A Case of Delayed Tension Pneumocephalus in a Patient Undergoing Facial Cosmetic Surgery

There has been a recognizable surge in cosmetic surgery in recent years, partly influenced by social media, and the easy accessibility to such medical procedures. As with all types of surgery, the risks of complications are real, and in this specific setting, they tend to occur in a younger age group. Here, we discuss a rare complication and subsequent presentation of tension pneumocephalus, following an episode of cardiac arrest in a 58 year old female, during elective cosmetic-facial surgery. Typically, pneumocephalus develops when there are skull or facial bone fractures, and presents characteristically with leakage of cerebrospinal fluid from the ears and/or nose. The absence of the typical clinical signs and the lack of a clinical history or radiologically evidence of skull or facial bone fractions, may result in a delayed diagnosis, permanent brain injury and death. Awareness of such an unusual complication is therefore crucial when considering any surgery to the head and face (including cosmetic surgery), or following prolonged resuscitative efforts, which may well develop days after the inciting event.

Investigating Factors of False-Positive Results of Aspergillus Galactomannan Assay: A Case-Control Study in Intensive Care Units

Background: Studies on false-positive galactomannan (GM) enzyme immunoassay (EIA) results and treatment for critically ill patients are scarce. Objectives: The study aimed to determine the false-positive rate of GM-EIA and to probe the risk factors of false positivity among patients in the intensive care units (ICUs). Methods: A case-control approach was conducted to review adult patients who had at least one GM-EIA result and were admitted to the ICU. Those who had no fungal culture were excluded. The clinical characteristics and critical care between patients with false-positive and true-negative GM index (GMI) were compared. Results: Of 206 patients enrolled and with GM-EIA results, 20 (9.7%) were considered to have false-positive antigenemia, including 9 in bronchoalveolar lavages (BAL) and 11 in serum. A total of 148 (71.8%) were true-negatives. After paired grouping of 1:4, factors researched in the previous studies showed no significant difference. However, compared with the true-negatives, patients with positive GM test results but were incompatible with the diagnosis of invasive aspergillosis were more prone to the risk of false positivity due to the use of colistin inhalation. It seemed to be the only factor that significantly increased the risk of false positivity after multivariate analysis (adjusted odds ratio, 35.68; 95% CI, 3.77-337.51, p = 0.002). Conclusions: Colistin inhalation treatment may contribute to false-positive GM-EIA results. The positive GMI among patients receiving colistin nebulization should be interpreted with caution.

[Study the role of lysosome-associated membrane protein type 2A for immune-mediated liver injury of primary biliary cholangitis]

Objective: To investigate the role of lysosome-associated membrane protein type 2A (LAMP-2A) for immune-mediated liver injury of primary biliary cholangitis (PBC). Methods: The association between LAMP-2A expression and PBC was examined by immunohistochemistry and electron microscopy in liver tissue samples from patients with PBC. Furthermore, the immunological damage of LAMP-2A overexpression on mouse liver was observed by adeno-associated virus (AAV) overexpression technique. The expression level of mRNA was analyzed by Student's t-test. The data were graphed and analyzed statistically using graphpad prism 5 (GraphPad Software).A value of p < 0.05 was considered statistically significant. Results: The expression of LAMP-2A in liver tissue of PBC patients was increased, and the autophagosome formation was observed in hepatocytes. C57BL/6 mice were injected into the caudal vein with LAMP-2A AAV for 6 weeks. The formation of autophagosomes in mouse hepatocytes was increased significantly. The expression of related molecules was abnormal; simultaneously, the degree of lymphocyte infiltration in the liver tissue of mice was significantly higher than the control group. Conclusion: An overexpression of LAMP-2A in the liver of patients with PBC may induce and/or promote the hepatic inflammatory response, especially the portal inflammatory infiltrate.

Clinical outcome and prognostic factors associated with invasive pulmonary aspergillosis: An 11-year follow-up report from Taiwan

Background

Invasive pulmonary aspergillosis (IPA) has high mortality rate but prognostic factors are not well established. The aim of our study was to evaluate the trend in in-hospital mortality over a period of 11 years and identify factors affecting the clinical outcomes of patients with IPA.

Method

We conducted a nationwide inpatient population study using data from the Taiwan National Health Insurance Research Database. A total of 407 IPA patients from 2002 to 2012 were included in the study. Differences in demographics, comorbidities, and treatment were evaluated between in-hospital death group and survival group. Multivariate analysis was also performed to identify risk factors for mortality.

Result

Male patients represented 63.14% of the patients (n = 257) and the mean age was 53.15 ± 20.93 years. Hematological cancer (n = 216, 53.07%) and diabetes mellitus (n = 75, 18.43%) were the most common underlying conditions. The overall case fatality rate was 30.22% with female slightly higher then male (32.67% versus 28.79%). The in-hospital case fatality rate increased since 2002 and peaked in 2006. It then declined over time with an in-hospital mortality of 25% in 2012. The in-hospital death group had a higher intubation rate (p<0.0001), a longer ICU stay (p = 0.0062), higher percentages of DM (p = 0.0412) and COPD (p = 0.0178), and a lower percentage of hematological cancer (p = 0.0079) as compared to survivor. The in-hospital death group was more likely to have steroid treatment (p<0.0001), develop acute renal failure (p<0.0001) and other infectious diseases (p = 0.0008) during hospitalization. Multivariate analysis identified female gender, older age (≥ 65 years old), intubation, bone marrow transplantation, acute renal failure, other infectious diseases and steroid use as predictive factors for mortality.

