Onset of Schamberg Disease and Resolution of Alopecia Areata During Treatment of Atopic Dermatitis With Dupilumab

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Crisis management during anaesthesia: sepsis.

BACKGROUND: Anaesthesia with concurrent sepsis is risky, and involves consideration of possible organ dysfunctions-respiratory, cardiovascular, renal, and haematological--as well as ensuring that appropriate antibiotics are given after taking the necessary microbiological specimens. Because prompt attention needs to be paid to so many body systems, the place for a structured approach during anaesthesia for a septic patient was assessed. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for sepsis, in the management of sepsis occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Sepsis was identified as the primary problem in 13 of the first 4000 reports (<1%) to AIMS. The incidents reported generally occurred in sick patients; 70% were ASA status III or worse. The COVER ABCD algorithm provided a diagnosis and corrective manoeuvre in only 15% (2/13) of reported incidents, and the sepsis sub-algorithm provided adequate therapeutic strategies in a further 38% (5/13) of the incidents. Eight cases required the use of additional sub-algorithms for desaturation (30%), cardiac arrest (15%), hypotension (8%), and aspiration (8%). CONCLUSION: Sepsis involves a serious physiological stress upon multiple organ systems. The use of a structured approach involving a core algorithm and additional sub-algorithms as required provides a series of checklists that can successfully deal with the complex multiple and interrelating problems that these patients present.

Crisis management during anaesthesia: water intoxication.

BACKGROUND: Irrigation of closed body spaces may lead to substantial perioperative fluid and electrolyte shifts. A syndrome occurring during transurethral resection of prostate (TURP), and a similar syndrome described in women undergoing transcervical endometrial ablation (TCEA) are both characterised by a spectrum of symptoms which may range from asymptomatic hyponatraemia to convulsions, coma, and death. Such potentially serious consequences require prompt recognition and appropriate management of this "water intoxication" syndrome. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for water intoxication, in the management of this syndrome occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: From the first 4000 incidents reported to AIMS, 10 reports of water intoxication were identified, two from endometrial ablations under general anaesthesia and eight from male urological procedures under spinal anaesthesia. The "core" crisis management algorithm detected a problem in seven cases; however, it was deficient in dealing with neurological presentations. Diagnosis of the cause of the incident would have required a specific water intoxication sub-algorithm in eight cases and a hypotension algorithm in a further two cases. Corrective strategies also required a specific sub-algorithm in eight cases, while the hypotension and cardiac arrest sub-algorithms were required in conjunction with the water intoxication sub-algorithm in the remaining two. CONCLUSION: This relatively uncommon problem is managed poorly using the "core" crisis management sub-algorithm and requires a simple specific sub-algorithm for water intoxication.

Crisis management during anaesthesia: desaturation.

BACKGROUND: Desaturation occurs for many reasons under anaesthesia, some rare and obscure, and many potentially life threatening. The rapidity with which the cause is determined and appropriate management is instituted varies considerably between anaesthetists. OBJECTIVES: To examine the role of a previously described "core" algorithm COVER ABCD-A SWIFT CHECK, supplemented by a specific sub-algorithm for desaturation, in the management of incidents of desaturation occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Amongst the first 4000 incidents reported to AIMS there were 584 episodes of desaturation in association with general anaesthesia; 41% were dealt with by COVER, 48% by ABCD, and 11% required a specific desaturation sub-algorithm. Nearly a fifth of all desaturations were caused by endobronchial intubation. Within the specific desaturation subgroup, half were due to pulmonary problems in the form of underlying lung disease, excessive secretions or obesity and a third could not be diagnosed. CONCLUSION: Desaturation may have many causes, some of which are obscure, and failure to respond promptly may place the patient at risk. In the face of persistent desaturation, management should consist of hand ventilation with 100% oxygen, completion of COVER ABCD-A SWIFT CHECK, and a return to a supine posture. Blood gases, chest radiography, and bronchoscopy may be required where desaturation is persistent and/or no apparent causes can be found.

The Australian Incident Monitoring Study. Difficult intubation: an analysis of 2000 incident reports.

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the incidence and circumstances of problems with endotracheal intubation; 85 (4%) indicated difficulties with intubation. One third of these were emergency cases, one third involved an initially unassisted trainee and one fifth were outside normal working hours. Failure to predict a difficult intubation was reported in one third of the cases, with another quarter presenting serious difficulty despite preoperative prediction. Difficulties with ventilation were experienced in 1 in 7 of the 85 reports; there was one cardiac arrest, but no death. Endotracheal intubation was not achieved in one fifth of the cases. The commonest complications reported amongst the 85 incidents were oesophageal intubation (18 cases), arterial desaturation (15 cases), and reflux of gastric contents (7 cases). Emergency trans-tracheal airways were required in 5 cases. Obesity, limited neck mobility and mouth opening, and inadequate assistance together accounted for two thirds of all the contributing factors. The most successful intubation aid in this series was a gum elastic bougie. A capnograph contributed to management in 28% and a pulse oximeter in 12% of the cases in which they were used. The most serious desaturations were associated with accidental oesophageal intubation. These data suggest a lack of reliable preoperative assessment techniques and skills for the prediction of difficult intubations. They also suggest the need for a greater emphasis on ensuring that the necessary equipment is available, and on teaching and learning drills for difficult intubation and any associated difficulty with ventilation.

