The association of body mass index with tumor aggression among men undergoing radical prostatectomy

OBJECTIVES

To evaluate the association of preoperative body mass index (BMI) on adverse pathology in peripheral (PZ) and transition zone (TZ) tumors at time of prostatectomy for localized prostate cancer.

METHODS

Clinical and pathologic characteristics were obtained from up to 100 consecutive prostatectomy patients from 10 prostate surgeons. BMI groups included normal (18.5-24.9), overweight (25-29.9) and obese (> 29.9). "Aggressive" pathology was defined as the presence of Grade Group (GG) 3 or higher and/or pT3a or higher. Pathologic characteristics were evaluated for association with BMI using univariate analyses. Our primary outcome was the association of BMI with adverse pathology, which was assessed using logistic regression accounting for patient age. We hypothesized that obese BMI would be associated with aggressive TZ tumor.

RESULTS

Among 923 patients, 140 (15%) were classified as "normal" BMI, 413 (45%) were "overweight", and 370 (40%) were "obese." 474 patients (51%) had aggressive PZ tumors while 102 (11%) had aggressive TZ tumors. "Obese" BMI was not associated with aggressive TZ tumor compared to normal weight. Increasing BMI group was associated with overall increased risk of aggressive PZ tumor (HR 1.56 [95CI 1.04-2.34]; P = 0.03). Among patients with GG1 or GG2, increasing BMI was associated with presence of pT3a or higher TZ tumor (P = 0.03).

CONCLUSIONS

Increased BMI is associated with adverse pathology in PZ tumors. TZ adverse pathology risk may be increased among obese men with GG1 or GG2 disease, which has implications for future studies assessing behavioral change among men whose tumors are actively monitored.

A nomogram based on peripheral lymphocyte for predicting 8-year survival in patients with prostate cancer: a single-center study using LASSO-cox regression

PURPOSE

The purpose of this study was to develop a functional clinical nomogram for predicting 8-year overall survival (OS) of patients with prostate cancer (PCa) primary based on peripheral lymphocyte.

PATIENTS AND METHODS

Using data from a single-institutional registry of 94 patients with PCa in China, this study identified and integrated significant prognostic factors for survival to build a nomogram. The discriminative ability was measured by concordance index (C-index) and ROC curves (Receiver Operating Characteristic Curves). And the predictive accuracy was measured by the calibration curves. Decision curve analyses (DCA) was used to measure the clinical usefulness.

RESULTS

A total of 94 patients were included for analysis. Five independent prognostic factors were identified by LASSO-Cox regression and incorporated into the nomogram: age, the T stage, the absolute counts of peripheral CD3(+)CD4(+) T lymphocytes, CD3(-)CD16(+)CD56(+) NK cells and CD4(+)/CD8(+) ratio. The area under the curve (AUC) values of the predictive model for 5-, 8-, and 10-year overall survival were 0.81, 0.76, and 0.73, respectively. The calibration curves for probability of 5-,8- and 10-year OS showed optimal agreement between nomogram prediction and actual observation. The stratification into different risk groups allowed significant distinction. DCA indicated the good clinical application value of the model.

CONCLUSION

We developed a novel nomogram that enables personalized prediction of OS for patients diagnosed with PCa. This finding revealed a relative in age and survival rate in PCa, and a more favorable prognosis in patients exhibiting higher levels of CD4 + T, CD4+/CD8 + ratio and CD3(-)CD16(+)CD56(+) NK cells specifically. This clinically applicable prognostic model exhibits promising predictive capabilities, offering valuable support to clinicians in informed decision-making process.

Care bundles and peripheral arterial catheters

HIGHLIGHTS

What we know about the topic: Recommendations for the use of vascular access care bundles to reduce infection are followed for different devices. The risk of arterial catheter-related infection is comparable with short-term, non-cuffed central venous catheters. There are practice concerns for clinicians inserting and caring for peripheral arterial catheters. What this paper adds: The selected studies had a theme of decreased infection after using bundled strategies for all devices. Few studies addressed use of bundles for care of peripheral arterial catheters. High-quality research should be performed about using care bundles for insertion and care of arterial catheters.

INTRODUCTION

A scoping review of the literature was performed.

AIMS/OBJECTIVES

To find information on the use of care bundles for care of arterial, central, and peripherally inserted venous catheters.

METHODS

Data was extracted by 2 independent researchers using standardized methodology.

RESULTS

Results of 84 studies included 2 (2.4%) randomized controlled trials, 38 (45.2%) observational studies, 29 (34.5%) quality projects, and 15 (17.9%) reviews. Populations had more adults than pediatric patients. All studies had the most prominent theme of decreased infection in all devices after using bundle strategies.

DISCUSSION AND CONCLUSIONS

The mapping of available evidence strongly supports the use of care bundles to reduce infection in the care of all intravascular devices. However, deficiencies regarding practice concerns about insertion and care of arterial catheters highlight areas for future research with the aim to eliminate the gap in the evidence of studies of care bundles for peripheral arterial catheters.

Factors determining success and the cost of materials used in securing intravenous access in an emergency setting: A prospective observational study

INTRODUCTION

Multiple failed attempts at securing intravenous catheter access cause increased patient dissatisfaction and higher costs. We aimed to identify the factors leading to multiple failed attempts and estimate the cost of resources wasted.

METHODS

Participants were recruited from the emergency department for a prospective, observational study. Healthcare workers inserting peripheral intravenous catheters were observed. Patient characteristics and the number of attempts needed were recorded.

RESULTS

Three hundred thirty-four patients were enrolled, and an average of 1.74 ± 1.026 (Range: 1 - 5) access attempts were needed per patient. Only 56.28% of the insertions were successful on the first attempt. On multivariate linear regression with attempts as the outcome variable, age (β = 0.01, 95%CI 0.004 - 0.014, p = 0.0006), catheter calibre (β 20G = -0.25, 95%CI -0.45 - -0.07, p = 0.008), visibility (β = 0.23, 95%CI 0.02 - 0.44, p = 0.026) and palpability (β = 0.44, 95%CI 0.21 - 0.66, p = 0.0001) of the vein were statistically significant predictors. The average total cost of materials required was $6.4 USD per patient, of which $1.76 USD was spent towards unsuccessfully inserted catheters that were consequently thrown away.

CONCLUSIONS

Our study shows that securing IV access often requires multiple attempts, with nearly 30% of the total cost amounting towards materials wasted. The risk of multiple attempts is highest for older patients with invisible and non-palpable veins.

Discovery of 1,3-disubstituted pyrazole peripheral cannabinoid receptor partial agonists

Partial agonists of peripheral cannabinoid receptors (CBRs) have potential therapeutic applications in several medical conditions. However, (-)-trans-Δ9-tetrahydrocannabinol (THC), the principal active component of marijuana, which is a partial agonist of CB1 and CB2 penetrates the central nervous system (CNS) and produces adverse effects. Peripherally restricted partial agonists of CBRs, particularly of CB1, can be used to treat illnesses safely and effectively with a better therapeutic index. Here, we report on our efforts to synthesize pyrazole partial CBR agonists with peripheral selectivity, resulting in lead compound 40. This compound is a potent partial agonist of CB1 with ∼ 5-fold higher plasma biodistribution over brain and represents an early lead for optimization.

Functional Duration of Peripheral Intravenous Cannula in Neonates with or without Splint: A Randomized Controlled Trial

OBJECTIVES

To determine the effect of splint on the functional duration of peripheral intravenous cannula (PIVC) in neonates.

METHODS

The trial was prospectively registered with the Clinical Trial Registry of India (CTRI/2021/09/036337). One-hundred-fifty cannulations in 71 neonates were randomized to splint (n = 75) and no-splint (n = 75) groups, respectively. The median (interquartile range, IQR) functional duration of PIVC was calculated from the time of PIVC insertion till removal due to the development of signs of PIVC failure or treatment completion. Kaplan-Meier survival analysis was used to compute the time to complication of PIVC. Complications related to PIVC were noted and multivariate Cox-proportion hazard analysis was done to find the predictors associated with PIVC failure.

