High incidence of (ultra)low oesophageal temperatures during cryoballoon pulmonary vein isolation for atrial fibrillation.

BACKGROUND: Low oesophageal temperatures (OTs) during cryoballoon pulmonary vein isolation (PVI) have been associated with complications. This study assessed the incidence of low OT in clinical practice during cryoballoon PVI and verified possible predictive values for low OT. METHODS: Consecutive patients who underwent PVI using the second-generation cryoballoon were retrospectively included. The distance from the oesophagus to the different pulmonary veins (PVs) (OP distance), body mass index (BMI), sex, age, balloon temperature and application time were studied as potential predictors of low OTs. Computed tomography was performed before the procedure to determine the OP distance. OT was measured using an oesophageal temperature probe. Applications were ended prematurely if the OT reached <16 °C. Low and ultralow OT were defined as OT <20 and <16 °C respectively. RESULTS: Two hundred and four patients were included. Low OT was observed in 54 patients (26%) and 27 patients (13%) reached ultralow OTs. OP distance was the only predictor of low OTs after multivariate analysis. A cut-off value of 19 mm showed 96.2% sensitivity and 37.8% specificity in predicting low OTs. No clinically relevant relation was found between low OTs and BMI, age, sex, balloon temperature or application duration. CONCLUSIONS: The incidence of low OT was 26% for cryoballoon PVI. OP distance was the only predictor of low OTs. Since an OP distance <19 mm was present in all patients in at least one PV, we recommend routine OT measurement during PVI cryoballoon therapy to prevent oesophagus-related complications.

Skeletal muscle mass and quality as risk factors for postoperative outcome after open colon resection for cancer.

BACKGROUND: The prevalence of colorectal cancer in the elderly is increasing and, therefore, surgical interventions with a risk of potential complications are more frequently performed. This study investigated the role of low skeletal muscle mass (sarcopenia), muscle quality, and the sarcopenic obesity as prognostic factors for postoperative complications and survival in patients with resectable colon cancer. METHODS: We conducted a retrospective chart review of 91 consecutive patients who underwent an elective open colon resection for cancer with primary anastomosis between 2011 and 2013. Skeletal muscle mass was measured as total psoas area (TPA) and total abdominal muscle area (TAMA) at three anatomical levels on the preoperative CT scan. Skeletal muscle quality was measured using corresponding mean Hounsfield units (HU) for TAMA. Their relation with complications (none vs one or more), severe complications, and survival was analyzed. RESULTS: The study included 91 patients with a mean age of 71.2 ± 9.7 years. Complications were noted in 55 patients (60 %), of which 15 (16.4 %) were severe. Lower HU for TAMA, as an indicator for impaired skeletal muscle quality, was an independent risk factor for one or more complications (all P ≤ 0.002), while sarcopenic obesity (TPA) was an independent risk factor for severe complications (all P ≤ 0.008). Sarcopenia was an independent predictor of worse overall survival (HR 8.54; 95 % confidence interval (CI) 1.07-68.32). CONCLUSION: Skeletal muscle quality is a predictor for overall complications, whereas sarcopenic obesity is a predictor for severe postoperative complications after open colon resection for cancer. Sarcopenia on itself is a predictor for worse overall survival.

Are computed tomography-based measures of specific abdominal muscle groups predictive of adverse outcomes in older cancer patients?

PURPOSE: It is unknown whether computed tomography (CT)-based total abdominal muscle measures are representative of specific abdominal muscle groups and whether analysis of specific abdominal muscle groups are predictive of the risk of adverse outcomes in older cancer patients. METHODS: Retrospective single-center cohort study in elective colon cancer patients aged ≥65 years. CT-based skeletal muscle (SM) surface area, muscle density and intermuscular adipose tissue (IMAT) surface area were determined for rectus abdominis; external- and internal oblique and transversus abdominis (lateral muscles); psoas; and erector spinae and quadratus lumborum (back muscles). Outcomes were defined as severe postoperative complications (Clavien-Dindo score >2) and long-term survival (median follow-up 5.2 years). RESULTS: 254 older colon cancer patients were included (median 73.6 years, 62.2% males). Rectus abdominis showed the lowest SM surface area and muscle density and the back muscles showed the highest IMAT surface area. Psoas muscle density, and lateral muscle density and percentage IMAT were associated with severe postoperative complications independent of gender, age and cancer stage. CONCLUSIONS: CT-based total abdominal muscle quantity and quality do not represent the heterogeneity that exists between specific muscle groups. The potential added value of analysis of specific muscle groups in predicting adverse outcomes in older (colon) cancer patients should be further addressed in prospective studies.

Primary prevention of catastrophic injury.

Motor vehicle crashes are a leading cause of injury and death until age 45. Efforts to prevent these injuries have largely followed the dictates of the public health movement focusing on interventions for entire communities or regulatory statutes. Individual interventions, more congruent with traditional psychological approaches, have been rare. This article argues that a blending of these two approaches is warranted. Evaluation of prevention programs should focus on multiple levels including the individual, the community, and regulatory processes. Identification of subgroups of adolescents and young adults with unique psychological and behavioral dispositions regarding injury must be paired with realistic interventions of adequate duration.

