The role of bedside ultrasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is often a debilitating condition characterized by headaches, blurry vision, nausea, and vomiting. Lumbar puncture (LP) is an essential component of the diagnostic and therapeutic approach; however, the procedure itself can cause postlumbar puncture headache. In addition to the clinical presentation, the use of bedside ultrasound to measure the optic nerve sheath diameter may aid in differentiating the 2 conditions.We hereby report a case of a 33-year old woman with known IIH who presented with recurrent headache after the initial therapeutic LP.

Vogt-Koyanagi-Harada disease: presentation and implications in undocumented immigrants.

Vogt-Koyanagi-Harada syndrome is an autoimmune disease involving pigmented tissue in the eyes, auditory system, skin, and central nervous system. It often presents as bilateral chronic granulomatous panuveitis. We report the case of a 32-year-old immigrant who presented to the emergency department asking for a second opinion for loss of vision and progressive hearing loss. We also will discuss the issue limited access to health care for a vulnerable population such as undocumented immigrants.

A prospective, single-center, nonblinded, comparative, postmarket clinical evaluation of a bovine-derived collagen with ionic silver dressing versus a carboxymethylcellulose and ionic silver dressing for the reduction of bioburden in variable-etiology, bilateral lower-extremity wounds.

OBJECTIVE: There are numerous dressings designed to manage the overabundance of matrix metalloproteinases, while also addressing the excessive bioburden found in chronic wounds. The authors compared the efficacy of 2 such dressings: a sodium carboxymethylcellulose/1.2% ionic silver (CMC), which theoretically reduces bacteria by providing silver ions, versus a bovine native collagen (BDC)/ionic silver dressing, which also delivers silver ions in an aqueous environment. Both dressings theoretically modulate the wound bed; CMC through moist wound care and fibrin ingrowth and BDC through matrix metalloproteinase balancing. METHODS: A prospective protocol was undertaken using patients as their own controls. Ten patients with bilateral venous stasis or diabetic foot ulcers were selected. One limb was randomized to treatment by either CMC or BDC, whereas the contralateral wound was treated with the other dressing. Biopsies for quantitative cultures were taken at weeks 1 and 4. Wound area was assessed at the weekly visits. RESULTS: The BDC wounds started with 1.0 × 10 (±1.2 × 10) bacteria, and the CMC wounds started with 1.4 × 10 (±1.3 × 10) bacteria. Over the 4-week period, the bacteria in the 3-ppm (parts per million) silver-treated wound increased 1.53 × 10, whereas in the 21-ppm silver-treated wound, the bacteria increased 1.42 × 10. The rates of closure for CMC-treated wounds was 0.79 ± 0.735 cm/wk and for BDC-treated wounds was 1.38 ± 1.44 cm/wk. Only 1 wound treated with either dressing exhibited a decrease in bacteria. CONCLUSION: Both CMC and BDC silver dressings appeared to have statistically similar efficacy regarding the rate of wound healing and little impact on the actual bioburden in chronic lower-extremity wounds. Interestingly, there was no correlation in the size of the wound and any effect on bioburden. Although the BDC dressing showed a higher absolute rate of wound closure, neither technology demonstrated a statistically significant difference in wound closure rate when corrected for initial wound size.

Liver functional reserve estimation: state of the art and relevance to local treatments.

More than 90% of cases of hepatocellular carcinoma develop as a consequence of underlying liver disease (most commonly viral hepatitis), often resulting in impaired liver function. In such cases, transplantation is an appealing alternative as it can potentially treat both the malignancy and the underlying disease. When a transplant is not readily available due to organ scarcity, borderline cases must be considered for resection. The function of the underlying liver can be assessed by the Child-Pugh score or by quantitative tests such as indocyanine green clearance, lidocaine metabolism, and arterial body ketone ratio; liver biopsy pathology scoring and the platelet count can serve as indicators of fibrosis and portal hypertension. Another important factor to be considered is the risk of tumor recurrence, either because of unrecognized metastasis or due to de novo tumor formation. Both factors must be considered in weighing resection against nonsurgical alternatives. Preoperative portal vein embolization is a strategy that can evoke 'regeneration' in anticipation of surgery, serving as a 'stress test' of the liver's regenerative capacity.

