Post-Operative Concurrent Chemoradiation with Mitomycin-C for Advanced Head and Neck Cancer

Purpose: Recent prospective randomized trials have shown concurrent chemo-radiation improves local-regional control in post-operative patients with squamous cell carcinomas of the head and neck (SCCHN) using cis-platinum based regimens. This report pools data from three randomized trials performed at Yale that employed mitomycin-C (MC), selecting those patients treated postoperatively, to evaluate the long term benefit of MC in the postoperative setting and to compare these results with other recently published randomized trials. Methods and Materials: Between 1980 and 1999, a total of 331 SCCHN patients from the three prospective trials were enrolled. Of those patients, 205 were post-operative of which 103 were randomized to receive mitomycin-C and radiation, while 102 received radiation alone or radiation with porfiromycin in the third trial. Patients were treated with daily radiotherapy to a total median dose of 60 Gy over 47 days. Patients who were randomized to MC received 15 milligrams per square meter (mg/M2) of mitomycin-C on days 5 and 47 (or last day). Results: The 5-year rate of local-regional control was higher in the MC arms (85.3% vs. 69.9%, p = .008). There was no statistically significant difference in overall survival or distant metastasis. Patients had a lower percentage of high risk factors in both arms of the study, compared to patients of the large prospective trials, including positive margins, 2 or more positive lymph nodes, or oropharynx primary. The gains in local-regional control realized with MC were similar to the improvements in the recently published randomized trials using cis-platinum. Conclusions: These results confirm significant gains in local-regional control using concurrent chemo-radiotherapy in the postoperative setting for patients with SCCHN. The lack of consensus over a benefit in overall survival and distant metastasis emphasizes the need for further prospective trials in the postoperative management of SCCHN

Epidurals for liver transplantation – Where are we?

Thoracic epidural analgesia (TEA) has been used as a mode of postoperative pain relief for orthotopic liver transplants (OLT) in a selected group of patients. It is not widely practiced in view of the impaired haemostasis associated with end-stage liver disease and severe unpredictable intraoperative coagulopathy. TEA in OLT may not be the technique of choice for routine administration of postoperative analgesia, but can be considered in patients who have a normal coagulation profile preoperatively. Safe conduct of TEA in OLT involves anaesthetic expertise and stringent monitoring in the postoperative period. This review discusses the status of thoracic epidural analgesia in patients undergoing an orthotopic liver transplant

Intraoperative cardiovascular monitoring in hypertensive patients

Bacground and Purpose: Hypertensive patients are more prone to perioperative ischaemia, arrythmias and cardiovascular instability. Attention should be paid to the presence of target organ damage, such as coronary artery disease. Material and Method: Haemodynamically unstable patients undergoing major surgery require more complex haemodynamic monitoring. Multiple studies have demonstrated the favourable outcome achieved by goal-directed fluid management during the intraoperative period. Conclusion: The trend in intraoperative haemodynamic monitoring, a key feature of anaesthetic practice is towards less invasive systems that provide continuous information. A balance is needed between the hazards of an invasive approach and the desire for a continuous stream of accurate information that is robust enough to withstand the surgical and physiological challenges in hypertensive patients. In spite of its importance for anaesthetists, there is no consensus as to which system is best. This review examines the recent developments in haemodynamic monitoring

Rabies vaccine and neuraxial anaesthesia

This case report of neuraxial anaesthesia for emergency orthopaedic surgery serves to highlight the dilemma faced by anaesthetists when surgical intervention becomes necessary in a patient on anti-rabies vaccine. The two issues of importance are the possible reduction in the efficacy of vaccination by an immunosuppressive effect of anaesthesia and surgery, and the possible need to avoid local anaesthetics for the provision of postoperative analgesia to assist in the early detection of any neurological deficit.Keywords: rabies; vaccine; anaesthesia; neuraxial bloc

The role of targeted viral load testing in diagnosing virological failure in children on antiretroviral therapy with immunological failure.

