People with type 1 diabetes and impaired awareness of hypoglycaemia have a delayed reaction to performing a glucose scan during hypoglycaemia: a prospective observational study

AIMS

Considering that people with type 1 diabetes and impaired awareness of hypoglycaemia (IAH) have a delayed perception of hypoglycaemia, the question arises whether they perform scans later in case of hypoglycaemia than people without IAH. We assessed whether time to performing a scan after reaching hypoglycaemia while using a flash glucose monitoring (flash GM) system is different in people with IAH compared with people without IAH.

METHODS

Ninety-two people with type 1 diabetes [mean (± sd) age 42 ± 14 years, HbA1c 57 ± 9 mmol/mol] using a flash GM system for 3 months were included. Flash GM data were assessed for time until scan after reaching hypoglycaemia level 1 (< 3.9 mmol/l) and level 2 (< 3.0 mmol/l) and compared for type 1 diabetes with vs. without IAH via unpaired t-test/Mann-Whitney U test (P < 0.05).

RESULTS

Significant differences were found only for the delay between reaching hypoglycaemia and scan between people with and without IAH for Gold score [hypoglycaemia level 1: IAH 78 (51-105) min vs. without IAH 63 (42-89) min, P = 0.03; night-time hypoglycaemia level 2: IAH 140 (107-227) min vs. without IAH 96 (41-155) min, P = 0.004] and Pedersen-Bjergaard score [hypoglycaemia level 1: IAH 76 (52-97) min vs. without IAH 54 (38-71) min, P = 0.011; night-time hypoglycaemia level 1: IAH 132 (79-209) min vs. without IAH 89 (59-143) min, P = 0.011; night-time hypoglycaemia level 2: IAH 134 (66-212) min vs. without IAH 80 (37-131) min, P = 0.002). Data are shown as median (i.q.r.).

CONCLUSIONS

Time until scan after reaching hypoglycaemia might be an objective assessment tool for IAH, but needs to be investigated comprehensively in future studies.

Direct ink writing of silica-bonded calcite scaffolds from preceramic polymers and fillers

Silica-bonded calcite scaffolds have been successfully 3D-printed by direct ink writing, starting from a paste comprising a silicone polymer and calcite powders, calibrated in order to match a SiO₂/CaCO₃ weight balance of 35/65. The scaffolds, fabricated with two slightly different geometries, were first cross-linked at 350 °C, then fired at 600 °C, in air. The low temperature adopted for the conversion of the polymer into amorphous silica, by thermo-oxidative decomposition, prevented the decomposition of calcite. The obtained silica-bonded calcite scaffolds featured open porosity of about 56%-64% and compressive strength of about 2.9-5.5 MPa, depending on the geometry. Dissolution studies in SBF and preliminary cell culture tests, with bone marrow stromal cells, confirmed the in vitro bioactivity of the scaffolds and their biocompatibility. The seeded cells were found to be alive, well anchored and spread on the samples surface. The new silica-calcite composites are expected to be suitable candidates as tissue-engineering 3D scaffolds for regeneration of cancellous bone defects.

First-line tracheal resection and primary anastomosis for postintubation tracheal stenosis

Introduction Tracheal stenosis following intubation is the most common indication for tracheal resection and reconstruction. Endoscopic dilation is almost always associated with recurrence. This study investigated first-line surgical resection and anastomosis performed in fit patients presenting with postintubation tracheal stenosis. Methods Between February 2011 and November 2014, a prospective study was performed involving patients who underwent first-line tracheal resection and primary anastomosis after presenting with postintubation tracheal stenosis. Results A total of 30 patients (20 male) were operated on. The median age was 23.5 years (range: 13-77 years). Seventeen patients (56.7%) had had previous endoscopic tracheal dilation, four (13.3%) had had tracheal stents inserted prior to surgery and one (3.3%) had undergone previous tracheal resection. Nineteen patients (63.3%) had had a tracheostomy. Eight patients (26.7%) had had no previous tracheal interventions. The median time of intubation in those developing tracheal stenosis was 20.5 days (range: 0-45 days). The median length of hospital stay was 10.5 days (range: 7-21 days). The success rate for anastomoses was 96.7% (29/30). One patient needed a permanent tracheostomy. The in-hospital mortality rate was 3.3%: 1 patient died from a chest infection 21 days after surgery. There was no mortality or morbidity in the group undergoing first-line surgery for de novo tracheal lesions. Conclusions First-line tracheal resection with primary anastomosis is a safe option for the treatment of tracheal stenosis following intubation and obviates the need for repeated dilations. Endoscopic dilation should be reserved for those patients with significant co-morbidities or as a temporary measure in non-equipped centres.

The impact of systemic fungal infection in patients with perforated oesophagus

INTRODUCTION

Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre.

METHODS

A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008).

RESULTS

We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications.

CONCLUSIONS

Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.

Air leaks following pulmonary resection for lung cancer: is it a patient or surgeon related problem?

INTRODUCTION

Prolonged air leak (PAL) is the most common complication after partial lung resection and the most important determinant of length of hospital stay for patients post-operatively. The aim of this study was to determine the risk factors involved in developing air leaks and the consequences of PAL.

