Does the Influenza Vaccine Prevent Sequelae Such as Myocarditis from Developing?

Vaccination continues to be a valuable and simple procedure to guard patients from an illness that may prevent them from completing their normal everyday tasks, missing days of work, and even lead to unnecessary sequelae. The following case describes one of the many complications that are seen on a regular basis in any community hospital in different regions of the world. The objective of this publication is to remind the public and practitioner of the urgency to vaccinate each season; thereby, curbing the virus's ability to mutate and preventing unwanted consequences such as bacterial super infection or myocarditis.

Experience with an enteral-based nutritional support regimen in critically ill trauma patients.

BACKGROUND: Assuring adequate enteral nutritional support in critically ill patients is challenging. By describing our experience, we sought to characterize the challenges, benefits, and complications of an approach that stresses enteral nutrition. STUDY DESIGN: We examined nutritional support received by victims of blunt trauma from 8 trauma centers. We grouped patients according to mean daily enteral caloric intake during the first 7 days. Group 1 received the fewest (0 kcal/kg/d) and group 5 the greatest (16 to 30 kcal/kg/d) number of calories in the first week. We focused our analyses on the patients remaining in the ICU for 8 days or longer and compared clinical outcomes among the groups. RESULTS: There were 1,100 patients in the ICU for 8 days or longer. Patients receiving the greatest number of enteral calories during the first week (group 5) had the highest incidence of ventilator-associated pneumonia (49%) and the lowest incidence of bacteremia (14%). Use of parenteral nutrition was associated with bacteremia (adjusted odds ratio = 2.5; 95% CI, 1.8-3.5), ventilator-associated pneumonia (adjusted odds ratio = 2.4; 95% CI, 1.7-3.3), and death (adjusted odds ratio = 1.9; 95% CI, 1.1-3.1). CONCLUSIONS: Enteral caloric intake during the first week was related to the pattern and severity of injury and was associated with important infectious outcomes. Our observations support moderating enteral intake during the first week after injury and avoiding parenteral nutrition.

Optimizing aesthetic results in skin grafting.

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented.

Transarterial chemoembolization and selective internal radiation for the treatment of patients with metastatic neuroendocrine tumors: a comparison of efficacy and cost.

BACKGROUND: Hepatic arterial therapy (HAT) has been proven to be effective at palliation of hormonal symptoms of metastatic neuroendocrine tumors (NETs), as well as a means of cytoreduction. Recently, the newer modalities of yttrium-90 and drug-eluting beads with doxorubicin (DEBDOX) have been reported to be effective in the treatment of metastatic NETs. The aim of this study was to compare the safety, efficacy, and cost of selective internal radiation with DEB therapy. METHODS: An institutional review board-approved, multicenter, multinational prospective treatment registry to investigate the safety and efficacy of yttrium-90 and doxorubicin microspheres was reviewed. RESULTS: In all, 43 patients underwent a combined 69 HAT treatments, with 15 patients receiving 23 yttrium-90 treatments and 28 patients receiving 46 DEBDOX treatments. The extent of disease-based on the number of lesions, bilobar distribution, patient performance status, and size of largest lesion-was similar in both the yttrium-90 and DEBDOX groups. After a median follow-up of 12 months, response rates were similar with the two treatments, but then there was a significantly lower response rate in the yttrium-90 group at 12 months than in the DEBDOX group. In an evaluation of cost for the two treatments, the median cost for yttrium-90 was $25,243 and the median cost for DEBDOX was $13,400. CONCLUSION: HAT is a safe and effective therapy in patients with unresectable NETs to the liver. The size of the lesions, total lesion volume, and expense of therapy need to be considered when choosing which HAT method is optimal.

Safety of hepatic resection in metastatic disease to the liver after yttrium-90 therapy.

BACKGROUND: Unresectable hepatic metastases from aerodigestive cancers are common and in most cases herald a poor prognosis. A small percentage of patients maybe amenable to surgical resection or ablation once the biology of the disease and the burden of hepatic disease are better understood. The use of hepatic arterial resin microspheres containing the ß emitter, yttrium-90, has been reported in the treatment of unresectable hepatic metastases. The goal of this review was to evaluate the use of yttrium-90 hepatic arterial therapy in the management of hepatic metastases and surgical downstaging. METHODS: We reviewed our prospective hepatic arterial therapy registry and found 44 patients who had received Sir Sphere treatment for unresectable hepatic malignancies from 11/06 to 7/08. Response was assessed by using CT-imaging and characterized using modified response evaluation criteria in solid tumors (RECIST). All patients were managed in a multidisciplinary tertiary referral center specializing in hepatic malignancies. RESULTS: A total of 44 patients, 34 men and 10 women, with a median age of 60 y (range 44-8), received 67 treatments. The disease types treated were one adenosquamous tongue, one adrenal, nine carcinoid, three cholangiocarcinoma, four esophageal, one gastric, one gastrinoma, one GIST, four HCC, 15 colorectal, one melanoma, one non-small-cell lung, one occular, and one sarcoma. Four patients treated proceeded to resection because of downstaging of disease or no evidence of extrahepatic progression. The median age in these patients was 61 y (range 49-62). All of the patients had less than 25% tumor burden in the liver. Surgical therapy consisted of two patients undergoing right hepatic lobectomy, one patient who also underwent two wedge resections of segment 3, and one patient who had a left lateral hepatectomy with right lobe microwave ablation. The median length of postoperative stay was 7 d. There was no evidence of liver dysfunction following resection in any of the patients. None of the patients show evidence of recurrence in the liver following resection. One patient has had progression of disease in the lungs following resection, histologically confirmed as metastatic rectal carcinoma. All of the patients are currently alive with a median survival of 2 y. CONCLUSION: Hepatic directed yttrium-90 is a minimally invasive, highly effective therapy that can be utilized to downstage the hepatic burden and/or assess the biology of the disease to allow for appropriate treatment. The use of yttrium-90 microspheres for radio-embolization of metastases in the liver can successfully downstage the lesions to allow for surgical resection in patients with amenable predictors, and can provide a significantly better prognosis in these patients. This form of therapy for the purposes of downstaging tumors for resection merits more extensive study in order to provide the best possible outcomes for patients with metastatic liver disease.

Safe treatment of trigger thumb with longitudinal anatomic landmarks.

OBJECTIVE: Stenosing tenosynovitis of the thumb flexor tendon sheath is also known as trigger thumb. It is an inflammatory process that involves the flexor tendon sheath at the A1 pulley. Successful percutaneous or open treatment of trigger thumb depends on the ability of the clinician to properly predict the location of the A1 pulley. Longitudinal anatomic landmarks can facilitate safe treatment for the trigger thumb while circumventing injury to the neurovascular bundles. METHODS: Fourteen fresh cadaveric hands were dissected to identify surface landmarks corresponding to the oblique course of the flexor pollicis longus tendon at the level of the A1 pulley. RESULTS: The longitudinal landmarks for the A1 pulley of the thumb are the palpable hook of the hamate and the midline of the thumb interphalangeal (IP) crease. Other bony prominences, such as the pisiform bone did not serve as effective landmarks while the thumb was in an abducted position. CONCLUSION: we encourage the use longitudinal anatomic landmarks to predict the location of the thumb A1 pulley. The hook of the hamate and the midline at the palmar interphalangeal crease are reliable landmarks for safe release of the A1 pulley while avoiding inadvertent injury to adjacent structures.