Diagnostic and therapeutic considerations in idiopathic hypereosinophilia with warm autoimmune hemolytic anemia.

Hypereosinophilic syndrome (HES) encompasses numerous diverse conditions resulting in peripheral hypereosinophilia that cannot be explained by hypersensitivity, infection, or atopy and that is not associated with known systemic diseases with specific organ involvement. HES is often attributed to neoplastic or reactive causes, such as chronic eosinophilic leukemia, although a majority of cases remains unexplained and are considered idiopathic. Here, we review the current diagnosis and management of HES and present a unique case of profound hypereosinophilia associated with warm autoimmune hemolytic anemia requiring intensive management. This case clearly illustrates the limitations of current knowledge with respect to hypereosinophilia syndrome as well as the challenges associated with its classification and management

A portfolio of electroacoustic compositions: blurring the lines between field recording, soundscape composition and acousmatic music

A portfolio of electroacoustic compositions that draw on environmental field recordings from around the world composed for stereophonic and multichannel formats. This includes nine concert works and four installation works, three of which are collaborative projects. Particular focus is given to the relationship between field recordings and the genres of pure field recording composition, soundscape composition and acousmatic composition. The accompanying commentary discusses the compositional processes and workflow behind the works and the fundamental aesthetic concerns that each composition addresses. It is informed by current research in the field as acquired through interviews with seven artists working in the field: Leah Barclay, Jonty Harrison, Francisco López, Brona Martin, Claude Schryer, Chris Watson and Hildegard Westerkamp. This practice-led research project investigates the use of field recordings in my practice and reflects upon how this relates to practitioners and research in the field

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Vulvar hibernoma

A 35 year old woman presented with 18 months history of a painless, soft, well-circumscribed, vulvar subcutaneous lump which measured approximately 7 cm. The lesion was completely excised and microscopically was consistent with a hibernoma. According to the available literature in English, this is the first reported case of hibernoma of the vulva

Ketamine-induced Changes in Blood Pressure and Heart Rate in Pre-hospital Intubated Patients

When a patient experiences trauma, pre-hospital rapid sequence intubation (RSI) is often the course of action. While RSI is associated with favorable neurological outcomes among traumatic brain injury patients, it also carries the risk of increased hypotension and bradycardia. Ketamine is a fast-acting anesthetic agent used in RSI, attractive due to its ability to raise heart rate (HR) and blood pressure (BP) and thus potentially lessening the severity of RSI-related hypotension and bradycardia. However, research in support of its use is inconclusive, with different studies reporting increases or decreases in BP and HR after ketamine administration. To study the effect of ketamine on HR and BP during RSI, we analyzed the data obtained from 1,516 patients who received trauma and non-trauma medical care including RSI from first responders and emergency personnel using two different statistical methods. We determined if there was any association between the vital signs prior to administration of ketamine and outcomes such as bradycardia and/or hypotension post-ketamine administration in patients undergoing RSI. We found that the vital signs prior to administration of ketamine (i.e. BP and HR) predict the development of bradycardia and/or hypotension in patients undergoing RSI and the relationship between baseline vital signs and the development of bradycardia and/or hypotension is moderated by the dose of ketamine. Results obtained from this study may help responders and emergency care personnel to identify the patients that are likely to benefit from ketamine as an anesthetic agent

Diagnostic and therapeutic considerations in idiopathic hypereosinophilia with warm autoimmune hemolytic anemia

Hypereosinophilic syndrome (HES) encompasses numerous diverse conditions resulting in peripheral hypereosinophilia that cannot be explained by hypersensitivity, infection, or atopy and that is not associated with known systemic diseases with specific organ involvement. HES is often attributed to neoplastic or reactive causes, such as chronic eosinophilic leukemia, although a majority of cases remains unexplained and are considered idiopathic. Here, we review the current diagnosis and management of HES and present a unique case of profound hypereosinophilia associated with warm autoimmune hemolytic anemia requiring intensive management. This case clearly illustrates the limitations of current knowledge with respect to hypereosinophilia syndrome as well as the challenges associated with its classification and management