RESULTS

Median (IQR) functional duration of PIVC in the splint and the no-splint group was 28 (23-48) and 30 (25-48) h, respectively (p = 0.477). PIVC duration was higher in the splint group in term neonates and the no-splint group in preterm neonates; however, the differences were not statistically significant. No difference was observed in continuous vs. intermittent infusion subgroups. Time to complication development was also comparable between the groups.

CONCLUSIONS

Splint application did not affect functional PIVC duration and its related complications in neonates.

Successful Revascularization of Critical Limb Ischemia: A Challenging Case of a Unilateral Tibial-to-Tibial Intervention

Critical limb ischemia requires urgent diagnosis and intervention. Limitations to percutaneous revascularization therapy stem from multilevel diseased vasculature. Retrograde revascularization utilizing anterior tibial artery access in complex and proximal lesions is an alternative route for intervention that can lead to limb salvage and symptom resolution.

X chromosome inactivation skewing is common in advanced carotid atherosclerotic lesions in females and predicts secondary peripheral artery events

BACKGROUND AND AIM

Sex differences in atherosclerosis have been described with female plaques being mostly perceived as stable and fibrous. Sex-specific mechanisms such as mosaic loss of the Y chromosome in men have been linked to cardiovascular health. In women, X-linked mechanisms such as X chromosome inactivation (XCI) skewing is common in several tissues. Yet, information on the role of XCI in female atherosclerotic plaques is lacking. Here, we investigated the presence of XCI skewing in advanced atherosclerotic lesions and its association with cardiovascular risk factors, histological plaque data, and clinical data.

METHODS

XCI skewing was quantified in 154 atherosclerotic plaque and 55 blood DNA samples of women included in the Athero-Express study. The skewing status was determined performing the HUMARA assay. Then, we studied the relationship of XCI skewing in female plaque and cardiovascular risk factors using regression models. In addition, we studied if plaque XCI predicted plaque composition, and adverse events during 3-years follow-up using Cox proportional hazard models.

RESULTS

XCI skewing was detected in 76 of 154 (49.4%) plaques and in 27 of 55 (67%) blood samples. None of the clinical risk factors were associated with plaque skewing. Plaque skewing was more often detected in plaques with a plaque hemorrhage (OR [95% CI]: 1.44 [1.06-1.98], P = 0.02). Moreover, skewed plaques were not associated with a higher incidence of composite and major events but were specifically associated with peripheral artery events during a 3-year follow-up period in a multivariate model (HR [95%CI]: 1.46 [1.09-1.97]; P = 0.007).

CONCLUSIONS

XCI skewing is common in carotid plaques of females and is predictive for the occurrence of peripheral artery events within 3 years after carotid endarterectomy.

Comparative efficacy of psychological interventions on immune biomarkers: A systematic review and network meta-analysis (NMA)

Psychological interventions are viable, cost-effective strategies for improving clinical and psychological impact of inflammation-related conditions. However, their efficacy on immune system function remains controversial. We performed a systematic review and frequentist random-effects network meta-analysis of randomised controlled trials (RCTs) assessing the effects of psychological interventions, against a control condition, on biomarkers of innate and adaptive immunity in adults. PubMed, Scopus, PsycInfo, and Web of Science were searched from inception up to Oct 17, 2022. Cohen's d at 95% confidence interval (CI) was calculated to assess the effect sizes of each class of intervention against active control conditions at post-treatment. The study was registered in PROSPERO (CRD42022325508). Of the 5024 articles retrieved, we included 104 RCTs reporting on 7820 participants. Analyses were based on 13 types of clinical interventions. Compared with the control conditions, cognitive therapy (d =  - 0.95, 95% CI: -1.64 to - 0.27), lifestyle (d =  - 0.51, 95% CI: -0.99 to - 0.02), and mindfulness-based (d =  - 0.38, 95% CI: -0.66 to - 0.09) interventions were associated with post-treatment reduction of proinflammatory cytokines and markers. Mindfulness-based interventions were also significantly associated with post-treatment increase in anti-inflammatory cytokines (d = 0.69, 95% CI: 0.09 to 1.30), while cognitive therapy was associated also with post-treatment increase in white blood cell count (d = 1.89, 95% CI: 0.05 to 3.74). Results on natural killer cells activity were non-significant. Grade of evidence was moderate for mindfulness and low-to-moderate for cognitive therapy and lifestyle interventions; however, substantial overall heterogeneity was detected in most of the analyses.

Improving difficult peripheral intravenous access requires thought, training and technology (DART3): a stepped-wedge, cluster randomised controlled trial protocol

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most used invasive medical device in healthcare. Yet around half of insertion attempts are unsuccessful leading to delayed medical treatments and patient discomfort of harm. Ultrasound-guided PIVC (USGPIVC) insertion is an evidence-based intervention shown to improve insertion success especially in patients with Difficult IntraVenous Access (BMC Health Serv Res 22:220, 2022), however the implementation in some healthcare settings remains suboptimal. This study aims to co-design interventions that optimise ultrasound guided PIVC insertion in patients with DIVA, implement and evaluate these initiatives and develop scale up activities.

METHODS

A stepped-wedge cluster randomized controlled trial will be conducted in three hospitals (two adult, one paediatric) in Queensland, Australia. The intervention will be rolled out across 12 distinct clusters (four per hospital). Intervention development will be guided by Michie's Behavior Change Wheel with the aim to increase local staff capability, opportunity, and motivation for appropriate, sustainable adoption of USGPIVC insertion. Eligible clusters include all wards or departments where > 10 PIVCs/week are typically inserted. All clusters will commence in the control (baseline) phase, then, one cluster per hospital will step up every two months, as feasible, to the implementation phase, where the intervention will be rolled out. Implementation strategies are tailored for each hospital by local investigators and advisory groups, through context assessments, staff surveys, and stakeholder interviews and informed by extensive consumer interviews and consultation. Outcome measures align with the RE-AIM framework including clinical-effectiveness outcomes (e.g., first-time PIVC insertion success for DIVA patients [primary outcome], number of insertion attempts); implementation outcomes (e.g., intervention fidelity, readiness assessment) and cost effectiveness outcomes. The Consolidated Framework for Implementation Research framework will be used to report the intervention as it was implemented; how people participated in and responded to the intervention; contextual influences and how the theory underpinning the intervention was realised and delivered at each site. A sustainability assessment will be undertaken at three- and six-months post intervention.

DISCUSSION

Study findings will help define systematic solutions to implement DIVA identification and escalation tools aiming to address consumer dissatisfaction with current PIVC insertion practices. Such actionable knowledge is critical for implementation of scale-up activities.

TRIAL REGISTRATION

Prospectively registered (Australian and New Zealand Clinical Trials Registry; ACTRN12621001497897).

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation

INTRODUCTION

Intravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access.

METHODS

We conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement.

RESULTS

During the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (-0.5 s, 95% CI: -1.1, -0.0).

CONCLUSIONS

Younger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Epidemiology and Outcomes of Peripheral and Non-Aortocaval Vascular Trauma in Scotland 2011 - 2018

OBJECTIVE

This population based study aimed to examine the demographics, mechanisms, and outcomes of patients in Scotland suffering peripheral and non-aortocaval vascular trauma between 2011 and 2018.

METHODS

A retrospective observational study was conducted using prospectively collected data derived from the Scottish Trauma Audit Group (STAG) from 1 January 2011 to 31 December 2018. Peripheral and non-aortocaval vascular trauma patients were identified using Abbreviated Injury Severity (AIS) codes. Demographics, mechanisms, types of injury, severity, and outcomes were analysed.

