Burden of disease and treatment patterns in patients with vitiligo: findings from a national longitudinal retrospective study in the UK.

BACKGROUND: UK studies examining vitiligo burden and vitiligo-related healthcare resource utilization (HCRU) are lacking. OBJECTIVE: To describe the incidence and prevalence of vitiligo, the demographic and clinical characteristics of patients with vitiligo, vitiligo burden, HCRU, incidence of mental health comorbidities and management strategies, including treatment patterns. METHODS: This retrospective study used UK Clinical Practice Research Datalink and Hospital Episode Statistics databases to analyse patients with vitiligo from 1 January 2010 to 31 December 2021. RESULTS: Among 17 239 incident patients, mean incidence of vitiligo was 0.16 (2010-2021) per 1000 person-years [PY; range 0.10 (2020-COVID-19) to 0.19 (2010/2013/2018)]; among 66 217 prevalent patients, prevalence increased from 0.21% (2010) to 0.38% (2021). The most common comorbidities recorded after vitiligo diagnosis were diabetes (19.4%), eczema (8.9%), thyroid disease (7.5%) and rheumatoid arthritis (6.9%). Mental health diagnoses recorded at any time included depression and/or anxiety (24.6%), depression (18.5%), anxiety (16.0%) and sleep disturbance (12.7%), and recorded after vitiligo diagnosis in 6.4%, 4.4%, 5.5% and 3.9%, respectively. Mental health comorbidities were more common in White (e.g. depression and/or anxiety 29.0%) than in Black (18.8%) and Asian (16.1%) patients. In adolescents, depression and/or anxiety was most commonly diagnosed after a vitiligo diagnosis than before (7.4% vs. 1.8%). Healthcare resources were used most frequently in the first year after vitiligo diagnosis (incident cohort), typically dermatology-related outpatient appointments (101.9/100 PY) and general practitioner consultations (97.9/100 PY). In the year after diagnosis, 60.8% of incident patients did not receive vitiligo-related treatment (i.e. topical corticosteroids, topical calcineurin inhibitors, oral corticosteroids or phototherapy), increasing to 82.0% the next year; median time from diagnosis to first treatment was 34.0 months (95% confidence interval 31.6-36.4). Antidepressants and/or anxiolytics were recorded for 16.7% of incident patients in the year after diagnosis. In 2019, 85.0% of prevalent patients did not receive vitiligo-related treatments. CONCLUSION: Most patients were not on vitiligo-related treatments within a year of diagnosis, with the time to first treatment exceeding 2 years, suggesting that vitiligo may be dismissed as unimportant. New effective treatments, early initiation and psychological intervention and support are needed to reduce the vitiligo burden on patients.

Vitiligo is a chronic disease in which cells that produce the skin pigment called melanin are attacked, resulting in white or pale patches of skin. It is diagnosed in an estimated 0.2­0.8% of people in Europe. This study aimed to describe how many new cases of vitiligo were recorded between 2010 and 2021 in the UK and the overall percentage of people with vitiligo. Linked national general practitioner (GP) and hospital-based records containing information on medical diagnoses, admissions and hospital visits were used. Records of other diseases and conditions, including mental health conditions, in combination with healthcare service use and treatment prescribed to patients with vitiligo, were studied to describe the impact of living with vitiligo. It was found that 0.16 new cases of vitiligo were recorded per 1000 person-years (for example, 0.16 new cases would have been recorded if 1000 people were followed for 1 year or if 100 people were all followed for 10 years) between 2010 and 2021. In 2021, 0.4% of the population studied had vitiligo. In the 5 years after a new diagnosis of vitiligo, the most common other diseases recorded were diabetes (19%), eczema (9%), thyroid disease (8%) and rheumatoid arthritis (7%), and the most common mental health conditions were depression and/or anxiety (25%). In the year after diagnosis, GP and dermatology outpatient visits were the most common type of medical services used. In 2019, 85% of all individuals with vitiligo were not receiving any vitiligo-related treatment (such as creams or phototherapy). It took approximately 34 months from diagnosis of vitiligo to the start of first treatment. The results suggest that new effective treatments and psychological interventions are needed to reduce the burden of vitiligo.

A Randomised Control Study Comparing C-MAC D-Blade Video Laryngoscope (Hyper Angulated Blade) and Macintosh Laryngoscope for Insertion of a Double-Lumen Tube in Patients Undergoing Elective Thoracotomy.

Background: The use of a double-lumen endotracheal tube is one of the common anesthetic techniques for operations in the thoracic cavity. However, when compared to a single-lumen tube, placement of a double-lumen tube is technically more difficult as a result of which it takes more time to insert and is associated with more complications such as mucosal injury, hoarseness, and sore throat, even in patients with no anticipated airway difficulty. The CMAC D-blade that is usually used in patients with anticipated airway difficulty, could assist in smooth and quick placement of double-lumen tube (DLT) even in patients with no anticipated airway difficulty. Aim of the Study: This study aimed to evaluate the effectiveness of the C-MAC D-blade in reducing the time taken to visualize the glottis and intubate patients with normal airway with a double-lumen tube. Setting and Design: This was a prospective open-label randomized control trial in a tertiary hospital. Materials and Methods: Seventy-three consenting adult patients with physical status classes I and II, as determined by the American Society of Anesthesiologists, scheduled to undergo elective thoracotomy, were randomly allocated to receive either C-MAC D-blade (Group D) or Macintosh blade (Group M). The primary objective was to compare the time taken for visualization of the glottis and intubation. Statistical Analysis Used: Chi-square/Fisher's exact test and t-test were used for statistical analysis. Results: Seventy-three patients were randomized (Group D = 36; Group M = 37). Time to visualize the glottic structures (4.56 ± 2.396 s vs. 7.27 ± 4.891 s, P = 0.01) was significantly better in Group D; however, the mean intubation time was comparable (55.92 ± 18.749 s vs. 51.08 ± 15.269 s, P = 0.61). Conclusion: C-MAC D-blade videolaryngoscope offers a better glottic view and lesser time to visualize glottis when compared with the Macintosh laryngoscope. However, the time taken to insert the DLT after visualization was longer. We infer that there is no advantage in the routine use of C-MAC D-blade for DLT insertion in patients with no anticipated airway difficulty.

