Topical Preparations for Reducing Cutibacterium acnes Infections in Shoulder Surgery: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Cutibacterium acnes (C acnes) is a commensal skin bacterium, primarily found in sebaceous glands and hair follicles, with a high prevalence in the shoulder region. It is the most common pathogenic organism in prosthetic joint infections after shoulder arthroplasty. Because of its low virulence, its diagnosis remains difficult. PURPOSE: To evaluate the relative effects of topical preparations in reducing C acnes in shoulder surgery. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: We searched the MEDLINE, Embase, PsychINFO, and Cochrane Library databases in March 2022. Randomized controlled trials (RCTs) comparing any form of topical preparation in arthroscopic or open shoulder surgery were included. The primary outcome was a reduction in the number of positive C acnes cultures. Secondary outcomes were adverse events related to the application of topical preparations. We performed a network meta-analysis to facilitate simultaneous comparisons between multiple preparations across studies. We calculated differences between preparations using odds ratios and their 95% CIs. The risk of bias was assessed using the Cochrane risk-of-bias tool. RESULTS: The search yielded 17 RCTs (1350 patients), of which 9 were suitable for the network meta-analysis (775 patients). Overall, 2 RCTs were deemed as having a low risk of bias, and 15 raised "some concerns" of bias. Preparations included benzoyl peroxide (BPO), BPO combined with clindamycin, chlorhexidine gluconate, hydrogen peroxide, povidone-iodine, and water with soap. Only BPO resulted in significantly lower odds of a positive C acnes culture compared with placebo or soap and water (odds ratio, 0.12 [95% CI, 0.04-0.36]). There was no statistically significant difference with all other topical preparations. The only adverse events were skin irritation from BPO and chlorhexidine gluconate in a small number of reported cases. CONCLUSION: BPO was the most effective topical agent in reducing the prevalence of C acnes in shoulder surgery. These results were limited by a combination of indirect and direct data. Future studies should focus on establishing the optimal frequency and duration of preoperative BPO to further reduce the burden of C acnes. REGISTRATION: CRD42022310312 (PROSPERO).

A systematic review of primary large cell neuroendocrine carcinoma of the prostate.

Background: Large cell neuroendocrine carcinoma (LCNEC) is a rare subtype of prostate cancer. The pathogenesis, clinical manifestation, treatment options, and prognosis are uncertain and underreported. Materials and methods: A systematic search was conducted in April 2022 through PubMed, Embase, and Cochrane. We reviewed cases of LCNEC developed either from de novo or transformation from prostate adenocarcinoma and summarized the relevant pathophysiological course, treatment options, and outcomes. Results: A total of 25 patients with a mean age of 70.4 (range 43 87 years old) from 18 studies were included in this review. 13 patients were diagnosed with de novo LCNEC of the prostate. 12 patients were from the transformation of adenocarcinoma post-hormonal therapy treatment. Upon initial diagnosis, patients diagnosed with de novo prostatic LCNEC had a mean serum PSA value of 24.6 ng/ml (range: 0.09-170 ng/ml, median 5.5 ng/ml), while transformation cases were significantly lower at 3.3 ng/ml (range: 0-9.3 ng/ml, median 0.05 ng/ml). The pattern of metastasis closely resembles prostate adenocarcinoma. Six out of twenty-three cases displayed brain metastasis matching the correlation between neuroendocrine tumors and brain metastasis. Three notable paraneoplastic syndromes included Cushings syndrome, dermatomyositis, and polycythemia. Most patients with advanced metastatic disease received conventional platinum-based chemotherapy with a mean survival of 5 months. There was one exception in the transformation cohort with a somatic BRCA2 mutation who was treated with a combination of M6620 and platinum-based chemotherapy with an impressive PFS of 20 months. Patients with pure LCNEC phenotype have worse survival outcomes when compared to those with mixed LCNEC and adenocarcinoma phenotypes. It is unclear whether there is a survival benefit to administering ADT in pure pathologies. Conclusion: LCNEC of the prostate is a rare disease that can occur de novo or transformation from prostatic adenocarcinoma. Most patients present at an advanced stage with poor prognosis and are treated with conventional chemotherapy regimens. Patients who had better outcomes were those who were diagnosed at an early stage and received treatment with surgery or radiation and androgen deprivation therapy (ADT). There was one case with an exceptional outcome that included a treatment regimen of M6620 and chemotherapy.