RESULTS

Of 30 831 patients admitted with trauma to Scottish hospitals, 569 (1.8%) patients suffered a vascular injury during the eight year study period with 275 (0.9%) patients sustaining a peripheral or non-aortocaval vascular injury. There were 221 (80%) men and 54 (20%) women with a median (range) age of 39 (14 - 88) years. Blunt trauma was responsible for 179 (65%) injuries, of which road traffic accidents were the most common mechanism. A further 67 (24%) injuries were due to penetrating trauma, of which assault was the most common cause. The most common injury was to abdominal arteries (e.g., hepatic, renal, splenic [n = 83]) with an associated mortality rate of 17%. The median (range) Injury Severity Score (ISS) was 16 (4 - 75). Sixteen (6%) patients died in the Emergency Department (ED). Two hundred and twenty-seven (83%) patients were taken to theatre during their admission with a 30 day peri-operative mortality rate of 10%, compared with an overall mortality rate of 16%. Injuries to an abdominal vein (e.g., portal, renal, splenic, superior mesenteric) had the highest number of associated deaths, with 11 (32%) of 34 cases resulting in a fatality.

CONCLUSION

There is a low incidence of vascular trauma in Scotland. Blunt force was responsible for more vascular injuries than penetrating trauma. Patients with peripheral and non-aortocaval vascular injuries are likely to be severely injured and suffer a high mortality rate.

Pretreatment C-reactive protein-to-albumin ratio predicts clinical outcomes in patients with peripheral T-cell lymphoma

PURPOSE

Peripheral T-cell lymphoma (PTCL) is an aggressive and heterogenous T-cell lymphoid malignancy. The prognostic value of C-reactive protein-to-albumin ratio (CAR) has never been assessed in PTCL.

MATERIALS AND METHODS

This study retrospectively reviewed the medical records of 76 patients diagnosed with various subtypes of PTCL. A CAR cutoff value of 0.794 was determined, and clinical outcomes, including response rate, overall survival (OS), and progression-free survival (PFS), were compared between the high (> 0.794) and low (≤ 0.794) CAR groups.

RESULTS

After induction therapy, complete response was achieved in 8 (32.0%) and 39 patients (76.5%) in the high and low CAR groups, respectively. During the median follow-up of 57.5 months, the high CAR group had significantly worse 5-year PFS and 5-year OS rates. Even with adjustment for the International Prognostic Index (≥ 3), Prognostic Index for PTCL-unspecified (≥ 3), and T cell score (≥ 2), high CAR remained a significant prognostic factor for PFS (hazard ratio [HR]: 4.01, 95% confidence interval [CI] 2.04-7.86, p < 0.001) and OS (HR: 2.97, 95% CI: 1.33-6.64, p = 0.008).

CONCLUSION

CAR may play a complementary role in predicting prognosis in patients with PTCL, considering its simplicity, objectivity, and easy accessibility.

The updated development of blood-based biomarkers for Huntington's disease

Huntington's disease is a progressive neurodegenerative disease caused by mutation of the huntingtin (HTT) gene. The identification of mutation carriers before symptom onset provides an opportunity to intervene in the early stage of the disease course. Optimal biomarkers are of great value to reflect neuropathological and clinical progression and are sensitive to potential disease-modifying treatments. Blood-based biomarkers have the merits of minimal invasiveness, low cost, easy accessibility and safety. In this review, we summarized the updated development of blood-based biomarkers for HD from six aspects, including neuronal injuries, oxidative stress, endocrine functions, immune reactions, metabolism and differentially expressed miRNAs. The blood-based biomarkers presented and discussed in this review were close to clinical applicability and might facilitate clinical design as surrogate endpoints. Exploration and validation of robust blood-based biomarkers require further standard and systemic study design in the future.

Migraine attacks are of peripheral origin: the debate goes on

BACKGROUND

Despite the pervasiveness of migraine, the underlying pathophysiological mechanisms initiating migraine attacks are far from well understood and are matter of scientific debate.

OBJECTIVE

In this narrative review, we discuss key evidence for that suggest a peripheral origin or central origin and provide directions for future studies that may provide further clarification.

DISCUSSION

Migraine pathogenesis is considered to involve the trigeminovascular system, a term that encompasses the trigeminal nerve and its axonal projections to the intracranial blood vessels. Beyond any doubt both peripheral and central mechanisms are involved in migraine pathogenesis, but an unresolved question is the how the initial activation occurs in a migraine attack. Evidence favoring a peripheral origin of migraine attacks, i.e., initial events occur outside of the blood-brain barrier, include the importance of sensitization of perivascular sensory afferents early on in a migraine attack. Evidence favoring a central origin include the occurrence of prodromal symptoms, migraine aura, and activation of structures within the central nervous system early in and during a migraine attack.

CONCLUSIONS

Both peripheral and central mechanisms are likely involved in a migraine attack, e.g., peripheral nociceptive input is necessary for pain transmission and cortical activity is necessary for pain perception. Yet, the debate of whether migraine attacks are initiated a peripheral or central site remains unresolved. The increased focus on prodromal symptoms and on the development of a human model of migraine aura will possibly provide key arguments needed to answer this question in the near future. Until then, we cannot draw firm conclusions and the debate goes on.

VIDEO LINK

Video recording of the debate held at the 1st International Conference on Advances in Migraine Sciences (ICAMS 2022, Copenhagen, Denmark) is available at: https://www.youtube.com/watch?v=NC0nlcKohz0 .

Associations between saliva and plasma cytokines in cognitively normal, older adults

BACKGROUND

Inflammatory responses play key roles in the development and progression of many pathological conditions, including neurodegenerative diseases. Accurate quantification of inflammatory factors in saliva would be highly advantageous, given its convenience and non-invasive nature, especially in elderly populations.

METHODS

In this study, we measured levels of 10 cytokines, and the pro-inflammatory factor, YKL-40, in plasma and saliva samples from a cohort of nondemented older adults (n = 71; 62% female; 70.3 ± 6.4 years) using sensitive electrochemiluminescence-based immunoassays.

RESULTS

We found that the mean levels of all cytokines were higher in saliva compared to plasma and that strong sex differences were observed for both saliva and plasma cytokines in this population. Comparing each cytokine between the two biofluids, we found that levels of interferon-gamma (IFNγ), interleukin (IL)-6 and tumor necrosis factor-alpha (TNFα) in blood were significantly correlated with their respective levels in saliva. We further observed that levels of these cytokines in blood were significantly correlated with additional cytokines in saliva, including IL-1β, IL-10, IL-8, IL12p70 and IL-13.

CONCLUSIONS

These findings show that inflammatory markers in saliva are associated with those found in circulation, suggesting shared inflammatory mechanisms between these two fluids. The higher levels of cytokines measured in saliva suggest that it might represent a better peripheral fluid to gauge inflammatory processes. Finally, our findings of robust sex differences in several salivary cytokines could have important implications for their potential use as disease biomarkers in the elderly and might be related to sex differences in the prevalence of age-related conditions.

A systematic review and meta-analysis of the stability of peripheral immune markers in healthy adults

Peripheral immune markers are widely used to predict risk for inflammatory disease. However, whether single assessments of inflammatory biomarkers represent stable individual differences remains unclear. We reviewed 50 studies (N = 48,674; 57 % male; mean age 54 (range 13-79) years) that assessed markers of inflammation on >1 occasion, with time between measures ranging from 24 h to 7+ years. Separate random effects meta-analyses were conducted for each inflammatory marker and time interval. Markers that had broad coverage across most time intervals included C-reactive protein (CRP; k = 37), interleukin (IL)-6 (k = 22), TNF-α (k = 10), and fibrinogen (Fg; k = 9). For CRP, IL-6, and TNF-α, stability estimates generally decreased with time, with strong to moderate stability over intervals <6 months (r's = 0.80-0.61), modest to moderate stability over 6 months - 3 years (r's = 0.60-0.51), and low stability for >3 years (r's = 0.39-0.30). Estimates were less reliable for Fg for time intervals ≤ 3 years although they generally followed the same pattern; more reliable findings suggested greater stability for Fg than other markers for intervals >3 years (r = 0.53). These findings suggest that single measures of inflammatory biomarkers may be an adequate index of stable individual differences in the short term (<6 months), with repeated measures of inflammatory biomarkers recommended over intervals ≥ 6 months to 3 years, and absolutely necessary over intervals >3 years to reliably identify stable individual differences in health risk. These findings are consistent with stability estimates and clinical recommendations for repeated measurement of other cardiovascular measures of risk (e.g., blood lipids, blood pressure).