The comparability of the WRAT-R reading test and NAART as estimates of premorbid intelligence in neurologically impaired patients.

A study by Wiens, Bryan, and Crossen (1993) suggests the Wide Range Achievement Test-Revised (WRAT-R) Reading subtest and North American Adult Reading Test (NAART) are adequate predictors of Wechsler Adult Intelligence Scale-Revised (WAIS-R) IQ scores for a normal population. Although it is common practice to use reading scores to estimate premorbid IQ in clinical populations, the WRAT-R and NAART have not been compared using individuals with brain dysfunction. The current study cross-validated the Wiens et al. (1993) study using neurologically impaired populations: traumatic brain injury (n = 118), dementia (n = 37), and other neurologic impairments (n = 77). The results were generally consistent across all three groups: (a) the WRAT-R and NAART were equivalent and accurate estimates of average VIQ levels; (b) the WRAT-R and NAART were equivalent but underestimates of higher intelligence ranges; and (c) the WRAT-R is a more accurate estimate for lower VIQ ranges, although both are overestimates. This third finding is in contrast to Wiens et al.'s (1993) results that suggest the WRAT-R is an accurate estimate of lower IQ ranges for normals. It is concluded that the WRAT-R is the preferred measure of premorbid verbal intelligence for psychometric and clinical reasons.

[Growth retardation as a result of a presumption of multiple food hypersensitivity]. / Groeiachterstand als gevolg van vermeende voedselovergevoeligheid.

Two sisters, aged 5 and 6 years, were admitted to the hospital because of growth retardation accompanying supposed multiple food hypersensitivity. The older girl had asthma. Her symptoms had given cause for several non-regular practitioners to diagnose her and subsequently her sister as having 'food hypersensitivity'. The diet they were put on was further restricted by their parents when the symptoms did not subside. The diet was shown to be very monotonous and the energy supply was only half of the recommended daily allowances. Stepwise normalization of the diet was achieved and both girls showed catch-up growth in the following years. Food hypersensitivity has a considerably higher incidence when self reported than when diagnosed according to established criteria (elimination, provocation, re-elimination). Dietary changes in children should always take place under the supervision of a dietician, who can ensure that the diet is nutritionally adequate.

Hepatocellular carcinoma after danazol treatment for hereditary angio-oedema.

Hereditary angio-oedema is characterised by recurrent episodes of laryngeal, intra-abdominal, facial or peripheral oedema. Danazol can be used as prophylaxis for recurrent attacks. Hepatotoxicity is a recognised adverse effect of danazol. We report an exceptional case of a danazol-induced hepatocellular carcinoma in a 75-year-old patient with hereditary angio-oedema.

Cauda equina syndrome secondary to complicated diverticulitis.

A 58-year-old woman presented to the emergency department with cauda equina syndrome and sepsis. The symptoms were attributed to a complicated episode of sigmoid diverticulitis. MRI showed that the diverticulitis had caused an intra-abdominal fistula to a presacrally localized abscess expanding into the spinal canal, compressing the cauda equina nerves. Although Hartmann's procedure was performed, the neurological symptoms persisted, causing the patient to remain partially paraplegic. This case report illustrates that cauda equina syndrome is a condition that can also be caused by intra-abdominal pathology such as diverticulitis.

Anoxic encephalopathy: a case study of an eight-year-old male with no residual cognitive deficits.

Anoxia is generally associated with impaired learning, memory, attention, and planning. We present a case of near-drowning (5-15 minute anoxia) with subsequent 15 hour coma that is extremely unique because of (1) the absence of neuropsychological and neurological deficits 3 1/2 months post-injury, and (2) the availability of pre-injury intelligence testing for comparison. Findings are important as previous research has suggested residual deficits will be evident after much briefer coma. The present findings suggest anoxic encephalopathy does not automatically result in neurological or cognitive impairment.

Family functioning, social support and depression after traumatic brain injury.

Functional outcome after traumatic brain injury (TBI) is thought to be dependent upon effective social support and avoidance of depressive episodes. Research indicates that post-injury changes often occur in the family's functioning, hence impacting the family's ability to provide the needed social support. Social support, in turn, has been hypothesized to work as a buffer between significant life event and levels of depressive symptoms. Thus poor social support after a TBI, due to changes in family functioning, could result in depressive episodes for the person with a TBI. This paper empirically examines this question by investigating whether social support is predictive of depression in persons who have sustained a TBI. Thirty-nine persons who had sustained TBI were interviewed to assess their family functioning, perceived social support, and current depressive symptomatology. The results showed that the effective use of problem-solving and behavioural coping strategies by the family in response to TBI was significantly related to lower levels of depression in the person who sustained the TBI. However, perceived social support was not predictive of depression.