Non-steroidal Anti-inflammatory Drugs and Cyclooxygenase-2 Inhibitors Do Not Affect Healing After Rotator Cuff Repair: A Systematic Review and Meta-analysis.

PURPOSE: To determine whether non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors affect healing rate, functional outcomes, and patient satisfaction after rotator cuff repair. METHODS: Medline, EMBASE, PsychINFO and the Cochrane Library were searched for randomized controlled trials (RCTs) investigating the use of NSAIDs and COX-2 inhibitors after arthroscopic rotator cuff repair. Primary outcomes included healing and retear rate, determined by radiological imaging. Secondary outcomes included shoulder-specific outcome measures and the visual analog scale (VAS). Risk of bias was graded using the Cochrane risk-of-bias v2.0 tool. The GRADE framework was used to assess certainty of findings. RESULTS: Seven RCTs with a total of 507 patients were included (298 randomized to NSAID/COX-2 vs 209 randomized to control). NSAIDs use did not yield a difference in retear rate (P = .77). NSAIDs were shown to significantly reduce pain in the perioperative period (P = .01); however, no significant difference was present at a minimum of 6 months (P = .11). COX-2 inhibitors did not significantly reduce pain (P = .15). Quantitative analysis of ASES and UCLA scores showed NSAIDs significantly improved functional outcomes versus control (P = .004). COX-2 inhibitors did not significantly improve functional outcomes (P = .15). Two trials were deemed "low" risk of bias, four trials were graded to have "some concerns", and one trial was graded to have "high" risk of bias. Retear rate and functional PROMs were deemed to have "low" certainty. VAS pain scale was graded to have "moderate" certainty. CONCLUSIONS: This systematic review and meta-analysis indicates that NSAIDs do not affect healing rate after arthroscopic rotator cuff repair, but they do significantly improve postoperative pain and functional outcomes. No significant difference was seen in pain or functional outcomes with the use of COX-2 inhibitors. LEVEL OF EVIDENCE: Level I, meta-analysis of randomized controlled trials.

Bilateral Warthin's tumour of the parotid gland: a 16-year retrospective analysis and systematic review.

OBJECTIVE: Warthin's tumours are the second most common benign parotid tumours in the UK. The World Health Organization states that 5-14 per cent of patients have bilateral Warthin's tumours. This study aimed to: assess the presence of contralateral Warthin's tumours in patients who underwent surgery over the past 16 years at a head and neck unit in England, and perform the first systematic literature review on bilateral Warthin's tumours. METHODS: A retrospective analysis was conducted on patients diagnosed with Warthin's tumour based on histology between 2005 and 2020. Additionally, a systematic review (International Prospective Register of Systematic Reviews ('PROSPERO') registration number: CRD42022326846) was performed using PubMed and the Cochrane Library. RESULTS: Among 290 patients diagnosed with Warthin's tumours based on histology following surgery, 24.5 per cent had bilateral Warthin's tumours. The systematic review identified 157 papers, with 14 meeting the inclusion criteria. CONCLUSION: This study revealed that 24.5 per cent of patients had bilateral Warthin's tumours, deviating from the suggested range. These findings are of interest to surgeons discussing the disease with patients.

Evaluating the stress of root canal treatment in patients and dentists compared to other dental treatments: A systematic review and meta-analysis.

This systematic review aimed to investigate whether root canal treatment caused greater stress than other dental treatments for patients and dentists. All peer-reviewed literature published in English between January 1990 and January 2023 was included. This included randomized/non-randomized control trials, cohort studies, case-control studies, and cross-sectional studies. An electronic search used PubMed, Scopus, Medline, Cochrane Collaboration, and Embase. Hand searching supplemented the screening pool. Studies examining physiological or psychological stress measures within patients or providers of dental treatment (dentists, dental specialists, and dental students) were eligible. The study must have reported on the stress outcome for root canal treatment and at least one other dental procedure. After screening 3639 eligible records, there were 23 studies included, varying from very-low to low certainty of evidence. This review found that root canal treatment was more psychologically stressful for patients than routine restorative or cleaning procedures. However, the stress of root canal treatment relative to other dental procedures, especially extractions, was inconclusive for both dental patients and providers. Since patients regard root canal treatment as more stress-evoking than other routine dental procedures, providers should endeavour to minimise their own bias toward root canal treatment when providing adequate information for an informed treatment choice.

