Laryngeal tuberculosis: a rare cause of critical airway obstruction.

Laryngeal tuberculosis (TB) is a rare condition, occurring in less than 1% of patients infected with pulmonary TB. We present a case of a 57-year-old male patient, who presented in extremis with audible stridor, increased work of breathing and cyanosis. In addition, the patient had a complex medical history, including a recent diagnosis of congenital malformation of the epiglottis. Emergency intervention was required to secure the airway, and after initial attempts at intubation were unsuccessful, an emergency tracheostomy was performed. Four days after initial presentation, his sputum tested positive for acid-fast bacilli, and a subsequent CT chest revealed pulmonary as well as laryngeal TB, which was confirmed on biopsy of the larynx. The patient was commenced on a 24-week course of anti-tuberculous treatment and was successfully decannulated 6 months after the emergency airway was established.

Long-Term Body Composition Changes in Women Following Roux-en-Y Gastric Bypass Surgery.

BACKGROUND: Although most individuals experience successful weight loss following Roux-en-Y gastric bypass (RYGB), weight regain is a concern, the composition of which is not well documented. Our aim was to evaluate changes in body composition and handgrip strength as a measure of functional status in participants from a previous 1-year post-RYGB longitudinal study who had undergone RYGB approximately 9 years prior. METHODS: Five women from an original larger cohort were monitored pre-RYGB and 1.5 months, 6 months, 1 year, and 9 years post-RYGB. Body composition was assessed at all time points using dual energy x-ray absorptiometry and multiple dilution. Handgrip strength was measured using a digital isokinetic hand dynamometer (Takei Scientific Instruments, Ltd, Tokyo, Japan). RESULTS: Mean time to final follow-up was 8.7 years. Lean soft tissue (LST) loss over the ~9-year period was on average 11.9 ± 5.6 kg. Compared with 1-year post-RYGB, 9-year LST was 4.4 ± 3.0 kg lower ( P = .03). Fat-free mass decreased over the 9-year period by 12.6 ± 5.8 kg. Mean fat mass (FM) decreased from 75.4 ± 22.6 kg pre-RYGB to 35.5 ± 21.5 kg 1 year post-RYGB but then trended toward an increase of 8.6 ± 7.0 kg between 1 year and 9 years post-RYGB ( P = .053). Loss of LST was correlated with loss of handgrip strength ( r = 0.64, P = .0005). CONCLUSION: The continued loss of lean mass associated with decreased handgrip strength occurring with long-term trend toward FM regain post-RYGB is concerning. The loss of LST and functional strength carries particular implications for the aging bariatric population and should be investigated further.

Evaluation of Bioelectrical Impedance Analysis in Critically Ill Patients: Results of a Multicenter Prospective Study.

BACKGROUND: In critically ill patients, muscle loss is associated with adverse outcomes. Raw bioelectrical impedance analysis (BIA) parameters (eg, phase angle [PA] and impedance ratio [IR]) have received attention as potential markers of muscularity, nutrition status, and clinical outcomes. Our objective was to test whether PA and IR could be used to assess low muscularity and predict clinical outcomes. METHODS: Patients (≥18 years) having an abdominal computed tomography (CT) scan and admitted to intensive care underwent multifrequency BIA within 72 hours of scan. CT scans were landmarked at the third lumbar vertebra and analyzed for skeletal muscle cross-sectional area (CSA). CSA ≤170 cm2 for males and ≤110 cm2 for females defined low muscularity. The relationship between PA (and IR) and CT muscle CSA was evaluated using multivariate regression and included adjustments for age, sex, body mass index, Charlson Comorbidity Index, and admission type. PA and IR were also evaluated for predicting discharge status using dual-energy x-ray absorptiometry-derived cut-points for low fat-free mass index. RESULTS: Of 171 potentially eligible patients, 71 had BIA and CT scans within 72 hours. Area under the receiver operating characteristic (c-index) curve to predict CT-defined low muscularity was 0.67 ( P ≤ .05) for both PA and IR. With covariates added to logistic regression models, PA and IR c-indexes were 0.78 and 0.76 ( P < .05), respectively. Low PA and high IR predicted time to live ICU discharge. CONCLUSION: Our study highlights the potential utility of PA and IR as markers to identify patients with low muscularity who may benefit from early and rigorous intervention.

Phase Angle and Impedance Ratio: Reference Cut-Points From the United States National Health and Nutrition Examination Survey 1999-2004 From Bioimpedance Spectroscopy Data.