METHODS

All patients undergoing lung resection between January 2002 and December 2007 in our hospital were studied retrospectively. Univariate analysis to predict risk factors for developing post-operative air leaks included patient demographics, smoking status, pulmonary function tests, disease aetiology (benign, malignant), neoadjuvant therapy (pre-operative radiotherapy/chemotherapy), extent and type of resection, and different consultant surgeons' practice. A logistic regression model was used for multivariate analysis.

RESULTS

A total of 1,911 lung resections were performed over the 6-year study period. An air leak lasting more than 6 days post-operatively was present in 129 patients (6.7%). This included 100 out of the 1,250 patients (8%) from the lobectomy group and 29 out of the 661 patients (4.4%) from the wedge/segmentectomy group. Using the multivariate analysis, the risk factors for developing an air leak included a low predicted forced expiratory volume in 1 second (pFEV(1)) (p<0.001), performing an upper lobectomy (p=0.002) and different consultant practice (p=0.02). PAL was associated with increased length of stay (p<0.0001), in-hospital mortality (p=0.003) and intensive care unit readmission (p=0.05).

CONCLUSIONS

Air leaks after pulmonary resections were at an acceptable rate in our series. Particular patients are at a higher risk but meticulous surgical technique is vital in reducing their incidence. Our study shows that pFEV1 is the strongest predictor of post-operative air leaks.

Malignant pleural mesothelioma presenting with a spontaneous hydropneumothorax: a report of 2 cases

Malignant pleural mesothelioma (MPM) originates in the mesothelial cells that line the pleural cavities. Most patients initially experience the insidious onset of chest pain or shortness of breath and have a history of asbestos exposure. It rarely presents as spontaneous pneumothorax. We report here two cases where malignant pleural mesothelioma presented with a spontaneous hydropneumothorax and was only discovered following surgery. We emphasise the need for a chest CT-scan preoperatively in older patients presenting with a secondary pneumo/hydropneumothorax.

Large pulmonary masses containing varicose veins: a rare presentation of benign metastasising leiomyomas

A 48-year-old woman presented with cough and chest pain. A chest radiograph and CT scans showed bilateral lung masses containing massive venous varices. A core biopsy specimen revealed benign metastasising leiomyoma with strong expression of progesterone receptors. A review of her medical history revealed a hysterectomy 11 years earlier. The lung masses showed significant reduction in size after induction of artificial menopause, although the pulmonary varices persisted.

Effects of a 2- to 4-week course of repetitive transcranial magnetic stimulation (rTMS) on neuropsychologic functioning, electroencephalogram, and auditory threshold in depressed patients

BACKGROUND

The safety of repetitive transcranial magnetic stimulation (rTMS) has only previously been formally studied in volunteers receiving a single session of stimulation or in a small number of depressed subjects receiving a 2-week treatment course. This study examined safety issues in depressed subjects receiving up to 4 weeks of rTMS. Efficacy results from this study have been previously reported.

METHODS

Eighteen subjects with DSM-IV major depression participated in a 2-week, parallel, double-blind, sham-controlled study of rTMS treatment. Twelve subjects then went on to receive 4 weeks active rTMS in an open follow-up. We examined the effects of rTMS on neuropsychologic function (up to 4 weeks), auditory threshold (up to 6 weeks exposure to rTMS noise), and an electroencephalogram (after 2 weeks). Data were analyzed by repeated measures analysis.

RESULTS

There were trends for improvement in neuropsychologic performance, probably due to practice effects. No mean changes in auditory threshold occurred, but two patients showed mild high-frequency hearing loss after several weeks of rTMS. Electroencephalograms in two patients, one of whom had sham stimulation, showed minor abnormality.

CONCLUSIONS

No significant mean deficits were demonstrated in this cohort. Overall, rTMS for up to 4 weeks is safe, but individual results suggest caution and the need for further investigation of the safety of several weeks of rTMS.

Imaging of an unusual case of parasitic twinning

Conjoined twins are rare in the literature and parasitic conjoined twins are rarer still. To our knowledge no cases of parasitic conjoined twins have previously been reported in the radiology literature. We present a case of parasitic conjoined twins in which radiographic findings played an important role in management.

Shock sensitization of startle in rats: the role of contextual conditioning

The role of contextual conditioning in the shock sensitization of startle effect was examined in 2 experiments with rats. Experiment 1 showed that shock sensitized the startle response only if it was given in the test context, and Experiment 2 showed that the sensitization effect was abolished in subjects preexposed to the test context. Taken together, these results show that shock sensitization of startle is mediated by contextual conditioning. The implications of this finding for using the shock sensitization of startle procedure as a model preparation for examining the neural and pharmacological bases of unconditioned fear are discussed.

Shock sensitization of startle in rats: the role of contextual conditioning

The role of contextual conditioning in the shock sensitization of startle effect was examined in 2 experiments with rats. Experiment 1 showed that shock sensitized the startle response only if it was given in the test context, and Experiment 2 showed that the sensitization effect was abolished in subjects preexposed to the test context. Taken together, these results show that shock sensitization of startle is mediated by contextual conditioning. The implications of this finding for using the shock sensitization of startle procedure as a model preparation for examining the neural and pharmacological bases of unconditioned fear are discussed.