The Use of Infrared Thermography in Determining Timing for Early Pedicle Division of the Preexpanded Bipedicled Visor Flap after Ischemic Preconditioning.

Background: The preexpanded bipedicled visor flap, supported by the bilateral superficial temporal vessels, stands as an ideal choice for upper and lower lip reconstruction in males. However, the bilateral tissue bridges after flap transfer caused patients significant cosmetic deformity and psychological burden. Early division of bilateral pedicles reduced the length of hospitalization and expenses. In this study, infrared thermography (IRT) was used to guide the early pedicle division after ischemic preconditioning. Methods: This study retrospectively analyzed patients who underwent preexpanded bipedicled visor flap surgery from April 2018 to October 2021. Pedicle division was scheduled at two weeks postflap transfer. Ischemic preconditioning was initiated 3-5 days in advance by repeatedly clamping both pedicles. The temperature alteration of the flap and the temperature difference compared to the normal adjacent tissue were evaluated by IRT. The division surgery was not scheduled until the perfusion assessment indicated adequate. This comprised of subjective examination and indocyanine green angiography. The threshold of temperature difference to determine the pedicle division was analyzed based on the temperature changes between the clamps. Results: A total of 8 male patients successfully conducted the pedicle division without any complications. The delay period after ischemic preconditioning ranged from 14 to 19 days (average 16 days). Through ischemic preconditioning training, the average temperature of the flap gradually increased from 31.85 ± 0.36°C to 33.89 ± 0.50°C, and the temperature difference with the normal surrounding tissues decreased from 2.89 ± 0.30°C to 1.15 ± 0.46°C (95% confidence interval (1.5, 0.8)). The temperature difference stayed unchanged after pedicle division. Conclusion: Ischemic preconditioning shortens the perioperative period to pedicle division. Monitoring the temperature change reflects the revascularization between the flap and the recipient site, thus guiding the pedicle division. The temperature difference less than 1.5°C after clamping both pedicles can be set as the safe threshold for pedicle division.

Identifying Trends of Percutaneous Injuries at an Australian Dental School.

OBJECTIVES: The aim of this study was to retrospectively examine trends in percutaneous exposure incidences (PEIs) at the School of Dentistry (SoD) from 2009 to 2019 and to report on the underreporting rate of PEIs, current attitudes, and awareness of PEI safety protocols from clinical staff and students at the SoD in 2019. METHODS: Retrospective data were collected from deidentified archival incident reports from 2009 to 2019 from the SoD's incident reporting system (UQSafe and Legacy Database). Additionally, cross-sectional data were collected via the validated Percutaneous Exposure Incident Questionnaires (PEIQ) completed by clinical staff and students of the SoD in 2019. RESULTS: From the archival data, the majority (79.9%) of the 618 reported PEIs involved students. Local anaesthetic-related procedures were the most common cause in the archival (31.5%) and survey data (23.7%), whereas the needle-prick was the most common causative instrument in both data sets. Additionally, the finger was the most common site of injury found in the archival (53.0%) and survey data (52.8%). From 345 responses to the survey, 42.1% of PEIs sustained were not reported. CONCLUSIONS: Students were at a higher risk of sustaining a PEI than staff members between 2009 and 2019. The reported knowledge on PEI classification and preventative measures is inadequate, suggesting that further PEI education is necessary. The study provides evidence of the trends in PEIs as well as data on the attitudes and awareness of student and staff at a dental teaching faculty to support the development of PEI safety management protocols.

Revisiting the musculocutaneous external oblique flap as a versatile alternative in large thoracic wall defects.

