar direction, especially the church's resistance to the sterilization of 'degenerates', which entered into effect in Germany in 1934. The article charts the various strategies these authors proposed for engaging in dialogue with the Catholic Church.

Resolution of hyperlipidemia follows surgical weight loss in patients undergoing Roux-en-Y gastric bypass surgery: a 6-year analysis of data.

BACKGROUND: Hyperlipidemia is a known risk factor for the development of atherosclerosis and coronary artery disease in morbidly obese individuals. The aim of our study was to review the trends in the serum lipid profiles of patients undergoing Roux-en-Y gastric bypass at our institution. METHODS: A retrospective 6-year analysis of data of patients undergoing Roux-en-Y gastric bypass was performed. The indicators of resolution of hyperlipidemia were reviewed for 6 months and then annually for 6 consecutive years. Hyperlipidemia was defined according to the American Heart Association and National Cholesterol Education Program Adult Treatment Panel III guidelines. The changes in the lipid profile of the patients with subnormal levels of high-density lipoprotein (HDL) cholesterol and total cholesterol/HDL cholesterol risk ratio were also examined. RESULTS: A total of 94 patients were diagnosed with hyperlipidemia, of whom 23 were receiving clinical treatment. The mean patient age was 39 ± 9 years, and the mean body mass index was 50 ± 9.6 kg/m(2), with a female predominance. The mean baseline serum levels were as follows: total cholesterol 220 ± 42.2 mg/dL, triglycerides 212 ± 123.5 mg/dL, low-density lipoprotein cholesterol 135 ± 34.2 mg/dL, and HDL cholesterol 51 ± 12 mg/dL. The optimization of serum total cholesterol, triglycerides, and low-density lipoprotein cholesterol profiles was seen in all patients within 6 months after surgery. The HDL cholesterol levels improved more slowly, reaching desirable levels within 12 months after surgery. All patients taking lipid-lowering agents no longer required the medication at the end of the study period. CONCLUSION: Roux-en-Y gastric bypass provides an effective remission of hyperlipidemia in morbidly obese patients, with most patients no longer requiring lipid-lowering agents within 6 months after surgery. The improvement in overall lipid profiles continued during follow-up after surgery.

Livros do Arco do Cego no Brasil colonial

Entre 1799 e 1801, em Lisboa, o frade mineiro José Mariano da Conceição Veloso esteve à frente da Casa Literária do Arco do Cego, que, na curta duração de três anos, publicou ao menos 80 obras, entre trabalhos de agricultura, navegação e medicina. O projeto editorial daquela casa deve ser compreendido no contexto do programa governamental ilustrado de d. Rodrigo de Souza Coutinho. Visando a modernização do Império, incluía a difusão de conhecimentos técnicos e práticos em terras sob domínio luso, especialmente na América. Como a pesquisa sobre o projeto de difusão contribui para o entendimento da ilustração no Brasil, este artigo apresenta elementos sobre seu funcionamento e sua recepção.

Between 1799 and 1801, the friar José Mariano da Conceição Veloso, a Minas Gerais native, headed Lisbon's Casa Literária do Arco do Cego, which in a brief three-year span published at least eighty works on topics that included agriculture, navigation, and medicine. This editorial project must be understood within the context of Dom Rodrigo de Souza Coutinho's enlightened government program. Meant to modernize the Empire, it included dissemination of technical and practical knowledge in lands under Portuguese dominion, especially in the Americas. As a contribution to an understanding of the Enlightenment in Brazil, this article presents elements from my research on the development of the project and how it was received.

The backlands unveiled

This essay presents readers with the central argument from three books, ranging from Euclides da Cunhato Guimarães Rosa and the hygienist movement of the 1920s, focusing on the theme of the sertão (backlands) in Brazilian literature and social thought. Based on this presentation, the essay emphasizes that linked to the topic under review, Brazilian intellectual tradition has nearly always encompassed classical themes from sociology and political science, like incorporation and nation-building. Afterdigressing to the three authors’ styles, the essay concludes by suggesting the validity of performing comparative studies on approaches to the Brazilian backlands and those conducted by North American scholars.

Dans cet essai on présente le thème central de trois livres qui, depuis Euclides da Cunha jusqu’àGuimarães Rosa en passant par le mouvement sanitarista des années 20, abordent le sertão dans la littérature et la pensée sociale au Brésil. Sur cette base, on voit qu’il est fréquent, dans la tradition intelectuelle brésilienne, d’associer l’idée de sertão à des sujets de la sociologie et de la science politique, tels que celui de l’incorporation et de construction de la nation. Finalement, après des considérations sur le style des auteurs, on propose d’effectuer des études comparatives entre les approches concernant le Brésil profond et celles utilisées par les chercheurs nord-américains.