Femoral artery aneurysms

True aneurysms are dilatations of blood vessels, bounded by the tunica intima, tunica media and tunica adventitia. False aneurysms are dilatations bounded by the tunica adventitia only, and are more common than true aneurysms. The femoral artery is the second most common location for true peripheral artery aneurysms, and the most common site of false aneurysms. If left untreated, devastating complications can occur, such as infection, rupture, ischaemia and limb loss. Femoral artery aneurysms should be identified early and managed by a vascular specialist. This article outlines the evidence for the epidemiology, investigation and management of femoral artery aneurysms.

Impact of WALANT Hand Surgery in a Secondary Care Hospital in Spain. Benefits to the Patient and the Health System

Purpose

The aim of this study is to compare patient benefits and economic costs of hand surgeries using the wide-awake local anesthesia no tourniquet (WALANT) technique versus a conventional major outpatient suite and review outcomes and complications in a series of cases of patients operated on using the WALANT technique.

Methods

A prospective cohort study was first conducted comparing 150 cases of ambulatory hand surgery (carpal tunnel syndrome and trigger finger) using the WALANT technique and not requiring an operating room setting with 150 cases of outpatient surgery performed in an operating room involving a preoperative evaluation and the use of sedation and tourniquet. Preoperative, intraoperative, and postoperative pain was monitored, and days requiring postoperative analgesia were recorded. The resources and costs were evaluated. and patient satisfaction was assessed using a specific survey.Subsequently, 580 patient medical records were retrospectively reviewed, including 419 carpal tunnel syndrome and 197 trigger finger interventions (616 WALANT surgeries).

Results

Intraoperative pain was equivalent for both groups, and postoperative pain was significantly lower in the WALANT group, with a reduced need for analgesics. Satisfaction was greater for the local anesthesia group. The use of personnel resources and hospital materials was reduced in the WALANT group, with a total estimated cost savings of 1.019 USD per patient.There were no complications related to the WALANT technique and the lidocaine and adrenaline combination. We found a complication rate of 5.58%, and, in line with the literature, most complications were minor, managed conservatively, and not related to the anesthetic technique.

Conclusions

Procedures such as carpal tunnel and trigger finger surgeries can be safely performed using wide-awake surgery. Patient satisfaction is higher than with the conventional procedure performed in the operating room. Pain control is excellent, especially during the postoperative period.

Clinical relevance

Hand surgery patients benefit from the WALANT technique in terms of comfort and timeliness because there is no need for preoperative tests or evaluations. In addition, it represents significant savings in hospital resources. In our case series, complications were in line with those previously reported with other anesthetic techniques.

Effects of stimulation area and temperature rates on offset analgesia

INTRODUCTION

Offset analgesia describes the effect of a slightly reduced nociceptive stimulus, resulting in a disproportionate large reduction in the pain perception. This effect may be associated with descending pain inhibition, but parameters influencing this phenomenon are poorly understood.

OBJECTIVES

In this study, 2 separate experiments were conducted to investigate both, the spatial aspects of offset analgesia and the influence of different rates of temperature rise.

METHODS

In both experiments, 29 healthy participants received individualized and heat-based offset analgesia paradigms applied to the forearm, with continuous assessment of pain intensity. In experiment 1, offset analgesia paradigms with 3 different rates of temperature rise were applied, whereas in experiment 2, offset analgesia paradigms with 2 different heat application areas were used.

RESULTS

The results of experiment 1 showed that different temperature rates had no effect on the offset analgesia response (P > 0.05). Experiment 2, however, showed the influence of the size of a stimulated area on offset analgesia (P = 0.009), which can be explained mainly by the influence of spatial summation of pain and habituation processes.

CONCLUSIONS

The study showed a lack of influence of different temperature rates on offset analgesia; however, spatial aspects of offset analgesia could be identified. These are most likely based on spatial summation of pain and altered adaptation to pain.

Age-related changes in peripheral nociceptor function

Pain and pain management in the elderly population is a significant social and medical problem. Pain sensation is a complex phenomenon that typically involves activation of peripheral pain-sensing neurons (nociceptors) which send signals to the spinal cord and brain that are interpreted as pain, an unpleasant sensory experience. In this work, young (4-5 months) and aged (26-27 months) Fischer 344 x Brown Norway (F344xBN) rats were examined for nociceptor sensitivity to activation by thermal (cold and heat) and mechanical stimulation following treatment with inflammatory mediators and activators of transient receptor potential (TRP) channels. Unlike other senses that decrease in sensitivity with age, sensitivity of hindpaw nociceptors to thermal and mechanical stimulation was not different between young and aged F344xBN rats. Intraplantar injection of bradykinin (BK) produced greater thermal and mechanical allodynia in aged versus young rats, whereas only mechanical allodynia was greater in aged rats following injection of prostaglandin E₂ (PGE₂). Intraplantar injection of TRP channel activators, capsaicin (TRPV1), mustard oil (TRPA1) and menthol (TRPM8) each resulted in greater mechanical allodynia in aged versus young rats and capsaicin-induced heat allodynia was also greater in aged rats. A treatment-induced allodynia that was greater in young rats was never observed. The anti-allodynic effects of intraplantar injection of kappa and delta opioid receptor agonists, salvinorin-A and D-Pen²,D-Pen⁵]enkephalin (DPDPE), respectively, were greater in aged than young rats, whereas mu opioid receptor agonists, [D-Ala2, N-MePhe4, Gly-ol]-enkephalin (DAMGO) and morphine, were not effective in aged rats. Consistent with these observations, in primary cultures of peripheral sensory neurons, inhibition of cAMP signaling in response to delta and kappa receptor agonists was greater in cultures derived from aged rats. By contrast, mu receptor agonists did not inhibit cAMP signaling in aged rats. Thus, age-related changes in nociceptors generally favor increased pain signaling in aged versus young rats, suggesting that changes in nociceptor sensitivity may play a role in the increased incidence of pain in the elderly population. These results also suggest that development of peripherally-restricted kappa or delta opioid receptor agonists may provide safer and effective pain relief for the elderly.

Parenteral Nutrition

Parenteral nutrition (PN) is a therapy to nourish patients who cannot tolerate feeding via the gut. Though a life-saving intervention, it does have risks associated. In this article, we aim to dispel myths associated with PN. Practitioners who manage critically ill patients or patients with intestinal failure should be equipped with evidence-based knowledge of PN including the indications, contraindications, feasibility, complications, and long-term management of PN.

Design and synthesis of endocannabinoid enzyme inhibitors for ocular indications

A small library of FAAH and dual FAAH/MAGL inhibitors designed for peripheral selectivity were targeted. Of these compounds, three were identified to have desirable FAAH inhibition and reduced permeability in a PAMPA assay. Those three compounds were advanced into a MAGL inhibitor assay and one was found to be a relative selective FAAH inhibitor, FAAH to MAGL IC₅₀ ratio of 1:27, and one was found to be more characteristic of a true dual enzyme inhibitor, FAAH to MAGL IC₅₀ ratio of 1:4. Both compounds showed activity in an ABPP assay, blockage of TAMRA-FP labeling of FAAH and MAGL in rat eye homogenate.

Risk factors for peripheral intravascular catheter-related phlebitis in critically ill patients: analysis of 3429 catheters from 23 Japanese intensive care units

Background

Phlebitis is an important complication occurring in patients with peripheral intravascular catheters (PIVCs). The risk factors for phlebitis in the intensive care unit (ICU) was examined.

Methods

A secondary analysis of a prospective multicenter cohort study was conducted, involving 23 ICUs in Japan—the AMOR–VENUS study. Consecutive patients aged ≥ 18 years admitted to the ICU with newly inserted PIVCs after ICU admission were enrolled. Characteristics of the ICU, patients, PIVCs, and the drugs administered via PIVCs were recorded. A marginal Cox regression model was used to identify the risk factors associated with phlebitis.