BACKGROUND: The external oblique myocutaneous flap has been previously described for reconstruction of chest-thoracic wall defects smaller than 400-500 cm2. However, it is utilized less often than workhorse flaps such as the omental, pectoralis, rectus abdominis, and latissimus dorsi myocutaneous flaps as many plastic surgeons are not aware that the flap can cover larger areas than previously documented. CASE PRESENTATION: We report a 57-year-old female tobacco user who underwent a resection of a grade 3 breast angiosarcoma resulting in a high left chest wall soft tissue defect approximating 900 cm2. The patient underwent an external oblique myocutaneous pedicle flap reconstruction of the defect, most notably in anticipation of postoperative adjuvant radiation therapy. No gross flap complications and or patient impairment were noted. Thirteen months status post flap reconstruction, the patient underwent an aortic valve replacement requiring re-elevation of the same flap for exposure. The flap demonstrated excellent viability during the procedure and postoperatively. CONCLUSION: The pedicled external oblique myocutaneous flap should be considered when reconstructing larger high chest wall defects when other more common flaps used in chest reconstruction may not be indicated. The external oblique myocutaneous flap is an excellent tool in the armamentarium of any reconstructive surgeon; it is a straightforward and versatile flap that can be safely and reliably used in durable reconstruction of defects of the chest wall and covers defects larger than previously described in the literature.

The prognostic importance of CXCR3 chemokine during organizing pneumonia on the risk of chronic lung allograft dysfunction after lung transplantation.

RATIONALE: Since the pathogenesis of chronic lung allograft dysfunction (CLAD) remains poorly defined with no known effective therapies, the identification and study of key events which increase CLAD risk is a critical step towards improving outcomes. We hypothesized that bronchoalveolar lavage fluid (BALF) CXCR3 ligand concentrations would be augmented during organizing pneumonia (OP) and that episodes of OP with marked chemokine elevations would be associated with significantly higher CLAD risk. METHODS: All transbronchial biopsies (TBBX) from patients who received lung transplantation between 2000 to 2010 were reviewed. BALF concentrations of the CXCR3 ligands (CXCL9, CXCL10 and CXCL11) were compared between episodes of OP and "healthy" biopsies using linear mixed-effects models. The association between CXCR3 ligand concentrations during OP and CLAD risk was evaluated using proportional hazards models with time-dependent covariates. RESULTS: There were 1894 bronchoscopies with TBBX evaluated from 441 lung transplant recipients with 169 (9%) episodes of OP and 907 (49%) non-OP histopathologic injuries. 62 (37%) episodes of OP were observed during routine surveillance bronchoscopy. Eight hundred thirty-eight (44%) TBBXs had no histopathology and were classified as "healthy" biopsies. There were marked elevations in BALF CXCR3 ligand concentrations during OP compared with "healthy" biopsies. In multivariable models adjusted for other injury patterns, OP did not significantly increase the risk of CLAD when BAL CXCR3 chemokine concentrations were not taken into account. However, OP with elevated CXCR3 ligands markedly increased CLAD risk in a dose-response manner. An episode of OP with CXCR3 concentrations greater than the 25th, 50th and 75th percentiles had HRs for CLAD of 1.5 (95% CI 1.0-2.3), 1.9 (95% CI 1.2-2.8) and 2.2 (95% CI 1.4-3.4), respectively. CONCLUSIONS: This study identifies OP, a relatively uncommon histopathologic finding after lung transplantation, as a major risk factor for CLAD development when considered in the context of increased allograft expression of interferon-γ inducible ELR- CXC chemokines. We further demonstrate for the first time, the prognostic importance of BALF CXCR3 ligand concentrations during OP on subsequent CLAD risk.

Case Report: Modified Laparoscopic Subtotal Cholecystectomy: An Alternative Approach to the "Difficult Gallbladder".

BACKGROUND Laparoscopic cholecystectomy is a commonly performed surgical procedure. In certain situations visualization of the Callot triangle can become difficult due to inflammation, adhesions, and sclerosing of the anatomy. Without being able to obtain the "critical view of safety" (CVS), there is increased risk of damage to vital structures. An alternative approach to the conventional conversion to an open cholecystectomy (OC) would be a laparoscopic subtotal cholecystectomy (LSC). CASE REPORT We present a case of a 56-year-old male patient with acute cholecystitis with a "difficult gallbladder" managed with LSC. Due to poor visualization of the Callot triangle due to adhesions, safe dissection was not feasible. In an effort to avoid injury to the common bile duct (CBD), dissection began at the dome of the gallbladder allowing an alternative view while ensuring safety of critical structures. CONCLUSIONS We discuss the potential benefits and risks of LSC versus conversion to OC. Our discussion incorporates the pathophysiology that allows LSC in this particular circumstance to be successful, and the considerations a surgeon faces in making a decision in management.

Impact of TGF-ß inhibition during acute exercise on Achilles tendon extracellular matrix.