A prospective two-armed trial assessing the efficacy and performance of a silver dressing used postoperatively on high-risk, clean surgical wounds.

Surgical site infections (SSI) are a known complication of surgery. Silver-containing wound treatments are popular, despite the lack of evidence of SSI reduction. A two-armed study was conducted between July 2007 and November 2008 to evaluate the efficacy and ease of use of a postoperative silver dressing. In the first arm of the study, patients undergoing clean general, vascular, orthopedic, and neurosurgical procedures were allocated to receive a postoperative silver dressing (POSD) or a standard dressing of nonstick gauze under a fluid occlusive dressing. Outcome variables included the incidence of antibiotic initiation for SSI, clinical signs of infection, and leukocyte counts. The second arm of the study was a prospective case series designed to evaluate the performance and handling characteristics of the POSD. Onehundred- ninety-nine (199) patients (mean age 59.2 [range 21-94] years) were enrolled in the first arm of the study. Three out of 99 (3%) patients in the POSD and six out of 100 (6%) control group patients received antibiotic therapy for SSI (P = 0.498). Differences in the percentage of patients with clinical signs of infection following surgery also were not statistically significant (POSD: n = 24, 24.2%; control: n = 30, 30%; P = 0.426). In the second arm, 34 out of 36 patients rated the study dressing easy to apply in (94%), and no pain on removal was noted in 38 out of 57 (66.7%) assessments. No patients in the dressing performance cohort developed an SSI. Prospective, randomized, controlled clinical studies with large sample sizes are warranted to evaluate the efficacy and cost-effectiveness of the POSD.

Clinical prognostic variables in young patients (under 40 years) with hepatitis B virus-associated hepatocellular carcinoma.

OBJECTIVE: The aim of this study was to determine the impact of hepatocelluar carcinoma (HCC) screening in chronic hepatitis B patients who did not meet the current screening recommendations. METHODS: Patients who were admitted to Bellevue Hospital Center with HCC were assessed for risk factors, cirrhosis and tumor-specific factors. Eligibility for liver transplantation or resection with favorable outcome was determined by applying Milan criteria. RESULTS: In all 93 patients were diagnosed with hepatitis B virus (HBV)-associated HCC, 18 of whom were under 40 years. Cirrhosis was infrequently associated with HCC in this group, with most cancers occurring in non-cirrhotic patients (12/18, 66.7%). No patient developed HCC outside the American Association for the Study of Liver Diseases (AASLD) cancer screening recommendations (young age, non-cirrhotic) were eligible for liver transplantation or resection with favorable outcomes (within Milan criteria). However, HCC patients who were diagnosed within AASLD screening recommendations did meet Milan criteria in 17.3% (14/81) patients. CONCLUSIONS: Current guidelines for HCC screening in patients with HBV may lead to a delay in diagnosis in non-cirrhotic patients under 40 years. Consideration should be given to modifying current recommendations to advocate entering HBV patients into a cancer-screening program at young age.

Liver functional reserve estimation: state of the art and relevance for local treatments: the Western perspective.

More than 90% of cases of hepatocellular carcinoma (HCC) develop as a consequence of underlying liver disease (most commonly viral hepatitis), often resulting in impaired liver function. In such cases, transplantation is an appealing alternative as it can potentially cure both the malignancy and the underlying disease. When transplant is not readily available due to organ scarcity, borderline cases must be considered for resection. The function of the underlying liver can be assessed by the Child Pugh score or by quantitative tests such as indocyanine green (ICG) clearance, metabolism of lidocaine to the metabolite MEG-X, and the arterial body ketone ratio (AKBR); liver biopsy pathology scoring and the platelet count can serve as indicators of fibrosis and portal hypertension. Another important factor to be considered is the risk of tumor recurrence, either because of unrecognized metastasis or due to de-novo tumor formation. Both factors must be considered in weighing resection against nonsurgical alternatives. Preoperative portal vein embolization is a strategy that can evoke regeneration in anticipation of surgery, serving as a "stress test" of the liver's regenerative capacity.