The Australian Incident Monitoring Study. Problems related to the endotracheal tube: an analysis of 2000 incident reports.

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to problems with the endotracheal tube; 189 (9%) were reported. The most common problem was endobronchial intubation which accounted for 42% of these 189 reports; endobronchial intubation was the most common cause of arterial desaturation in the 2000 incidents. Obstructions and oesophageal intubation each accounted for 18% of the 189 problems with tubes. The remainder was made up of disconnections and leaks (7% each), misplacements other than endobronchial or oesophageal (4%), inappropriate choice of tube (3%), cuff herniation (1%), failure to deflate the cuff and foreign body in the tube (0.5% each). The pulse oximeter and capnograph first detected 58% of these incidents; a further 25% were detected clinically. The pulse oximeter is the "front-line" monitor for endobronchial intubation, and the capnograph the "front-line" monitor for oesophageal intubation, disconnection and obstruction. Recommendations are made for how to prevent problems and how to determine the nature of those that do occur.

Tramadol: pain relief by an opioid without depression of respiration.

Two independent clinical trials were conducted simultaneously. In one, tramadol and pethidine were compared in 30 patients by patient-controlled analgesia during the first 24 h following abdominal surgery. The mean 24 h consumption of tramadol and pethidine was 642 mg and 606 mg respectively, giving a potency estimate of tramadol relative to pethidine of 0.94 (95% confidence interval 0.72-1.17). In the second trial, the effect on respiration of three doses of tramadol (0.5, 1.0, and 2.0 mg.kg-1) was compared with that of morphine sulphate (0.143 mg.kg-1) by intravenous injection during stable halothane anaesthesia. At approximately 1.5 times the equipotent dose, as estimated from the first trial, tramadol transiently depressed the rate of respiration but had no effect on end-tidal carbon dioxide tension. Morphine caused apnoea or considerable depression of ventilation. The results suggest that mechanisms other than opioid receptor activity play a significant role in the analgesia produced by tramadol.

A comparison of the effects of codeine and tramadol on laryngeal reactivity.

The effect of tramadol on laryngeal reflex activity was assessed in a double-blind cross-over study in six volunteers receiving single oral doses of either codeine 50 mg, tramadol 50 mg or tramadol 100 mg. Laryngeal reactivity was measured by the response to the inhalation of dilute ammonia vapour. The minimum ammonia concentration required to induce a glottic stop was recorded prior to drug administration, and at 15, 30, 45, 60, 90, 120, 150 and 180 min thereafter. Psychometric tests were performed at 0, 45 and 105 min to detect any relationship between central sedation and changes in laryngeal reflex activity. The concentration of ammonia required to induce a glottic stop increased in all treatment groups, but more so in the tramadol groups. The time course suggested that the codeine effect peaked early, and had returned to normal within 2 h. For tramadol 100 mg, laryngeal depression appeared to be still increasing at the end of the 3-h study period. No correlation was found between laryngeal and sedative effects. Tramadol is produced as a racemic mixture, in which one isomer acts through an opioid receptor pathway whilst the other affects noradrenergic and serotonergic mechanisms. Both of these routes of action may be involved in the suppression of the response to experimentally induced cough.

Variables of patient-controlled analgesia. 2. Concurrent infusion.

The effectiveness of morphine after surgery by patient-controlled analgesia alone or with a concurrent infusion was studied. The infusion did not reduce the dose of self-administered analgesic and patients treated in this way received twice as much drug as those who used patient-controlled analgesia alone. Pain control was similar in both groups. The practice of patient-controlled analgesia plus infusion requires critical review.

Effects of forebrain ablation on growth in teleost fishes.

The effect of forebrain extirpation on food uptake and growth was studied in different teleost species. In the case of wild species such as Carassius gibelio and Macropodus opercularis concolor, a prolonged enhancement of food uptake and body growth was found following forebrain ablation. In the case of domesticated species such as the common goldfish (Carassius auratus) and Macropodus opercularis, there was no effect of forebrain extirpation on either food uptake or growth.

How paradise fish (Macropodus opercularis, L.) explores a chessboard.

We investigated the exploratory movements of Anabantid fishes in a chessboard-like aquarium (divided into 25 communicating compartments) as a new environment. The analysis was based on the observation of the route of two inbred strains of paradise fish (Macropodus opercularis; Teleostei, Anabantoidae). We recorded their movement within the blocks until 100 steps, and compared the obtained process with hypothetical random walks. It turns out within the same period of time the fish meets significantly more new compartments than in the simulated process. The discrepancy between the two processes can be interpreted as the result of a successful exploratory strategy of the fish. In this exploratory movement the fish prefers the outer compartments to the inner ones, a fact that explains the striking difference between the actual behaviour and the "uniform simulation". This is obviously so, since the empirical data show that the transition probabilities from the actual compartment to the possible neighbouring compartments differ greatly. However, a model taking this inhomogeneity into account still does not fit sufficiently, indicating that this exploratory strategy is more complicated than our memoryless construction. Moreover, there are differences between the two strains investigated, which might reflect some role of genetic factors.