Results

A total of 2741 consecutive patients from 23 ICUs were reviewed for eligibility, resulting in 1359 patients and 3429 PIVCs being included in the analysis population. The median dwell time was 46.2 h (95% confidence interval [CI], 21.3–82.9). Phlebitis occurred in 9.1% (95% CI, 8.2–10.1%) of catheters (3.5 cases/100 catheter days). The multivariate analysis revealed that the only factors that increased the risk of developing phlebitis were drugs administered intravenously. This study included 26 drugs, and 4 were associated with increased phlebitis: nicardipine (HR, 1.85; 95% CI, 1.29–2.66), noradrenaline (HR, 2.42; 95% CI, 1.40–4.20), amiodarone (HR, 3.67; 95% CI, 1.75–7.71) and levetiracetam (HR, 5.65; 95% CI, 2.80–11.4). Alternatively, factors significantly associated with a reduced risk of phlebitis were: standardized drug administration measures in the ICU (HR, 0.35; 95% CI, 0.17–0.76), 30≤ BMI (HR, 0.43; 95% CI, 0.20–0.95), catheter inserted by a doctor as nurse reference (HR, 0.55; 95% CI, 0.32–0.94), and upper arm insertion site as forearm reference (HR, 0.52; 95% CI, 0.32–0.85). The nitroglycerin was associated with a reduced phlebitis risk (HR, 0.22; 95% CI, 0.05–0.92).

Conclusion

Various factors are involved in the development of phlebitis caused by PIVCs in critically ill patients, including institutional, patient, catheter, and drug-induced factors, indicating the need for appropriate device selection or models of care in the ICU.

Trial registration: UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019, July 1, 2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01009-5.

A comparison of first-attempt cannulation success of peripheral venous catheter systems with and without wings and injection ports in surgical patients-a randomized trial

BACKGROUND

A peripheral venous catheter (PVC) is the most widely used device for obtaining vascular access, allowing the administration of fluids and medication. Up to 25% of adult patients, and 50% of pediatric patients experience a first-attempt cannulation failure. In addition to patient and clinician characteristics, device features might affect the handling and success rates. The objective of the study was to compare the first-attempt cannulation success rate between PVCs with wings and a port access (Vasofix® Safety, B. Braun, abbreviated hereon in as VS) with those without (Introcan® Safety, B. Braun, abbreviated hereon in as IS) in an anesthesiological cohort.

METHODS

An open label, multi-center, randomized trial was performed. First-attempt cannulation success rates were examined, along with relevant patient, clinician, and device characteristics with univariate and multivariate analyses. Information on handling and adherence to use instructions was gathered, and available catheters were assessed for damage.

RESULTS

Two thousand three hundred four patients were included in the intention to treat analysis. First-attempt success rate was significantly higher with winged and ported catheters (VS) than with the non-winged, non-ported design (IS) (87.5% with VS vs. 78.2% with IS; P_Chi < .001). Operators rated the handling of VS as superior (rating of "good" or "very good: 86.1% VS vs. 20.8% IS, P_Chi < .001). Reinsertion of the needle into the catheter after partial withdrawal-prior or during the catheterization attempt-was associated with an increased risk of cannulation failure (7.909, CI 5.989-10.443, P < .001 and 23.023, CI 10.372-51.105, P < .001, respectively) and a twofold risk of catheter damage (OR 1.999, CI 1.347-2.967, P = .001).

CONCLUSIONS

First-attempt cannulation success of peripheral, ported, winged catheters was higher compared to non-ported, non-winged devices. The handling of the winged and ported design was better rated by the clinicians. Needle reinsertions are related to an increase in rates of catheter damage and cannulation failure.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02213965 , Date: 12/08/2014.

Peripheral intravenous catheter and intraosseous device insertions reported from the 1st July 2016 to 30th June 2017 in an Australian state ambulance service: An observational study

OBJECTIVE

To overcome the lack of larger, population-based studies reporting the prevalence of insertion of PIVCs and IO devices, and to describe the patient-related and service-related characteristics of these devices, inserted by paramedics, in an Australian state ambulance service.

METHODS

A retrospective analysis of the electronic Ambulance Report Form (medical record) and Computer Aided Dispatch system from the 1st July 2016 until 30th June 2017.

RESULTS

709,217 events were analysed. Of these, 20.4% involved at least one successful PIVC insertion and 0.07% involved at least one successful IO device insertion; most of the time on first attempt (89% and 86.4% respectively). Most PIVCs were inserted into the right antecubital fossa or dorsum of the right hand while IO devices were inserted into the proximal tibia. Of male patients, 21.4% received PIVCs while 19.5% of female patients received PIVCs. Very low numbers of both male and female patients received IOs (0.1%). Medical, non-traumatic presentations were the most common presentation and received the most insertions of both devices, followed by trauma presentations. Advanced Care Paramedics inserted 84.0% of PIVCs while Critical Care Paramedics inserted 94.4% of IO devices. Time treating and transporting patients generally increased with number of attempts at vascular access undertaken.

CONCLUSIONS

Queensland paramedic practices relating to insertion of PIVCs, and IO devices appears consistent with documented practice internationally. Further study is required to determine whether the antecubital fossa and dorsum of the hand insertions are clinically necessary in this population as areas of flexion and distal extremities are generally to be avoided for PIVC insertion.

Diabetic Peripheral Neuropathy

Diabetic painless and painful peripheral neuropathy remains the most frequent complication of diabetes mellitus, but the pathophysiology remains undescribed, there are no robust clinical endpoints and no efficient treatment exists. This hampers good clinical practice, fruitful clinical research and successful pharmacological trials, necessary for the development of early detection, prevention and treatment. This chapter supplies an update on background and treatment of diabetic peripheral neuropathy. Goals and perspectives for future clinical and scientific approaches are also described.

Nurse knowledge and confidence on peripheral intravenous catheter insertion and maintenance in pediatric patients: A multicentre cross-sectional study

PURPOSE

To examine nursing knowledge and confidence of peripheral intravenous catheter insertion and maintenance in pediatric patients.

DESIGN AND METHODS

An online survey using validated questionnaires was conducted in ten (tertiary and district) hospitals in Indonesia from May to September 2020. Multivariable general linear models were used to investigate associations between nurses' characteristics and knowledge and confidence on the catheter insertion and maintenance score.

RESULTS

A total of 413 out of 458 pediatric nurses completed the survey (a response rate of 90%). The mean score of the nurse knowledge on insertion was 18.9(±3.3) (maximum score: 21), and the maintenance score was 6.5(±2.0) (maximum score: 12). The median score of the nurse insertion and maintenance confidence was quite high: 44 (IQR = 7) out of 50 and 37 (IQR = 4) out of 45, respectively. Initial patient assessment, catheter securement, site assessment and management of complications are areas where nurse knowledge and confidence are still lacking. Adjusted analysis indicates that training and work experience were significantly associated with the knowledge and confidence score (p < 0.05).

CONCLUSION

Pediatric nurses were largely confident in their skills but this was not reflected in their knowledge scores. Training and experience were important predictors for nursing knowledge and confidence in catheter insertion and maintenance.

PRACTICE IMPLICATIONS

The results provide nursing and hospital managers and educational institutions to understand areas of intravenous catheter insertion and maintenance in which nurses lack of knowledge and confidence as well as to formulate tailored and ongoing training to improve nurse knowledge, confidence, practices and optimize patients' care.

Giant Aggressive Odontogenic Fibroma in a 15-month-old Female: Case Report and Review of Literature

INTRODUCTION

Odontogenic fibroma (OF) is a rare benign tumor of mesenchymal odontogenic tissue with variable global incidence. Two variants comprising extraosseous /peripheral (POF) and intraosseous /central (COF) have been identified based on the anatomical origin of the tumor. OF isslow growing, and often asymptomatic with characteristic radiographic appearance of a unilocular or multilocular cyst frequently associated with unerupted or displaced teeth while histologically, varying amount of inactive odontogenic epithelium embedded in a mature relatively dense collagenous stroma is diagnostic. The absence of odontogenic epithelium does not exclude the diagnosis of odontogenic fibroma.