Conclusion

The present study shows the trend in mortality among patients with IPA over an 11-year period. Female gender, older age, intubation, bone marrow transplantation, acute renal failure, other infectious diseases and steroid use were identified as risk factors for mortality.

Galactomannan Testing and the Incidence of Invasive Pulmonary Aspergillosis: A 10-Year Nationwide Population-Based Study in Taiwan

Background

The clinical impact of the galactomannan (GM) test for the diagnosis of invasive pulmonary aspergillosis (IPA) is controversial. Our study evaluated the incidence and trends of IPA and GM testing in patients with aspergillus infections.

Methods

We conducted a nationwide inpatient population study using the Taiwan National Health Insurance Research Database. A total of 346 IPA (62.14% male) patients from the years 2002 to 2011 were identified for inclusion in the study.

Results

The average incidence of IPA was 1.51 per million person-years. Over the study period, we observed an increasing trend from 0.94 to 2.06 per million person-years (P < 0.0001). We observed male predominance in IPA incidence (M/F: 1.85/1.15). Both males and females showed significantly increasing trends of IPA incidence over time (0.87 to 4.55 and 0.36 to 2.07 per million person-years for the males and females, respectively). GM testing for IPA significantly increased from 2002 to 2011, and the GM test was utilized more frequently for males than females. The increase in the incidence of IPA might be positively associated with the increase in GM testing over the past decade.

Conclusion

The incidence rates of both IPA and GM testing have increased over time. GM testing is recommended for the early diagnosis of patients with suspected aspergillosis.

Is asymptomatic peripheral arterial disease associated with walking endurance in patients with COPD?

Objective

Symptomatic peripheral arterial disease (PAD) is associated with impaired walking endurance in patients with chronic obstructive pulmonary disease (COPD). However, it is unknown whether asymptomatic PAD is associated with impaired walking endurance in patients with COPD.

Methods

This prospective cross-sectional study enrolled 200 COPD patients (mean age: 70.9 years) who volunteered to perform ankle-brachial index (ABI) and 6-minute walk test (6MWT) consecutively. Demographic data, lung function, dyspnea scales, and cardiovascular risk factors were recorded. The ABI was used to detect PAD (ABI <0.90). All patients were free of PAD symptoms at enrollment.

Results

Of the 200 COPD patients, 17 (8.5%) were diagnosed with asymptomatic PAD. The COPD patients without asymptomatic PAD did not walk significantly further on the 6MWT than the COPD patients with asymptomatic PAD (439±86 m vs 408±74 m, P=0.159). The strongest correlation with the distance walked on the 6MWT was Medical Research Council dyspnea scale (r²=−0.667, P<0.001), followed by oxygen-cost diagram (r²=0.582, P<0.001) and forced expiratory volume in 1 second (r²=0.532, P<0.001). In multivariate linear regression analysis, only age, forced expiratory volume in 1 second, and baseline pulse oximetry were independently correlated with the distance covered on the 6MWT (P<0.05). However, body mass index, baseline heart rate, and ABI were not correlated with the distance covered on the 6MWT.

Conclusion

Asymptomatic PAD is not associated with walking endurance in patients with COPD. Therefore, it is important to detect and treat asymptomatic PAD early so that COPD patients do not progress to become exercise intolerant. Limited by the small sample size and predominantly male (99%) population in the study, further large-scale prospective studies are needed to verify the results.

Western mental health training for traditional Chinese medicine practitioners

OBJECTIVE

To investigate the impact of a Western mental health training course for Traditional Chinese Medicine (TCM) practitioners.

METHOD

  A combined qualitative and quantitative approach was applied to examine the changes in the TCM practitioners' clinical practice characteristics and attitudes. Focus groups and structured questionnaire surveys were conducted to compare their responses before and after the Course.

RESULTS

After a 10-week training course conducted by psychiatrists and family physicians, there were significant changes in confidence of the TCM practitioners for diagnosis (33% being confident before the Course vs. 76% after the Course) and management (24% vs. 55%) of common mental health problems. The causal effects of better classifications to recognition of mental health problems were explained by the qualitative responses. Proportion of TCM practitioners being confident of referring mental health patients to other healthcare professionals doubled from 25% to 50% after the Course. Nonetheless, there was no significant change in percentage of these patients being recommended to Western doctors owing to a lack of formal referral channel.

CONCLUSIONS

Western mental health training for TCM practitioners has positive impact on their clinical practice. However, the practical barriers in making referrals highlight the need of closer collaboration between conventional and traditional medicine.

Antibiotic use: do parents act differently for their children?

BACKGROUND

Many children in the community take antibiotics inappropriately. Previous studies comparing parents with other adults suggest that parents are more judicious with antibiotics for their children. This study aims to explore the difference between parents' use of antibiotics for themselves and for their children.

METHODS

The study adopted a combined qualitative and quantitative approach. Eight focus groups were conducted with 56 participants purposively recruited from community centres and of different socio-economic strata. The qualitative data collected were used to construct a questionnaire for the telephone survey, which recruited 2471 adults randomly selected from the local household directory, of whom 547 had ever brought their children or grand children for medical consultation.

RESULTS

Both the qualitative and quantitative approaches showed that parents were more cautious with antibiotics for children than for themselves. The main reason was their concern of side effects. Fever was the most important drive for their desire of antibiotics for children. The misconception of antibiotics' effectiveness for sore throat was another determinant of the desire. These attitudes and behaviour were not affected by the respondents' sex, age, education or household income.

CONCLUSION

On the whole, parents did to their children what they would do for themselves, but to a lesser extent. Parents' better knowledge and attitudes will lead to more appropriate use of antibiotics for their children.