Objectives  To determine the improvement in positive predictive value of immunological failure criteria for identifying virological failure in HIV-infected children on antiretroviral therapy (ART) when a single targeted viral load measurement is performed in children identified as having immunological failure. Methods  Analysis of data from children (<16 years at ART initiation) at South African ART sites at which CD4 count/per cent and HIV-RNA monitoring are performed 6-monthly. Immunological failure was defined according to both WHO 2010 and United States Department of Health and Human Services (DHHS) 2008 criteria. Confirmed virological failure was defined as HIV-RNA >5000 copies/ml on two consecutive occasions <365 days apart in a child on ART for ≥18 months. Results  Among 2798 children on ART for ≥18 months [median (IQR) age 50 (21-84) months at ART initiation], the cumulative probability of confirmed virological failure by 42 months on ART was 6.3%. Using targeted viral load after meeting DHHS immunological failure criteria rather than DHHS immunological failure criteria alone increased positive predictive value from 28% to 82%. Targeted viral load improved the positive predictive value of WHO 2010 criteria for identifying confirmed virological failure from 49% to 82%. Conclusion  The addition of a single viral load measurement in children identified as failing immunologically will prevent most switches to second-line treatment in virologically suppressed children

Materialtechnische Eigenschaften kieferorthopädischer Brackets nach Recycling

Heute bieten sich dem kieferorthopädischen Behandler viele verschiedene Bracketsysteme an, die sich in Material, Zusammensetzung und Art unterscheiden. Es findet sich eine Vielzahl konventioneller Brackets wie auch zunehmend recycelte Brackets, die näher untersucht werden sollten, damit eine Differenzierung ihrer Materialeigenschaften vorgenommen werden kann. In dieser Arbeit wurden insgesamt 300 Brackets (neue und recycelte Brackets) mehreren materialtechnischen Prüfungen, wie Korrosion, rasterelektronenmikroskopische Untersuchungen, lichtmikroskopische Untersuchungen zur Ermittlung von Bracketslot-Beschädigungen, Reibungsversuche, Scherhaftfestigkeitsversuche und Härteprüfungen unterzogen. Unter den getesteten Brackets befanden sich neun Metallbrackets, die mittels Abflämmen recycelt wurden, im Säurebad recycelte Brackets, mit dem Gerät Big Jane recycelte Brackets und von einer Firma recycelte Brackets. Die Analyse der Korrosionseigenschaften der recycelten Brackets sollte dazu beitragen, die Biokompatibilität der Prüfkörper beurteilen zu können. Die Biokompatibilität stellt ein entscheidendes Kriterium für den klinischen Einsatz dentaler Werkstoffe dar und ist be-sonders im Hinblick auf die Prävalenz von Nickelallergien von Bedeutung. Die Ergebnisse des statischen Immersionstests lagen für alle recycelten Brackets in einem akzeptablen Bereich, da die gemessenen Nickelionenabgaben deutlich unter der Nickelmenge lagen, die täglich mit der Nahrung aufgenommen wird. Härtewerte der Bracketsysteme sollten dazu beitragen, die Stabilität der Prüfkörper einschätzen zu können. Die recycelten Brackets zeigten Härtewerte in einem Normbereich. Die Scherhaftfestigkeitsversuche bei alle recycelten Brackets lagen ebenfalls im Normbereich. Nur die von einer Firma recycelten Brackets zeigten niedrige Scherhaftfestigkeitswerte. Die Reibungswerte für alle recycelten Brackets lagen ebenfalls in einem akzeptablen Bereich. Die rasterelektronmikroskopischen Bilder von allen recycelten Bracketsystemen zeigten Korrosionsspuren an der Bracketbasis, am Bracketslot, Beschädigungen des Bracketslots und Adhäsivreste an der Bracketbasis. Das flammenrecycelte Bracket schnitt am schlechtesten unter dem Rasterelektronmikroskop ab, mit zu hohen Korrosionswerten an der Bracketbasis und am Bracketslot sowie großen Beschädigungen an der Bracketbasis. Bei den flammenrecycelten Brackets konnte man die Adhäsivreste besser entfernen und die von einer Firma recycelten Brackets zeigten weniger Adhäsivreste als die übrigen recycelten Brackets. Im Säurebad recycelte Brackets und mit dem Gerät Big Jane recycelte Brackets wiesen erhöhte Adhäsivreste auf. Die Präzision des Bracketslots wird im Fall der flammenrecycelten und der im Säurebad recycelten Brackets deutlich verschlechtert. Nach DIN 13971-2 ist z.B. das Slotmaß in einem 18er Bracket auf 0,46 + 0,04 mm genormt. Dieses Maß und die Toleranz müssen die Hersteller garantieren. Die mikroskopischen Untersuchungen für die Bracketslot-Beschädigungen zeigten nach dem Recycling ein Bracketslotmaß, das um mehr als 0,08 mm von den angegebenen Slotmaßen abwich. Diese Abweichung war größer als von den Normvorgaben gefordert. Die Hersteller kieferorthopädischer Produkte sind gemäß Medizinproduktegesetz verpflichtet, zur Garantie einer "sicheren und effizienten" Therapie den aktuellen Stand der Technik bezüglich Fertigung und Qualität zu berücksichtigen. Dieser ist in einschlägigen nationalen und internationalen Normen festgeschrieben. So sind beispielsweise die Slotdimensionen definiert und sehr eng toleriert. Die vorgestellten Recyclingmethoden sind nicht in jedem Fall geeignet, diese Vorgaben einzuhalten

