Incidence of candidaemia in prolonged venovenous extracorporeal membrane oxygenation.

This single-centre retrospective study reports the dynamics of the incidence of candida bloodstream infection (CBSI) in 145 patients receiving venovenous extracorporeal membrane oxygenation (ECMO) for respiratory support between January 2014 and December 2018. The incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with an increasing trend in OR (P=0.005), and a window of continued risk after decannulation was observed. Of the 13 patients who developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. There is a need for prospective studies aiming to improve ECMO diagnostic stewardship practices and discourage unnecessary antifungal prophylaxis or empiric management.

Tracheal tube obstruction as a complication of transoesophageal echocardiography.

Complications of transoesophageal echocardiography are numerous and may have serious consequences. We present the case of a 31-year-old woman with postoperative airway obstruction secondary to a transesophageal echocardiography probe. The patient had been admitted with acute myocarditis and required temporary mechanical support with a biventricular assist device. She deteriorated on the intensive care unit several hours later with hypoxaemia, high airway pressures and reduced tidal volumes. Sedation was adequate and no external obstruction in the breathing circuit was observed. The tracheal tube was noted to be permanently deformed in the oropharynx, causing airway obstruction. Tracheal tube exchange was required, and the patient recovered from the event. We suspect that the position of the transoesophageal echocardiography probe in the operating theatre had contributed to the deformity, and the presence of airway obstruction was masked by the reduced ventilatory parameters instituted while on mechanical circulatory support. The biventricular assistance devices were explanted subsequently, and the patient was discharged home on day 31. This is the first reported case of a kinked tracheal tube where transoesophageal echocardiography probe placement was suspected to have contributed. A high index of suspicion is required for this complication on the intensive care unit.

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.

One in 16 patients prescribed opioids after a surgical procedure will become a long-term user. The lack of procedure-specific guidelines after common dental procedures contributes to the opioid overprescribing problem. We convened a multidisciplinary panel to develop consensus recommendations for opioid prescribing after common dental procedures. We used a three-step modified Delphi method to develop a consensus recommendation for outpatient opioid prescribing for 14 common dental procedures. The multi-institution, multidisciplinary panel represented seven relevant stakeholder groups (oral surgeons, periodontists, endodontists, general dentists, general surgeons, oral surgery residents, and oral surgery patients). The panel determined the minimum and maximum number of opioid tablets a clinician should consider prescribing. For all 14 surgical procedures, ibuprofen was recommended as initial therapy. The maximum number of opioid tablets recommended varied by procedure (overall median = 5 tablets, range = 0-15 tablets). Zero opioid tablets were recommended as the maximum number for six of 14 (43%) procedures, one to 10 opioid tablets was the maximum for four of 14 (27%) procedures, and 11-15 tablets was the maximum for four of 14 (27%) procedures. Procedure-specific prescribing recommendations may help provide guidance to clinicians and help address the opioid overprescribing problem.

Assessment of scoring systems to describe the position of tracheostomy tubes within the airway - the lunar study.

BACKGROUND: Malposition of tracheostomy tubes is difficult to detect at the bedside and may contribute to eventual device misplacement. Endoscopic examination can be undertaken via tracheoscopic (T-view) or trans-laryngeal (L-view) approach, offering more precise detail regarding positioning within the airway. The aims of this study were to evaluate inter-rater agreement between bespoke T and L view scoring systems and subsequently whether T-views could predict L-views. METHODS: Adult intensive care unit patients with percutaneous or surgical tracheostomies were included and paired T and L-views of their tracheostomy tube within the airway were taken on up to four occasions. Images were later scored by five independent raters using bespoke scoring systems. The primary outcome was to determine the T and L view scoring system with the best inter-rater agreement, defined by weighted kappa and intra-class correlation coefficients. The secondary outcome was to assess agreement between T and L-view scoring systems. RESULTS: Seventy-one T-views and 43 L-views were obtained from a total of 20 patients. Images were scored by five raters, resulting in 355 T-view scores, 215 L-view scores and 215 paired T and L-view scores for comparison. There was good inter-rater agreement (highest T-view k = 0.84, L-view k = 0.72). There was poor agreement between T and L-view scores for each of the paired images (highest k = 0.25) although extreme-to-extreme misclassification rates remained acceptable. CONCLUSIONS: Whilst our data demonstrated good inter-rater agreement between scoring systems, it is not possible to reliably predict the T-view orientation and position of a tracheostomy tube within the airway from the paired L-view. CLINICAL TRIAL REGISTRATION: NCT01356719.

Effects of four treatment strategies for temporomandibular joint closed lock.

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)(15) compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P≤0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P≥0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.

How much do mental disorders contribute to New Zealand's tobacco epidemic?

OBJECTIVE: To quantify the share of tobacco consumed by people with 12-month mental disorders in New Zealand. METHODS: Estimates of current smoking prevalence and the 12-month prevalence of three groups of mental disorders--anxiety, mood and substance use disorders--were derived from the New Zealand Mental Health Survey, a nationally representative survey of almost 13,000 adults (16+ years) fielded in 2003-4. Estimates of the smoking intensity ratio (comparing smokers with mental disorders to those without mental disorders) were derived from the 2006-7 New Zealand Health Survey. RESULTS: Approximately 33% of all cigarettes are consumed by people with 12-month mental disorders (males 27%, females 39%), using an estimated smoking intensity ratio of 1.21. Among this group, anxiety disorders account for almost one-half of consumption, mood disorders for over one-quarter and substance use disorders for about one-fifth. CONCLUSION: This study quantifies for the first time the contribution of mental disorders to tobacco consumption in New Zealand. In particular, it identifies anxiety disorders as an important risk factor for tobacco use. People with mental disorders are an important target group for tobacco control. Enhanced collaboration and sharing of expertise between smoking cessation service providers and community mental health services are urgently needed.