BACKGROUND: Raw bioimpedance parameters (eg, 50-kHz phase angle [PA] and 200-kHz/5-kHz impedance ratio [IR]) have been investigated as predictors of nutrition status and/or clinical outcomes. However, their validity as prognostic measures depends on the availability of appropriate reference data. Using a large and ethnically diverse data set, we aimed to determine if ethnicity influences these measures and provide expanded bioimpedance reference data for the U.S. METHODS: The National Health and Nutrition Examination Survey (NHANES) is an ongoing compilation of studies conducted by the U.S. Centers for Disease Control and Prevention designed to monitor nutrition status of the U.S. POPULATION: The NHANES data sets analyzed were from the years 1999-2000, 2001-2002, and 2003-2004. RESULTS: Multivariate analysis showed that PA and IR differed by body mass index (BMI), age, sex, and ethnicity (n = 6237; R2 = 41.2%, P < .0001). Suggested reference cut-points for PA stratified by age decade, ethnicity, and sex are provided. CONCLUSION: Ethnicity is an important variable that should be accounted for when determining population reference values for PA and IR. We have provided sex-, ethnicity-, and age decade-specific reference values from PA for use by future studies in U.S. POPULATIONS: Interdevice differences are likely to be important contributors to variability across published population-specific reference data and, where possible, should be evaluated in future research. Ultimately, further validation with physiologically relevant reference measures (eg, dual-energy x-ray absorptiometry) is necessary to determine if PA/IR are appropriate bedside tools for the assessment of nutrition status in a clinical population.

Bile Acids Increase Independently From Hypocaloric Restriction After Bariatric Surgery.

OBJECTIVES: To measure changes in the composition of serum bile acids (BA) and the expression of Takeda G-protein-coupled receptor 5 (TGR5) acutely after bariatric surgery or caloric restriction. SUMMARY BACKGROUND DATA: Metabolic improvement after bariatric surgery occurs before substantial weight loss. BA are important metabolic regulators acting through the farnesoid X receptor and TGR5 receptor. The acute effects of surgery on BA and the TGR5 receptor in subcutaneous white adipose tissue (WAT) are unknown. METHODS: A total of 27 obese patients with type 2 diabetes mellitus were randomized to Roux-en-Y gastric bypass (RYGB) or to hypocaloric diet (HC diet) restriction (NCT 1882036). A cohort of obese patients with and without type 2 diabetes mellitus undergoing vertical sleeve gastrectomy was also recruited (n = 12) as a comparison. RESULTS: After vertical sleeve gastrectomy, the level of BA increased [total: 1.17 ±â€Š1.56 µmol/L to 4.42 ±â€Š3.92 µmol/L (P = 0.005); conjugated BA levels increased from 0.99 ±â€Š1.42 µmol/L to 3.59 ±â€Š3.70 µmol/L (P = 0.01) and unconjugated BA levels increased from 0.18 ±â€Š0.24 µmol/L to 0.83 ±â€Š0.70 µmol/L (P = 0.009)]. With RYGB, there was a trend toward increased BA [total: 1.37 ±â€Š0.97 µmol/L to 3.26 ±â€Š3.01 µmol/L (P = 0.07); conjugated: 1.06 ±â€Š0.81 µmol/L to 2.99 ±â€Š3.02 µmol/L (P = 0.06)]. After HC diet, the level of unconjugated BA decreased [0.92 ±â€Š0.55 µmol/L to 0.32 ± 0.43 µmol/L (P = 0.05)]. The level of WAT TGR5 gene expression decreased after surgery, but not in HC diet. Protein levels did not change. CONCLUSIONS: The levels of serum BA increase after bariatric surgery independently from caloric restriction, whereas the level of WAT TGR5 protein is unaffected.

The Influence of Bariatric Surgery on Serum Bile Acids in Humans and Potential Metabolic and Hormonal Implications: a Systematic Review.

Recent research suggests a mechanistic role for bile acids (BA) in the metabolic improvement following bariatric surgery. It is believed that the hormonal and metabolic effects associated with changes in systemic BAs may be related to the farnesoid X receptor (FXR) and a G-protein coupled receptor (TGR5). This systematic review examines changes in systemic BAs following bariatric procedures. Studies were included if they reported the measurement of systemic BAs in humans at at least one time point after bariatric surgery. Eleven papers were identified that met the inclusion criteria. Seven studies reported the effect of Roux-en-Y gastric bypass (RYGB) on fasting BAs. The majority (6/7) reported that fasting BAs increased after RYGB. Data regarding fasting BAs after vertical sleeve gastrectomy (VSG) and laparoscopic gastric banding (LAGB) are inconsistent. Data regarding post-prandial BA changes after RYGB, VSG, and LAGB are also inconsistent. More research is needed to investigate the connection between BAs and the metabolic improvement seen after bariatric surgery.