Intraoperative cardiovascular monitoring in hypertensive patients

Bacground and Purpose: Hypertensive patients are more prone to perioperative ischaemia, arrythmias and cardiovascular instability. Attention should be paid to the presence of target organ damage, such as coronary artery disease. Material and Method: Haemodynamically unstable patients undergoing major surgery require more complex haemodynamic monitoring. Multiple studies have demonstrated the favourable outcome achieved by goal-directed fluid management during the intraoperative period. Conclusion: The trend in intraoperative haemodynamic monitoring, a key feature of anaesthetic practice is towards less invasive systems that provide continuous information. A balance is needed between the hazards of an invasive approach and the desire for a continuous stream of accurate information that is robust enough to withstand the surgical and physiological challenges in hypertensive patients. In spite of its importance for anaesthetists, there is no consensus as to which system is best. This review examines the recent developments in haemodynamic monitoring

HIV/AIDS-tuberculosis (pulmonary and extra pulmonary) co-infection: CD4 correlation

Background: AIDS is the leading cause of death among people 15-59 years old in low income countries. Worldwide, approximately one-third of all AIDS-related deaths are associated with TB. TB is the primary cause of death for 10-15% of patients with HIV infection. So the present study was conducted to find the correlation between sputum positivity and CD4 cell count in patients with HIV/AIDS-Tuberculosis co-infection.Methods: The present study was a retrospective hospital based study of patients with HIV/AIDS-Tuberculosis co-infection, attending ART centre, department of medicine, Osmania general hospital, Hyderabad, Telangana, India between November 2014 to September 2015. Data included clinical profile, complete blood picture, renal and liver function tests, sputum microscopy and C/S and chest X-Ray and others as and when required.Results: We included 180 HIV/AIDS infected patients on ART with tuberculosis (TB) co-infection. Out of 180 patients, 132 were males and 48 were females. Among male’s ≥40 (51.51%) year’s age group and among females 30-39 (56.25%) year’s age group was the most commonly affected. Out of 180 cases 60 were sputum positive. 60 sputum negative pulmonary tuberculosis and 60 were extra pulmonary TB. CD4 cell count was &lt;200/mm3 in 36 (60%) of sputum positive TB, 43 (71.7%) of sputum negative pulmonary TB &amp; 39 (65%) of extra pulmonary TB patients. CD4 cell count was 200-400/mm3 in 16(26.7%) of sputum positive pulmonary TB, 13 (21.7%) of sputum negative TB and 19 (31.7%) of extra pulmonary TB patients. CD4 cell count was &gt;400/mm3 in 8 (13.3%) of sputum positive pulmonary TB, 4 (6.6%) of sputum negative pulmonary TB and 2 (3.3%) of extra pulmonary TB patients.Conclusions: Present study concludes that male sex and age group &gt;30 years were the commonly affected population. All forms of tuberculosis were common when CD4 count was &lt;200 cells/mm3. The sputum negativity was higher with lower CD4 counts.