Pediatric perioperative fluid management.

Appropriate fluid management is vital for adequate tissue perfusion and balancing the internal milieu especially in perioperative settings and critically ill children. Pediatric population is heterogeneous so one formula may not suffice and hence both the quantitative and qualitative perspective of fluid management should be based on physiology and pathology of the child along with their perioperative needs. In perioperative setup, the fluid is administered to meet fluid deficits (fasting, and other daily based losses), blood losses and third space losses. Anesthetists have always followed pediatric maintenance fluid calculations based on Holiday and Segar formula; based on studies conducted on healthy children more than 70 years ago. Recently, there has been a lot of debate about this concept, especially as there are serious concerns regarding the development of complications like hyponatremia and hyperglycemia, both of which can result in neurological damage or even mortality in a sick child. This review is an attempt to provide a historical perspective and current evidence-based approach to peri-operative pediatric fluid management. We performed a PUBMED search for articles using keywords including 'children', 'intravenous fluid therapy', 'crystalloids', 'colloids', 'fluid homeostasis', 'blood loss', 'estimation of blood loss', 'blood loss management', 'perioperative fluid ' to get our source articles.

A randomized control led study comparing CMAC video laryngoscope and Macintosh laryngoscope for insertion of double lumen tube in patients undergoing elective thoracotomy.

BACKGROUND AND AIMS: Double lumen tube (DLT) insertion for isolation of lung during thoracic surgery is challenging and is associated with considerable airway trauma. The advent of video laryngoscopy has revolutionized the management of difficult airway. Use of video laryngoscopy may reduce the time to intubate for DLTs even in patients with normal airway. MATERIAL AND METHODS: A total of 87 ASA 1-3 adults, scheduled to undergo elective thoracotomy, requiring a DLT were randomly allocated to videolaryngoscope (CMAC) arm or Macintosh laryngoscope arm. It was on open label study, and only the patient was blinded. The primary objective of this study was to compare the mean time taken for DLT intubation with CMAC (Mac 3) and Macintosh laryngoscope blade and the secondary objectives included the hemodynamic response to intubation, the level of difficulty using the intubation difficulty scale (IDS), and complications associated with intubation. Data was analysed using the statistical software SPSS (version 18.0). RESULTS: The time taken for intubation was not significantly different (42.8 ± 14.8 s for CMAC and 42.5 ± 11.5 s for Macintosh laryngoscope P -0.908). The CMAC video laryngoscope was associated with an improved laryngoscopy grade (Grade I in 81.8% with CMAC and in 46.5% with Macintosh), less pressure applied on the tongue, and less external laryngeal pressure required. Hemodynamic responses to intubation were similar in both groups. CONCLUSION: Macintosh blade is as good as CMAC (mac 3) blade to facilitate DLT intubation in adult patients with no anticipated airway difficulty, however CMAC was superior as it offers better laryngoscopic view, needed less force, and fewer external laryngeal manipulations.

A randomized clinical trial comparing the King Vision (channeled blade) and the CMAC (D blade) videolaryngoscopes in patients with cervical spine immobilization.

Background and Aims: Cervical spine immobilization renders direct laryngoscopy difficult. The CMAC D blade and the channeled blade of the King Vision videolaryngoscopes, have both been used for difficult airway management. Our hypothesis is that the channeled blade of the King Vision would be superior to the CMAC D blade in terms of ease of intubation. We tested this hypothesis in a randomized comparison of the two videolaryngoscopes in patients with simulated cervical spine immobilization. Material and Methods: Hundred patients with no anticipated airway difficulty were randomly allocated to two groups after obtaining informed written consent. Following induction, manual inline stabilization (MILS) was applied to simulate a cervical spine injury and immobilzation. Patients were intubated with either of the two videolaryngoscopes. Time for visualization of the glottis, procedural time, intubation difficulty scale (IDS), and hemodynamic response were recorded. Results: The time to visualize the glottis was shorter in the CMAC D group as compared to the King Vision group (P < 0.001). The incidence of external laryngeal manipulation was less in the King Vision group (P < 0.001). The ease of intubation was superior in the King Vision group, based on the IDS (P < 0.001). The haemodynamic response was similar between the groups. Conclusion: King Vision channeled videolaryngoscope was difficult to introduce into the mouth of the patient during laryngoscopy. Once introduced into the mouth, the time for intubation was less and less external laryngeal manipulation maneuvers were performed to achieve successful intubation. The ease of endotracheal intubation was superior for the King Vision videolaryngoscope. The King Vision videolaryngoscope with proper tranining, could be a safe and portable alternative in patients with cervical spine immobilization.