The purpose of this study was to evaluate the role of TGF-ß1 in regulating tendon extracellular matrix after acute exercise. Wistar rats exercised (n = 15) on a treadmill for four consecutive days (60 min/day) or maintained normal cage activity. After each exercise bout, the peritendinous space of each Achilles tendon was injected with a TGF-ß1 receptor inhibitor or sham. Independent of group, tendons injected with inhibitor exhibited ~50% lower Smad 3 (Ser423/425) (P < 0.05) and 2.5-fold greater ERK1/2 phosphorylation (P < 0.05) when compared with sham (P < 0.05). Injection of the inhibitor did not alter collagen content in either group (P > 0.05). In exercised rats, hydroxylyslpyridinoline content and collagen III expression were lower (P < 0.05) in tendons injected with inhibitor when compared with sham. In nonexercised rats, collagen I and lysyl oxidase (LOX) expression was lower (P < 0.05) in tendons injected with inhibitor when compared with sham. Decorin expression was not altered by inhibitor in either group (P > 0.05). On the basis of evaluation of hematoxylin and eosin (H&E) stained cross sections, cell numbers were not altered by inhibitor treatment in either group (P > 0.05). Evaluation of H&E-stained sections revealed no effect of inhibitor on collagen fibril morphology. In contrast, scores for regional variation in cellularity decreased in exercised rats (P < 0.05). No differences in fiber arrangement, structure, and nuclei form were noted in either group (P > 0.05). Our findings suggest that TGF-ß1 signaling is necessary for the regulation of tendon cross-link formation, as well as collagen and LOX gene transcription in an exercise-dependent manner.

Idiopathic Pulmonary Fibrosis: Epidemiology, Clinical Features, Prognosis, and Management.

Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic interstitial lung pneumonia associated with the histologic pattern of usual interstitial pneumonia (UIP). Although UIP is a distinct histologic lesion, this histologic pattern is not specific for IPF and can also be found in other diseases (e.g., connective tissue disease and asbestosis). Clinical features of IPF include progressive cough, dyspnea, restrictive ventilatory defect, and progressive fibrosis and destruction of the lung parenchyma. IPF is rare (13-42 cases/100,000), and primarily affects older adults (>50 years of age). The diagnosis of IPF often requires surgical lung biopsy, but the diagnosis can be affirmed with confidence in some patients provided the results of computed tomographic (CT) scans and clinical features are consistent. The clinical course is variable, but inexorable progression (typically over months to years) is typical. Mean survival from the onset of symptoms approximates 3 to 5 years. Medical treatment is only modestly effective, primarily by slowing the rate of disease progression. Lung transplantation is the best therapeutic option.

Influence of acute and chronic streptozotocin-induced diabetes on the rat tendon extracellular matrix and mechanical properties.

Diabetes is a major risk factor for tendinopathy, and tendon abnormalities are common in diabetic patients. The purpose of the present study was to evaluate the effect of streptozotocin (60 mg/kg)-induced diabetes and insulin therapy on tendon mechanical and cellular properties. Sprague-Dawley rats (n = 40) were divided into the following four groups: nondiabetic (control), 1 wk of diabetes (acute), 10 wk of diabetes (chronic), and 10 wk of diabetes with insulin treatment (insulin). After 10 wk, Achilles tendon and tail fascicle mechanical properties were similar between groups (P > 0.05). Cell density in the Achilles tendon was greater in the chronic group compared with the control and acute groups (control group: 7.8 ± 0.5 cells/100 µm(2), acute group: 8.3 ± 0.4 cells/100 µm(2), chronic group: 10.9 ± 0.9 cells/100 µm(2), and insulin group: 9.2 ± 0.8 cells/100 µm(2), P < 0.05). The density of proliferating cells in the Achilles tendon was greater in the chronic group compared with all other groups (control group: 0.025 ± 0.009 cells/100 µm(2), acute group: 0.019 ± 0.005 cells/100 µm(2), chronic group: 0.067 ± 0.015, and insulin group: 0.004 ± 0.004 cells/100 µm(2), P < 0.05). Patellar tendon collagen content was ∼32% greater in the chronic and acute groups compared with the control or insulin groups (control group: 681 ± 63 µg collagen/mg dry wt, acute group: 938 ± 21 µg collagen/mg dry wt, chronic: 951 ± 52 µg collagen/mg dry wt, and insulin group: 596 ± 84 µg collagen/mg dry wt, P < 0.05). In contrast, patellar tendon hydroxylysyl pyridinoline cross linking and collagen fibril organization were unchanged by diabetes or insulin (P > 0.05). Our findings suggest that 10 wk of streptozotocin-induced diabetes does not alter rat tendon mechanical properties even with an increase in collagen content. Future studies could attempt to further address the mechanisms contributing to the increase in tendon problems noted in diabetic patients, especially since our data suggest that hyperglycemia per se does not alter tendon mechanical properties.