CASE REPORT

A 15 months old female presented with 3 months history of left lower jaw swelling which showed aggressive growth following incisional biopsy. Parents said lesion was noticed for the first time as pinpoint on the submandibular area and was too small to warrant any worries. Initial radiograph revealed absence of bony involvement but the second showed evidence of bony involvement. An impression of soft tissue sarcoma was made and incisional biopsy was sent for pathological diagnosis which revealed peripheral odontogenic fibroma. The rapidity of growth following incisional biopsy bellied a benign lesion.

CONCLUSION

An aggressive odontogenic fibroma with multifocal points in a 15months old girl.

Exploration of the anti-insomnia mechanism of Ganoderma by central-peripheral multi-level interaction network analysis

Background

Ganoderma (Lingzhi in Chinese) has shown good clinical outcomes in the treatment of insomnia, restlessness, and palpitation. However, the mechanism by which Ganoderma ameliorates insomnia is unclear. We explored the mechanism of the anti-insomnia effect of Ganoderma using systems pharmacology from the perspective of central-peripheral multi-level interaction network analysis.

Methods

The active components and central active components of Ganoderma were obtained from the TCMIP and TCMSP databases, then screened to determine their pharmacokinetic properties. The potential target genes of these components were identified using the Swiss Target Prediction and TCMSP databases. The results were matched with the insomnia target genes obtained from the GeneCards, OMIM, DisGeNET, and TCMIP databases. Overlapping targets were subjected to multi-level interaction network analysis and enrichment analysis using the STRING, Metascape, and BioGPS databases. The networks analysed were protein-protein interaction (PPI), drug-component-target gene, component-target gene-organ, and target gene-extended disease; we also performed gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses.

Results

In total, 34 sedative-hypnotic components (including 5 central active components) were identified, corresponding to 51 target genes. Multi-level interaction network analysis and enrichment analysis demonstrated that Ganoderma exerted an anti-insomnia effect via multiple central-peripheral mechanisms simultaneously, mainly by regulating cell apoptosis/survival and cytokine expression through core target genes such as TNF, CASP3, JUN, and HSP90αA1; it also affected immune regulation and apoptosis. Therefore, Ganoderma has potential as an adjuvant therapy for insomnia-related complications.

Conclusion

Ganoderma exerts an anti-insomnia effect via complex central-peripheral multi-level interaction networks.

What's New in Neuraxial Labor Analgesia

Purpose of Review

This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed.

Recent Findings

There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia.

Summary

Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 10⁶/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.

Neuroimaging of Dizziness and Vertigo

Dizziness and vertigo are common symptoms in the primary care and emergency settings, resulting in a significant decrease in quality of life and a high cost burden to the US health care system. The etiology of these symptoms is difficult to elucidate owing to a wide range of diseases with overlapping manifestations. The broad differential diagnosis based on whether the disease process is central or peripheral is showcased. Each differential will be categorized into neoplastic, infectious or inflammatory, structural, traumatic, and iatrogenic causes. Computed tomography scans, MRI, and vascular imaging are frequently complimentary in providing diagnoses and guidance in management.

Complications Associated with Peripheral Nerve Blocks

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Popliteal artery aneurysms treatments: early midterm results of the use of endovascular stent grafts

Background/aim

Popliteal artery aneurysms (PAAs) are abnormal bulgings, which account for 70% of all peripheral artery aneurysms. They are usually asymptomatic. In this study, we present our long-term results of endovascular stent grafts in the treatment of PAA in the light of literature data.

Material and methods

A total of 63 legs of 63 patients with PAA, who were treated with endovascular techniques in our clinic between July 2010 and July 2019, were retrospectively analyzed. All patients underwent color Doppler ultrasound (DUS), magnetic resonance angiography (MRA), or computed tomography angiography (CTA) to identify the diameter and length of PAAs, vessel tortuosity, the presence and degree of thrombus, and diameter in the healthy landing zone and to visualize tibioperoneal vascular structures. A Viabahn stent graft was inserted in all patients.

Results

57 patients (90.5%) were males with a mean age of 76.35 ± 7 years. 24 patients (38.1%) were symptomatic, while 11 patients (17.5%) had a concomitant abdominal aortic aneurysm (AAA). The mean follow-up period was 46.05 ± 25.01 months. The primary patency rate was 79.3%. A graft thrombosis was observed in 13 patients (20.6%) during a mean follow-up period of 8.31 ± 5.91 months. The number of distal arteries was significantly lower in the patients with thrombosis than those without.

Conclusions

Endovascular treatment of PAA using stentgrafts is safe in selected cases. However, it is reasonable to avoid endovascular treatment due to an increased risk for thrombosis in patients with a low number of patent distal arteries or impaired distal flow.

Extended dwell and standard ultrasound guided peripheral intravenous catheters: Comparison of durability and reliability

Background Vascular access is a critical component of emergency department (ED) care. Ultrasound guided placement of peripheral intravenous (USIV) catheters is increasingly common. However, USIV are thought to suffer from reduced durability and higher complication rates. Extended dwell catheters (EDC) are long peripheral IVs placed under combined ultrasound and wire guidance. The goal of this study is to compare dwell times and complication rates of EDC to standard peripheral USIV. Methods We performed a retrospective cohort study at a tertiary care adult ED comparing IV placements during a 17-month period (8/1/2018-12/31/2019), stratified by standard USIV versus EDC. The primary outcome was catheter dwell time and secondary outcomes included need for inpatient vascular access team (VAST) consultation, peripherally inserted central catheter (PICC) insertions, and radiocontrast extravasations. Multivariable Cox regression time-to-event analyses were used to evaluate dwell times, adjusting for age, gender, BMI and end-stage renal disease. Results 359 EDC and 4190 standard USIV were included for analysis. Most USIV (95.6%) and EDC (98.3%) were placed by ED technicians trained in ultrasound vascular access. EDC median dwell time (5.9 days [95%CI: 5.1-6.7]) exceeded standard USIV (3.8 days [95% CI: 3.6-4.0]). Patients with EDC placed in the ED required less VAST consultation (0.84 vs 0.99 charges/encounter), had similar rates of PICC line use (8.0% vs 8.4% of encounters) and had no radiocontrast extravasation events. Multivariable Cox regression demonstrated survival benefit (longer dwell time) favoring EDC (HR 0.70 [95%CI 0.60-0.81]). Conclusion Use of EDC results in longer dwell time and reduces subsequent use of vascular access resources, while maintaining low complication rates. EDC demonstrate superior durability which may justify their selection over standard USIV in some patients.

Feasibility of peripheral OCT imaging using a novel integrated SLO ultra-widefield imaging swept-source OCT device

Purpose

To describe the feasibility of peripheral OCT imaging in retinal diseases using a novel full-field device.

Methods

A total of 134 consecutive eyes were referred and imaged on the Optos Silverstone swept-source OCT (SS-OCT) (Optos PLC; Dunfermline, UK). Scanning laser ophthalmoscope (SLO) images and the associated SS-OCT images were obtained in the posterior pole, mid-periphery or far periphery based on the nature of the referral and on new areas of interest observed in the optomap images at the time of imaging.

Results

A total of 134 eyes (96 patients) were enrolled in the study. One hundred and twenty-five eyes (91 patients) with 38 retinal pathologies were prospectively assessed and 9 eyes (5 patients) were excluded due to incomplete image acquisition. The average age of the subjects was 54 years (range 21–92 years). Thirty-nine out of 125 eyes (31%) had macular pathologies. Eighty-six out of 125 eyes (69%) had peripheral only pathologies, an area which cannot be visualized by standard OCT devices with a 50 degree field-of-view.

Conclusions

The ability to capture peripheral pathologies using an integrated SLO-UWF imaging with full-field swept-source provided high-grade anatomical insight that confirmed the medical and surgical management in a majority of cases. Its use in the mid- and far periphery provides a holistic clinical picture, which can potentially aid in the understanding of various retinal pathologies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10792-021-01837-7.