Randomized effectiveness study of four therapeutic strategies for TMJ closed lock.

For individuals with temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock), interventions vary from minimal treatment to surgery. In a single-blind trial, 106 individuals with TMJ closed lock were randomized among medical management, rehabilitation, arthroscopic surgery with post-operative rehabilitation, or arthroplasty with post-operative rehabilitation. Evaluations at baseline, 3, 6, 12, 18, 24, and 60 months used the Craniomandibular Index (CMI) and Symptom Severity Index (SSI) for jaw function and TMJ pain respectively. Using an intention-to-treat analysis, we observed no between-group difference at any follow-up for CMI (p > or = 0.33) or SSI (p > or = 0.08). Both outcomes showed within-group improvement (p < 0.0001) for all groups. The findings of this study suggest that primary treatment for individuals with TMJ closed lock should consist of medical management or rehabilitation. The use of this approach will avoid unnecessary surgical procedures.

Successful treatment of oral squamous cell carcinoma with intralesional fluorouracil in a Malayan tapir (Tapirus indicus).

An oral mass was observed in a Malayan tapir (Tapirus indicus). Squamous cell carcinoma was diagnosed by histologic examination of a biopsy specimen. A series of intralesional injections using fluorouracil resulted in complete regression of the neoplasm with no recognized adverse effects.

Mutagenic screening of marker grenade dyes by the Salmonella reversion assay, L5178Y/TK+/- mouse lymphoma assay, and in vivo sister chromatid exchange analysis in mice.

Two dyes (C.I. Solvent Yellow No. 33 and a mixture of C.I. Solvent Yellow No. 33 and C.I. Solvent Green No. 3) were tested for mutagenicity in the Salmonella reversion assay and the L5178Y/TK+/- mouse lymphoma assay, and also for sister chromatid exchange (SCE) induction in vivo in C57B1/6J mice. In addition, a greater than 99.9% pure sample of the yellow dye [2-(2'-quinolyl)-1,3-indandione] was tested with and without exogenous activation in the Salmonella reversion assay and the L5178Y/TK+/- mouse lymphoma assay. Neither C.I. Solvent Yellow No. 33 nor the C.I. Solvent Yellow No. 33 and Solvent Green No. 3 mixture was positive for inducing SCEs in vivo. All three dyes were tested in the standard plate incorporation test in seven Salmonella strains TA98, TA100, TA102, TA104, TA1535, TA1537, and TA1538. The dyes were negative with and without exogenous activation in TA98, TA1535, and TA1538. One test with TA1537 was positive with the greater than 99.9% purified yellow dye. All three dyes gave weakly positive results (less than a twofold increase) with S-9 in TA100 and were clearly positive in TA102 and TA104 both with and without S-9. They also induced mutation at the thymidine kinase locus in mouse lymphoma cells, produced both large- and small-colony trifluorothymidine-resistant mutants, and were clastogenic. The purified yellow dye was further tested for SCE induction in mouse lymphoma cells and was determined to give a slightly positive response in the presence of S-9.

A repeated dose pharmacokinetic study of a new hypnotic agent, zopiclone (Imovane).

Eleven volunteers were dosed once daily for 14 days with zopiclone (7.5 mg/day). The peak plasma zopiclone concentration (65 ng/ml) occurred at 1.4 h after dosing and thereafter declined by a biexponential process, with half-lives of 2.0 and 6.5 h, to 3 ng/ml by 24 h after dosing. Repeated once daily dosing did not markedly alter the peak plasma zopiclone concentration or the pharmacokinetic parameters of absorption or elimination.

A pharmacokinetic study of repeated doses of a new controlled release form of ketoprofen.

Nine volunteers were dosed once daily for 15 days with a controlled release formulation of ketoprofen. The peak plasma ketoprofen concentration (4.2 micrograms/ml) and apparent elimination half-life (8.4 h) did not markedly alter during the course of the study. Plasma ketoprofen concentrations at 24 h after dosing were 0.79 micrograms/ml. These minimum ketoprofen concentrations suggest that this formulation is suitable as a once daily dosing regimen.

Observations on the clinical pharmacology and plasma concentrations of diacetolol, the major human metabolite of acebutolol.

1 The pharmacological effects and plasma levels of diacetolol, the major human metabolite of acebutolol, were measured in a double-blind, balanced study in which five healthy men received single oral doses of diacetolol 100, 200, 400 and 800 mg, or placebo, at weekly intervals. 2 Resting and exercise heart rate (HR), forced expiratory volume in 1 second (FEV1), resting and exercise peak expiratory flow rate (PEFR), and plasma concentrations of diacetolol were determined at 0, 2, 4, 6, 8 and 24 h after each treatment. 3 Diacetolol caused a slight dose-related reduction in resting HR and a substantial dose-related reduction in exercise HR. AT the same time it was found that diacetolol had no significant effects on FEV1 and resting and exercise PEFR. 4 Mean highest observed plasma concentrations (ng/ml) of diacetolol were 177 at a mean of 4.4 h after the 100 mg dose, 243 at 4.0 h after the 200 mg dose, 807 at 5.2 h after the 400 mg dose, and 1,306 at 4.4 h after the 800 mg dose. 5 Using the mean data, there was a strong correlation (r = 0.90) between % reduction in exercise HR and the logarithm of the plasma concentration of diacetolol. 6 Diacetolol exhibits marked cardiac beta-adrenoceptor blocking activity in man which is still evident 24 h after the administration of the higher doses of the drug. No adverse effects on pulmonary function could be detected.