A novel use of integra™ bilayer matrix wound dressing on a pediatric scalp avulsion: a case report.

OBJECTIVE: Soft tissue injuries with full-thickness skin involvement not amenable to local flaps may be treated with dermal matrices and subsequent skin grafting. METHODS: A pediatric patient presented with a 50-cm(2) scalp avulsion down to periosteum and outer cranial table post-vehicular trauma. After cultivating healthy cranial neodermis with Integra Bilayer Matrix Wound Dressing, a novel modification of treatment protocol was attempted by removal of the silastic layer. RESULTS: Neodermis transformation to granulation tissue followed by contraction of the wound reduced alopecia while also eliminating the need for a split-thickness skin graft to the area. CONCLUSION: A novel modification of treatment protocols utilizing acellular dermal matrices improved aesthetic outcomes and may present a cost-, time-, and procedure-sparing treatment option for avulsion injuries.

The effect of chronic treadmill exercise and acetaminophen on collagen and cross-linking in rat skeletal muscle and heart.

The purpose of this study was to determine whether exercise and/or acetaminophen (APAP) alter collagen and cross-linking in the rat gastrocnemius muscle, soleus muscle, and heart. Male Wistar rats (n = 50; 8 wk old) were divided into placebo (PLA) or APAP groups and sedentary (SED) or exercised (RUN) groups. APAP (200 mg/kg) was administered daily by oral gavage. Exercised groups ran on a treadmill 5 days/wk for 8 wk with progression to 60 min/day, 20 m/min, and 8° incline. Tissues were assayed for collagen (hydroxyproline) and hydroxylyslpyridinoline (HP) and lysylpyridinoline (LP) cross-links by HPLC. Collagen content (µg/mg dry weight) was greater in both the gastrocnemius (SED-PLA: 114 ± 16 vs. RUN-PLA: 244 ± 32; P < 0.001) and soleus (SED-PLA: 51 ± 7 vs. RUN-PLA: 99 ± 27; P = 0.005) of exercised animals. In contrast, collagen content was not significantly greater in exercised animals treated with APAP (SED-APAP: 113 ± 16 vs. RUN-APAP: 145 ± 21) and soleus (SED-APAP: 55 ± 8 vs. RUN-APAP: 57 ± 10). HP cross-linking (mmol/mol collagen) in the gastrocnemius (SED-PLA: 126 ± 28, RUN-PLA: 50 ± 7, SED-APAP: 41 ± 7, and RUN-APAP: 30 ± 4) and soleus muscles (SED-PLA: 547 ± 107, RUN-PLA: 318 ± 92, SED-APAP: 247 ± 64, and RUN-APAP: 120 ± 17) was lower in exercised rats compared with sedentary rats (P < 0.05). Cross-linking was further reduced in animals treated with APAP (P < 0.05). Neither heart collagen nor cross-linking was influenced by exercise or APAP (P > 0.05). Our findings suggest that exercise and APAP have tissue-specific effects on muscle collagen. Given the widespread use of APAP as an analgesic and antipyretic, further work in humans is warranted.

Volume of fluids administered during resuscitation for severe sepsis and septic shock and the development of the acute respiratory distress syndrome.

PURPOSE: The purpose of this study was to examine the association between the volume of intravenous (IV) fluids administered in the resuscitative phase of severe sepsis and septic shock and the development of the acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS: This was a retrospective cohort study of adult patients admitted with severe sepsis and septic shock at a large academic public hospital. The relationship between the volume of IV fluids administered and the development of ARDS was examined using multivariable logistic regression analysis. RESULTS: Among 296 patients hospitalized for severe sepsis and septic shock, 75 (25.3%) developed ARDS. After controlling for confounding variables, there was no significant association between the volume of IV fluids administered in the first 24 hours of hospitalization and the development of ARDS (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.95-1.18). Serum albumin (OR, 0.52; 95% CI, 0.31-0.87) and Acute Physiology and Chronic Health Evaluation II score (OR, 1.08; 95% CI, 1.04-1.13) on admission were the most informative covariates for the development of ARDS in the regression model. CONCLUSIONS: For patients hospitalized for severe sepsis and septic shock, fluid administration to improve end-organ perfusion should remain the top priority in early resuscitation despite the potential risk of inducing ARDS.