Effect of Nimodipine and Botulinum Toxin A on Peripheral Nerve Regeneration in Rats: A Pilot Study

BACKGROUND

Peripheral nerve damage is a frequent problem, with an estimated 2.8%-5.0% of trauma admissions involving peripheral nerve injury. End-to-end, tension-free microsurgical repair (neurorrhaphy) is the current gold standard treatment for complete transection (neurotmesis). While neurorrhaphy reapproximates the nerve, it does not address the complex molecular regenerative process. Evidence suggests that botulinum toxin A (BTX) and nimodipine (NDP) may improve functional recovery, but mechanisms of action remain unknown.

METHODS

This research investigates BTX and NDP for their novel capacity to improve neural regeneration in the setting of neurorrhaphy using a Lewis rat tibial nerve neurotmesis model. In a triple-masked, placebo-controlled, randomized study design, we compared functional (rotarod, horizontal ladder walk), electrophysiological (conduction velocity, duration), and stereological (axon count, density) outcomes of rats treated with: NDP+saline injection, BTX+NDP, Saline+placebo, and BTX+placebo. Additional controls included sham surgery +/- BTX.

RESULTS

NDP+saline outperformed other treatment groups in the ladder walk. This group had the fewest deep slips (15.07% versus 30.77% in BTX+NDP, P = 0.122), and the most correct steps (70.53% versus 55.58% in BTX+NDP, P = 0.149) in functional testing. NDP+saline also had the fastest nerve conduction velocity (0.811m/s versus 0.598m/s in BTX+NDP, P = 0.126) among treatment groups. BTX+NDP had the highest axon count (10,012.36 versus 7,738.18 in NDP+Saline, P = 0.009).

CONCLUSION

This study is the first to test NDP with BTX in a multimodal assessment of nerve recovery following neurotmesis and neurorrhaphy. NDP outperformed BTX+NDP functionally. Future work will focus on nimodipine in an effort to improve nerve recovery in trauma patients.

No effect of passive stretching on neuromuscular function and maximum force-generating capacity in the antagonist muscle

Purpose

The present study investigated whether or not passive stretching increases the force-generating capacity of the antagonist muscle, and the possible neuromuscular mechanisms behind.

Methods

To this purpose, the neuromuscular function accompanying the force-generating capacity was assessed in 26 healthy male volunteers after passive stretching and in a control session. Before and after passive intermittent static stretching of the plantar flexors consisting of five sets × 45 s + 15 s-rest, maximum voluntary isometric contraction (MVC) and surface electromyographic root mean square (sEMG RMS) were measured in the tibialis anterior (the antagonist muscle). Additionally, evoked V wave, H-reflex, and M wave were elicited by nerve stimulation at rest and during MVC. Ankle range of motion (ROM) and plantar flexors MVC and EMG RMS were measured to check for the effectiveness of the stretching manoeuvre.

Results

No change in MVC [p = 0.670; effect size (ES) − 0.03] and sEMG RMS/M wave during MVC (p = 0.231; ES − 0.09) was observed in the antagonist muscle after passive stretching. Similarly, no change in V wave (p = 0.531; ES 0.16), H-reflex at rest and during MVC (p = 0.656 and 0.597; ES 0.11 and 0.23, respectively) and M wave at rest and during MVC (p = 0.355 and 0.554; ES 0.04 and 0.01, respectively) was observed. An increase in ankle ROM (p < 0.001; ES 0.55) and a decrease in plantar flexors MVC (p < 0.001; ES − 1.05) and EMG RMS (p < 0.05; ES − 1.72 to − 0.13 in all muscles) indicated the effectiveness of stretching protocol.

Conclusion

No change in the force-generating capacity and neuromuscular function of the antagonist muscle after passive stretching was observed.

Comprehensive analysis of peripheral T-cell and natural killer/T-cell lymphoma in Asian patients: A multinational, multicenter, prospective registry study in Asia

Background

Peripheral T-cell lymphomas (PTCLs) are uncommon and their frequency is regionally heterogeneous. Several studies have been conducted to evaluate the clinical features and treatment outcomes of this disease entity, but the majority of these were conducted in limited areas, making it difficult to comprehensively analyze their relative frequency and clinical features. Furthermore, no consensus treatment for PTCLs has been established. Therefore, we conducted an Asia-specific study to understand the relative frequency of PTCLs and assess treatments and their outcomes in Asian patients.

Methods

We performed a multinational, multicenter, prospective registry of adult patients with PTCLs that was named as the International Cooperative non-Hodgkin T-cell lymphoma prospective registry study where thirty-two institutes from six Asian countries and territories (Korea, China, Taiwan, Singapore, Malaysia, and Indonesia) participated.

Findings

A total of 486 patients were registered between April 2016 and February 2019, and more than a half of patients (57%) had stage III or IV. Extranodal natural killer (NK)/T- cell lymphoma was the most common subtype (n = 139,28.6%), followed by angioimmunoblastic T-cell lymphoma (AITL, n = 120,24.7%), PTCL-not otherwise specified (PTCL-NOS, n = 101,20.8%), ALK-positive anaplastic large cell lymphoma (ALCL, n = 34,6.9%), and ALK-negative ALCL (n = 30,6.2%). The median progression-free survival (PFS) and overall survival (OS) were 21.1 months (95% CI,10.6-31.6) and 83.6 months (95% CI, 56.7-110.5), respectively. Upfront use of combined treatment with chemotherapy and radiotherapy showed better PFS than chemotherapy alone in localized ENKTL whereas consolidation with upfront autologous stem cell transplantation (SCT) provided longer PFS in advance stage ENKTL. In patients with PTCLs other than ENKTL, anthracycline-containing chemotherapies were widely used, but the outcome of those regimens was not satisfactory, and upfront autologous SCT was not significantly associated with survival benefit, either. The treatment outcome of salvage chemotherapy was disappointing, and none of the salvage strategies showed superiority to one another.

Interpretation

This multinational, multicenter study identified the relative frequency of each subtype of PTCLs across Asian countries, and the survival outcomes according to the therapeutic strategies currently used.

Funding

Samsung Biomedical Research Institute.

Ruptured giant aneurysm of a cortical middle cerebral artery: A case report

Background

Aneurysms of the cortical branches of the middle cerebral artery (MCA) are rare. They usually are secondary to traumatic or infectious etiologies and are rarely idiopathic. The specific characteristics of idiopathic aneurysms in such location are not well defined in the literature. The authors report a rare case of a ruptured giant idiopathic cortical MCA aneurysm with review of the available literature on this clinical entity.

Case Description

A 24-year-old female presented with headache, disturbed level of consciousness, and right-sided weakness. Imaging studies showed a left frontoparietal intracerebral hematoma and a giant saccular aneurysm in the posterior parietal cortical branch of the MCA. The patient had no history of head trauma or active infection; therefore, the aneurysm was considered idiopathic. A microsurgical clipping of the aneurysm with evacuation of the hematoma was performed. There were no surgical complications, and the patient achieved a good outcome modified Rankin Scale of 1 with no neurological deficits.

Conclusion

Idiopathic aneurysms of the cortical branches of the MCA are rare, and usually present with intraparenchymal hemorrhage due to rupture. There is no clear consensus regarding the optimal management strategy. This case shows that timely management can lead to good outcomes.

Peripheral dentinogenic ghost cell tumor-report of two cases and review of the literature

Peripheral dentinogenic ghost cell tumor (DGCT) is a rare and non-aggressive benign odontogenic tumor. They usually affect the elderly and are predominantly located in the anterior region of the jaws. Their differential diagnosis includes reactive/inflammatory gingival lesions. We report here two cases of peripheral DGCT in a 73-year-old female and a 48-year-old male patient and review the cases published in the literature. Both lesions presented as a nodular lesion in the mandible, and panoramic radiography showed no abnormalities. Microscopically, it was observed to be an ameloblastomatous epithelial proliferation associated with clusters of ghost cells and dysplastic dentin. Immunohistochemistry revealed positivity for cytokeratin 19 and a low Ki-67 proliferative index. Based on histopathological features and the absence of radiographic findings, a diagnosis of peripheral DGCT was rendered. The low number of cases published of peripheral DGCT makes case reports important in providing information that helps in their diagnoses and management.

