Management of severe odontogenic infections in pregnancy

BACKGROUND

The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant.

METHODS

A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy.

RESULTS

A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion.

CONCLUSIONS

Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.

Emergency angio-embolisation in the operating theatre for trauma patients using the C-Arm digital subtraction angiography

BACKGROUND AND AIMS

Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control.

METHODS

A retrospective study of trauma patients, with Injury Severity Score (ISS ≥ 9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts.

RESULTS

A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n = 32). None of the patients who received angioembolisation in the operating theatre (n = 32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures.

CONCLUSION

The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.

A Comparison of Three Minimally Invasive Cardiac Output Devices with Thermodilution in Elective Cardiac Surgery

This study compared the cardiac output responses to haemodynamic interventions as measured by three minimally invasive monitors (Oesophageal Doppler Monitor, the VigileoFlotrac and the LiDCOrapid) to the responses measured concurrently using thermodilution, in cardiac surgical patients. The study also assessed the precision and bias of these monitors in relation to thermodilution measurements.

After a fluid bolus of at least 250 ml, the measured change in cardiac output was different among the devices, showing an increase with thermodilution in 82% of measurements, Oesophageal Doppler Monitor 68%, VigileoFlotrac 57% and LiDCOrapid 41%. When comparing the test devices to thermodilution, the kappa statistic showed at best only fair agreement, Oesophageal Doppler Monitor 0.34, LiDCOrapid 0.28 and VigileoFlotrac -0.03. After vasopressor administration, there was also significant variation in the change in cardiac output measured by the devices. Using Bland-Altman analysis, the precision of the devices in comparison to thermodilution showed minimal bias, but wide limits of agreement with percentage errors of Oesophageal Doppler Monitor 64.5%, VigileoFlotrac 47.6% and LiDCOrapid 54.2%. These findings indicate that these three devices differ in their responses, do not always provide the same information as thermodilution and should not be used interchangeably to track cardiac output changes.

Rashba spin-splitting control at the surface of the topological insulator Bi2Se3

The electronic structure of Bi(2)Se(3) is studied by angle-resolved photoemission and density functional theory. We show that the instability of the surface electronic properties, observed even in ultrahigh-vacuum conditions, can be overcome via in situ potassium deposition. In addition to accurately setting the carrier concentration, new Rashba-like spin-polarized states are induced, with a tunable, reversible, and highly stable spin splitting. Ab initio slab calculations reveal that these Rashba states are derived from 5-quintuple-layer quantum-well states. While the K-induced potential gradient enhances the spin splitting, this may be present on pristine surfaces due to the symmetry breaking of the vacuum-solid interface.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

BACKGROUND

Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery.

METHODS

We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech(®)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists.

RESULTS

There were 4 patients with a median age of 50 (43-69) years. The median duration of the condition prior to PTCSL was 102 (60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130 (125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18 (10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up.

CONCLUSION

PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique.

Culture of Iris Pigment Epithelial Cells on Expanded-Polytetrafluroethylene (ePTFE) Substrates for the Treatment of Age-Related Macular Degeneration

Introduction:

Transplantation of an intact differentiated retinal pigment epithelial (RPE) cell layer may provide a means to treat Age-Related Macular Degeneration (AMD). However, harvesting RPE cells can be a technically complicated procedure. Our current work aimed to prepare intact differentiated iris pigment epithelial (IPE) cell layers, which are easy to obtain and have the same embryonic origin and similar properties as RPE cells, on ePTFE substrates for transplantation purposes to rescue deteriorated photoreceptors in AMD.

Methods:

IPE cells isolated from rat eyes were seeded on different substrates, including fibronectin n-heptylamine (HA) ePTFE substrates, HA ePTFE substrates, ePTFE substrates and fibronectin tissue culture polystyrene (TCPS) as control. Cell number and morphology were assessed at each time interval. The formation of tight junction was examined by immunostaining of junction proteins.

Results:

An obvious increasing trend of cell number was observed in IPE cells on fibronectin n-heptylamine (HA) ePTFE substrate, exhibiting heavy pigmentation and epithelial morphology. At Day 28, tight junction formation was indicated by cell-cell junctional proteins along cell borders.

Conclusion:

Harvested IPE cells cultured on fibronectin HA-ePTFE substrates can differentiate and form a cell monolayer that may be suitable for transplantation.