Hemophagocytic Lymphohistiocytosis Complicating T-Cell Lymphoma in a Patient with HIV Infection.

Hemophagocytic lymphohistiocytosis (HLH), while uncommon, may be a devastating complication of lymphoma and/or human immunodeficiency virus (HIV) infection. While several of the diagnostic criteria for HLH are relatively nonspecific, particularly in the setting of a systemic inflammatory response, more diagnostic specificity may be achieved with marked elevations in serum ferritin (e.g., >100,000 ng/mL). Increased suspicion of HLH, particularly in the setting of persistent, unexplained fevers, pancytopenia, and transaminitis, should prompt consideration of HLH. Earlier diagnosis and initiation of therapy have the potential to alter the natural history and poor prognosis of this disorder. We present a patient with HIV infection who developed relapsed T-cell lymphoma complicated by hemophagocytic lymphohistiocytosis.

In situ forming, resorbable graft copolymer hydrogels providing controlled drug release.

In situ forming hydrogels are promising drug delivery vehicles due to their ease of delivery as liquids and their ability to be used in sites with irregular geometries. In this work, we report on in situ forming, resorbable hydrogels based on N-isopropylacrylamide (NIPAAm) as a fluid-like controlled release gel. These gels are the first resorbable NIPAAm-based gels providing controlled release without relying on affinity between the drug and device. Therefore, these gels provide a more flexible delivery system which can be used to deliver any drug at a controlled rate. The polymers contain repeat units of NIPAAm with (R)-α-Acryloyloxy-ß,ß-dimethyl-γ-butyrolactone (DBLA) and varying amounts of hydrophilic Jeffamine® M-1000 acrylamide (JAAm) grafts. The graft copolymer architecture allows the water content of the hydrogels to be tuned over a wide range while keeping the initial gelation temperature below body temperature. Incorporation of JAAm in the polymers led to greater water content, faster gel degradation, and reduced burst release. Sustained release of the antimicrobial drugs cefazolin and vancomycin (over about 5 and 7 days, respectively) was observed from gels containing an intermediate amount of grafts which combined reduced phase separation with a degradation time of 40 days. The degradation byproducts of one hydrogel formulation were cytocompatible to NIH 3T3 fibroblasts at concentrations up to 2.5 wt %. This class of terpolymer hydrogels is a promising local delivery system for a wide variety of drugs, particularly for applications involving irregular geometries such as implant interfaces.

Prevalence of left-sided colorectal cancer and benefit of flexible sigmoidoscopy: a county hospital experience.

The best way to evaluate the colon for both diagnosis of symptoms and surveillance is colonoscopy. However, access to colonoscopy is often restricted. Our objective was to assess the anatomic distribution and stage at presentation of colorectal cancer (CRC) in a county hospital population, the prevalence and distribution of CRC in younger patients, and the utility of flexible sigmoidoscopy for early diagnosis of left-sided cancers in this population. We performed a retrospective chart review of 151 patients who underwent colorectal resection from 2001 to 2003. Overall, 66.9 per cent of patients underwent resection for left-sided CRC. Forty-two (27.8%) of 151 were under age 50. In patients over 50, 66.1 per cent were found to have left-sided CRC compared with 69 per cent of patients under 50. Fifty per cent (50.3%) of patients had stage III or IV (advanced) disease. Forty-nine and a half per cent of patients over 50 and 52.3 per cent under 50 had advanced disease. Forty-eight and a half per cent of patients with left-sided CRC had advanced stage disease compared with 54% of patients with right-sided CRC. In patients under 50, the rates were 55.2 per cent and 46.1 per cent respectively. Two-thirds of the CRC occurred in the left side of the colon in both older and younger population. Flexible sigmoidoscopy should be considered as an early tool in the diagnosis of CRC.