Bioimpedance at the bedside: current applications, limitations, and opportunities.

The loss of muscle mass is a defining characteristic of malnutrition, and there is ongoing interest in the assessment of lean tissue at the bedside. Globally, bioimpedance techniques have been widely appreciated for their noninvasiveness, safety, ease of use, portability, and relatively low cost compared with other clinically available methods. In this brief update, we review the 3 primary types of commercially available bioimpedance devices (single- and multiple-frequency and spectroscopy) and differentiate the underlying theory and current applications of each. We also address limitations and potential opportunities for using these devices at the bedside for clinical assessment. Mixed reports in the validation literature for all bioimpedance approaches have raised questions about absolute accuracy to estimate whole body composition in clinical populations, particularly those with abnormal fluid status and/or body geometry in whom underlying method assumptions may be violated. Careful selection of equations can improve whole body estimates by single- and multiple-frequency techniques; however, not all devices will allow for this approach. Research is increasing on the use of bioimpedance variables including phase angle and impedance ratio as potential markers of nutrition status and/or clinical outcomes; consensus on reference cut-points for interpreting these markers has yet to be established. Novel developments in the bioimpedance spectroscopy approach are allowing for improved fluid management in individuals receiving dialysis; these developments have implications for the clinical management of other conditions associated with fluid overload and may also provide enhanced whole body estimates of lean tissue through new modeling procedures.

Vitamin D status following bariatric surgery: implications and recommendations.

Individuals with extreme obesity who qualify for bariatric surgery are frequently vitamin D deficient before and after surgery. The anatomical changes that occur during some bariatric procedures may lead to decreased absorption of vitamin D, although vitamin D absorption and metabolism has not been quantified or compared across surgeries, and multiple other factors could influence vitamin D status in these individuals. Vitamin D treatment and dosing studies show that there is variability in how individuals respond to supplementation regimens regardless of the bariatric procedure. It is unknown if improving vitamin D status before and/or after bariatric surgery can affect health-related outcomes in this population beyond the traditional roles of vitamin D. Vitamin D has been purported to positively influence a variety of obesity-related comorbidities. Furthermore, in light of the potential role of vitamin D in immunity and inflammation, it seems important to consider the ramifications of vitamin D deficiency in the postbariatric individual in the critical care setting and particularly in the context of aging. Additional research is needed to develop evidence-based guidelines for optimal treatment of vitamin D deficiency in individuals before and after bariatric surgery and to determine the impact of vitamin D repletion on non-bone health-related outcomes in these individuals.

A new way to measure mid-upper-arm circumference in african villages.

In 2011 we published a study on how to detect the threshold for malnutrition in children, simply using their own hands and without any technical tool. The fight against malnutrition can only be reached when its measurements involve every single child, almost continuously, in the affected villages. In this paper we try to show that, thanks to our method, it is possible to use mid-upper-arm-circumference as a measurement for malnutrition in children, discriminating between severe and moderate malnutrition and providing the basis for the decision on whether to admit a child to a nutritional rehabilitation unit or not. We trained 63 participants in four groups (Group 1: doctors and clinical officers; Group 2: nurses and students; as Group 3 we defined the 20 best participants and Group 4 consisted of 10 more intensely trained participants) to measure the circumference of 9 different artificial arms (between 9 and 13 cm) using their own fingers and hands. The training was short and consisted of an introduction of 5 min, a first training phase of 10-15 min, a test, the critical discussion of the results, a second training phase of 5 min and a final test. We found that 95.3% of participants in the general group and 97.9% in the intensely trained group have identified the severely malnourished child; 87.3% in the general group and 91.9% in the intensely trained group have additionally identified the moderately malnourished child. Both groups haven't admitted the well nourished child to a therapeutic feeding program retaining their resources. The third group reached without any additional training the results in the above categories. A subsequent discussion with the participants on the influence of procurement, maintenance and pricing of our tool, found our method much less vulnerable than others. We conclude that this method should be considered as a future training in the villages to detect the trend towards malnutrition early enough.

Anesthetic management of a malnourished, 7-year-old child in Malawi undergoing a pneumonectomy.

In this report, we describe the case of a 7-year-old girl presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, with hypoxia and respiratory distress. Investigations demonstrated an endobronchial tumor, and she underwent a radical left-sided pneumonectomy. This case highlights the challenges of anesthesia in a resource-depleted setting.