Duration of peripheral intravenous catheter patency in children

Objective

This study aimed to compare the impact of saline lock to running a slow continuous infusion to-keep-vein-open (TKVO) on the total time a peripheral intravenous (PIV) catheter remained patent.

Method

A retrospective chart review of all children admitted to the paediatric ward of a regional hospital in Saskatchewan December 1, 2013 through February 28, 2014. Characteristics of patients with PIV catheters were abstracted from the health records, including patient size, catheter size and site, and total time each PIV catheter spent (i) infusing therapeutic fluids or medications, (ii) running a TKVO infusion, or (iii) saline locked. The duration of catheter patency was compared with the proportion of time that TKVO infusions were run, as well as patient gender and age.

Results

During 375 admissions, there were 189 PIVs which met inclusion criteria. The proportion of nontherapeutic time a PIV catheter spent TKVO compared to saline locked did not affect the total time the PIV catheter was patent (P=0.33). Gender had no influence, but older age, a nonmodifiable factor, was associated with increased time a PIV catheter remained patent (P=0.028).

Discussion

Peripheral intravenous (PIV) catheter insertion can be a painful and traumatic procedure. On the paediatric ward of a regional hospital, TKVO infusions were not superior to saline lock for prolonging PIV catheter patency.

Efficacy of Tofacitinib in the Treatment of Psoriatic Arthritis: A Systematic Review

INTRODUCTION

Therapeutic approaches for psoriatic arthritis (PsA) include non-pharmacologic therapies, symptomatic treatments, tumor necrosis factor inhibitors, interleukin inhibitors, cytotoxic T lymphocyte antigen 4 immunoglobulin, and Janus kinase inhibitors. This systematic review aimed to provide complete and up-to-date information on efficacy of tofacitinib in the treatment of PsA, giving special attention to non-skin manifestations (peripheral arthritis, axial disease, enthesitis, and dactylitis).

METHODS

A search of studies published between January 2016 and June 2020 was carried out on PubMed and Google Scholar.

RESULTS

The number of studies with tofacitinib in PsA is limited and most of them are post hoc analyses from OPAL Broaden and OPAL Beyond. Tofacitinib has been demonstrated to be efficacious for the treatment of all disease manifestations in PsA. Superior effectivity to placebo is achieved at the earliest time point evaluated, and maintained over time. Patients who switch from placebo to tofacitinib show the same improvements; however, the time to initial response is faster in patients who firstly receive tofacitinib, compared with those switching subsequently. Additional data suggest that tofacitinib may be also effective for the treatment of the axial domain.

CONCLUSIONS

Tofacitinib has been demonstrated to be efficacious for the treatment of peripheral and axial involvement, enthesitis, and dactylitis manifestation in PsA. Further prospective and long-term studies are required to corroborate and complete the present results. Similarly, real-world evidence is also necessary to complement the information obtained in clinical trials, and thereby to have a better overview of real efficacy and safety of the drug.

Attention attracts action in healthy participants: An insight into optic ataxia?

Patients with optic ataxia following lesions to superior parts of the posterior parietal cortex make large errors when reaching to targets in the peripheral visual field. These errors are characterised by a contraction, or attraction, towards the point of fixation. These patients also have a reduced ability to allocate visual attention away from the point of fixation, but it is unclear whether the core symptom of misreaching is related to these attentional problems. In neurologically-intact adults, we tested the effect of an attention-demanding dual-task performed at fixation upon visually-guided reaching to peripheral targets. The dual task was associated with delayed movement initiation, and a shortened deceleration phase of movement suggesting a reduced ability to benefit from online control. It also induced a small but consistent shift of reaching endpoints towards the side of fixation. Our experimental restriction of visual attention thus impaired both the programming and control of reaching, and induced a spatial pattern of errors that was qualitatively reminiscent of optic ataxia, albeit much less severe. These findings are consistent with a close functional link between attention and action in the healthy brain, and suggest that attentional disturbances could be a core component of optic ataxia following parietal lesions.

Peripherally misfolded proteins exacerbate ischemic stroke-induced neuroinflammation and brain injury

BACKGROUND

Protein aggregates can be found in peripheral organs, such as the heart, kidney, and pancreas, but little is known about the impact of peripherally misfolded proteins on neuroinflammation and brain functional recovery following ischemic stroke.

METHODS

Here, we studied the ischemia/reperfusion (I/R) induced brain injury in mice with cardiomyocyte-restricted overexpression of a missense (R120G) mutant small heat shock protein, αB-crystallin (CryAB^R120G), by examining neuroinflammation and brain functional recovery following I/R in comparison to their non-transgenic (Ntg) littermates. To understand how peripherally misfolded proteins influence brain functionality, exosomes were isolated from CryAB^R120G and Ntg mouse blood and were used to treat wild-type (WT) mice and primary cortical neuron-glia mix cultures. Additionally, isolated protein aggregates from the brain following I/R were isolated and subjected to mass-spectrometric analysis to assess whether the aggregates contained the mutant protein, CryAB^R120G. To determine whether the CryAB^R120G misfolding can self-propagate, a misfolded protein seeding assay was performed in cell cultures.

RESULTS

Our results showed that CryAB^R120G mice exhibited dramatically increased infarct volume, delayed brain functional recovery, and enhanced neuroinflammation and protein aggregation in the brain following I/R when compared to the Ntg mice. Intriguingly, mass-spectrometric analysis of the protein aggregates isolated from CryAB^R120G mouse brains confirmed presence of the mutant CryAB^R120G protein in the brain. Importantly, intravenous administration of WT mice with the exosomes isolated from CryAB^R120G mouse blood exacerbated I/R-induced cerebral injury in WT mice. Moreover, incubation of the CryAB^R120G mouse exosomes with primary neuronal cultures induced pronounced protein aggregation. Transduction of CryAB^R120G aggregate seeds into cell cultures caused normal CryAB proteins to undergo dramatic aggregation and form large aggregates, suggesting self-propagation of CryAB^R120G misfolding in cells.

CONCLUSIONS

These results suggest that peripherally misfolded proteins in the heart remotely enhance neuroinflammation and exacerbate brain injury following I/R likely through exosomes, which may represent an underappreciated mechanism underlying heart-brain crosstalk.

Atomic Force Microscopy Reveals Membrane Protein Activity at the Single Molecule Level

Atomic force microscopy has emerged as a valuable complementary technique in membrane structural biology. The apparatus is capable of probing individual membrane proteins in fluid lipid bilayers at room temperature with spatial resolution at the molecular length scale. Protein conformational dynamics are accessible over a range of biologically relevant timescales. This chapter presents methodology our group uses to achieve robust AFM image data of the General Secretory system, the primary pathway of protein export from the cytoplasm to the periplasm of E. coli. Emphasis is given to measuring and maintaining biochemical activity and to objective AFM image processing methods. For example, the biochemical assays can be used to determine chemomechanical coupling efficiency of surface adsorbed translocases. The Hessian blob algorithm and its extension to nonlocalized linear features, the line detection algorithm, provide automated feature delineations. Many of the methods discussed here can be applied to other membrane protein systems of interest.

What Every Neuropathologist Needs to Know: Peripheral Nerve Biopsy

Peripheral neuropathy is a common disorder with many possible etiologies including metabolic diseases, inflammatory conditions, infections, malignancy, inherited diseases, drugs, and toxins. In most instances, diagnosis and treatment plan can be established based on clinical presentation, family history, laboratory results, genetic testing, and electrophysiological studies. But in some situations, a peripheral nerve biopsy remains a valuable tool. This is especially true in patients with rapidly progressive disease, with atypical presentation or for whom other approaches fail to yield a definitive diagnosis. The pathologic examination starts with basic decisions about specimen triage. A few basic questions help to provide an initial framework for the assessment of a nerve biopsy-is the specimen adequate; are there inflammatory changes; are there vascular changes; is there amyloid; are there changes to axonal density and the Schwann cell-myelin-axon unit. In the appropriate context and with such an approach peripheral nerve biopsies can still represent a clinically helpful test.