Lectin from Agaricus Bisporus Suppresses Akt Phosphorylation and Arrests Cell Cycle Progression in Primary Human Retinal Pigment Epithelial Cells

Anomalous retinal pigment epithelial (RPE) cells have been implicated in the development of retinal diseases. Lectin from the edible mushroom Agaricus bisporus (ABL) was found to inhibit growth of RPE cells. To elucidate the mechanism through which ABL inhibits RPE cell proliferation, we investigated the changes in cell proliferation-related signaling pathways and cell cycle distribution patterns. Primary human RPE cells were grown with or without the lectin (ABL) supplement (20ug or 90ug/ml) for three days. Phosphorylation statuses of Akt, Jnk and p38 as well as p53 expression level were investigated by Western blotting. Cellular distributions in various cell cycle phases were investigated using flow cytometry. After ABL treatment (90ug/ml), Akt was found to be hypo-phosphorylated while the expression levels of p53, phosphorylated-Jnk and phosphorylated-p38 were not altered. The amount of cells present at S phase was reduced. Our results showed that ABL hypo-phosphorylated Akt and this observation is in line with the finding that ABL could attenuate cell proliferation. As the level of p53 was not significantly altered by ABL, this suggested that the mechanism in which ABL arrested cell proliferation was independent of Akt-mediated MDM2 activation but was possibly mediated by altering G1 to S phase transition.

Optimising the management of choroidal neovascularisation in Asian patients: consensus on treatment recommendations for anti-VEGF therapy

In Asian countries, age-related macular degeneration (AMD), specifically wet AMD or choroidal neovascularisation (CNV), is an important cause of blindness and visual handicap. Vascular endothelial growth factors (VEGF) play an integral role in the development of CNV and thus provide an important therapeutic target. Current treatment paradigms for neovascular AMD recognise the place of photodynamic therapy (PDT) in the management of this condition. However, combination therapy targeting different pathways to produce a synergistic effect may result in improved visual outcomes and reduced duration of treatment. Anti-VEGF therapy has greatly improved treatment outcomes in patients with CNV, and a growing body of evidence supports the role of these agents as monotherapy or in combination with PDT. In particular, anti-VEGF may be a first-line treatment option in certain types of subfoveal myopic CNV as well as for classic and occult juxtafoveal and subfoveal CNV. The implementation of evidence-based medicine into current clinical practice is paramount to improving patient care. The authors, who are also members of the Singapore Medical Retina Advisory Board, outline the consensus points and recommended treatment algorithms based on currently available knowledge to provide a structured management approach to the treatment of Asian patients with CNV.

Intermittent treatment with olanzapine causes sensitization of the metabolic side-effects in rats

The second generation antipsychotic drugs are effective treatments for psychotic disorders. Many of these compounds, including the drug olanzapine, have been associated with metabolic side-effects, including weight gain, impaired glucose tolerance and insulin resistance, which increase the risk of developing cardiometabolic disorders. Rodent models of olanzapine-induced metabolic side-effects have been used to study the physiology of these effects, but only at a single time point after drug treatment. The purpose of the present study was to examine longitudinal changes with chronic antipsychotic drug treatment. Adult female rats were treated with either olanzapine (15 mg/kg) or vehicle for five consecutive days each week, followed by a 48 h washout period. Animals were then challenged with either olanzapine (15 mg/kg) or vehicle, and fasting glucose and insulin values were recorded, as well as glucose clearance in the glucose tolerance test. Treatment with olanzapine was continued for 10 weeks, with weekly tests of metabolic indices. Rats treated acutely with olanzapine showed both glucose dysregulation and insulin resistance; for the group treated during the week with olanzapine, these effects did not change by the end of ten weeks of treatment. However, in the group of animals challenged only once per week with olanzapine, the metabolic side-effects markedly intensified with the passage of time, whereby glucose intolerance and insulin resistance increased significantly compared to both baseline values and all other treatment groups. This previously unreported sensitization phenomenon represents a novel finding that may have clinical implications for patients receiving intermittent antipsychotic drug dosing or with variable adherence to treatment.

Retinal detachment repair by vitrectomy: simplified formulae to estimate the risk of failure

AIM

Devise simplified formulae, using preoperative clinical data, to give risk estimates of (1) failure and (2) proliferative vitreoretinpathy (PVR) following primary retinal detachment repair by vitrectomy.

METHODS

641 patients were analysed as part of an RCT investigating use of 5-fluorouracil and low-molecular-weight heparin. Treatment status had no effect on success rates and did not therefore form part of the analyses. Preoperative risk factors for surgical failure and for PVR within 6 months of retinal detachment surgery were identified, and a multiple variable logistic regression model developed. Further analyses were performed to devise a simple points system to produce risk estimates of failure.

RESULTS

Three risk factors were related to failure-previous lens extraction (p=0.046), grade C PVR (p=0.039) and extent of detachment (p<0.001). Three risk factors were also related to failure due to PVR-vitreous haemorrhage (p=0.088), grade C PVR (p=0.044) and extent of detachment (p<0.001). There was good agreement between risk estimates produced by the points system and those calculated directly using a multivariate regression model. The points-system model gave an area under the receiver operating characteristic curve of 0.658. The receiver operating characteristic curve for the PVR model gave an area under the curve of 0.8399 suggesting greater diagnostic value.

CONCLUSIONS

A simple points system may be used as a clinical guide to identify patients at higher risk of failure following retinal detachment repair by vitrectomy. This may help clinicians select appropriate surgical approaches and stratify cases in research and surgical training.