Frailty and risk of complications in head and neck oncologic surgery. Systematic review and dose-response meta-analysis.

BACKGROUND: There is emerging evidence that frail individuals present a decreased physiological reserve, decreased ability to maintain homeostasis, and increased vulnerability to stressors. The concept of frailty has become increasingly recognized as a valuable measure in oncological surgical patients, including those with head and neck cancer. Preoperative screening for frailty may provide an individualized risk assessment that can be used by an interdisciplinary team for preoperative counseling and to improve outcomes. The aim of this meta-analysis was to evaluate the relationship between frailty and the risk of major postoperative complications in frail individuals submitted to head and neck oncologic surgery. MATERIAL AND METHODS: PubMed, SCOPUS, Web of Science, Google Scholar and OpenThesis were systematically searched to identify studies that evaluated the risk of major postoperative complications in frail individuals undergoing head and neck oncologic surgery. The search was performed on August 31, 2020, without language or date restrictions. Two independent investigators screened the searched studies based on each paper's title and abstract. Relevant studies were read in full and selected according to the eligibility criteria. Frailty was assessed by modified Frailty Index (mFI-11) and major postoperative complications were measured by the Clavien-Dindo classification. We performed a categorical and dose-response meta-analysis using a random-effects model to evaluate the association between frailty and the risk of major postoperative complications in patients submitted to head and neck oncologic surgery. The results of the meta-analysis were expressed as relative risk (RR) and 95% confidence interval (95% CI). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: Four studies (9,947 patients) were included in this systematic review and meta-analysis. Frail patients presented an increased risk of life-threatening complications requiring intensive care unit (ICU) admission (RR = 4.67; 95% CI 1.54-14.10) and 30-day mortality (RR = 8.10; 95% CI 2.30-28.57) compared to non-frail patients. We found evidence of dose-response trend between mFI-11 and major postoperative complications. CONCLUSIONS: Higher frailty scores are associated with a significant increase in ICU-level complications and 30-day mortality after head and neck oncologic surgery.

Phylogenetic relationships of Brazilian isolates of Pythium insidiosum based on ITS rDNA and cytochrome oxidase II gene sequences.

Pythium insidiosum is an aquatic oomycete that is the causative agent of pythiosis. Advances in molecular methods have enabled increased accuracy in the diagnosis of pythiosis, and in studies of the phylogenetic relationships of this oomycete. To evaluate the phylogenetic relationships among isolates of P. insidiosum from different regions of Brazil, and also regarding to other American and Thai isolates, in this study a total of thirty isolates of P. insidiosum from different regions of Brazil was used and had their ITS1, 5.8S rRNA and ITS2 rDNA (ITS) region and the partial sequence of cytochrome oxidase II (COX II) gene sequenced and analyzed. The outgroup consisted of six isolates of other Pythium species and one of Lagenidium giganteum. Phylogenetic analyses of ITS and COX II genes were conducted, both individually and in combination, using four different methods: Maximum parsimony (MP); Neighbor-joining (NJ); Maximum likelihood (ML); and Bayesian analysis (BA). Our data supported P. insidiosum as monophyletic in relation to the other Pythium species, and COX II showed that P. insidiosum appears to be subdivided into three major polytomous groups, whose arrangement provides the Thai isolates as paraphyletic in relation to the Brazilian ones. The molecular analyses performed in this study suggest an evolutionary proximity among all American isolates, including the Brazilian and the Central and North America isolates, which were grouped together in a single entirely polytomous clade. The COX II network results presented signals of a recent expansion for the American isolates, probably originated from an Asian invasion source. Here, COX II showed higher levels bias, although it was the source of higher levels of phylogenetic information when compared to ITS. Nevertheless, the two markers chosen for this study proved to be entirely congruent, at least with respect to phylogenetic relationships between different isolates of P. insidiosum.

Efficacy and safety of 10% HES 130/0.4 versus 10% HES 200/0.5 for plasma volume expansion in cardiac surgery patients.

AIM: Hydroxyethyl starch (HES) solutions are frequently used for perioperative volume replacement. Whereas older HES specimen tended to accumulate in the plasma and to cause negative effects on hemostasis, more recent products, e.g., HES 130/0.4, are characterised by improved pharmacological properties. The present study was designed to compare the efficacy and safety of 10% HES 130/0.4 and 10% HES 200/0.5. METHODS: In this post-hoc analysis of a prospective, randomised, double-blind, multi-center therapeutic equivalence trial, 76 patients undergoing elective on-pump cardiac surgery received perioperative volume replacement using either 10% HES 130/0.4 (N.=37) or 10% HES 200/0.5 (N.=39) up to a maximum dose of 20 mL kg-1. RESULTS: Equivalent volumes of investigational medication were infused until 24 hours after the first administration (1577 vs. 1540 mL; treatment difference 37 [-150; 223] mL; P<0.0001 for equivalence). Whereas standard laboratory tests of coagulation were comparable between groups, von Willebrand factor activity on the first postoperative morning tended to be higher following treatment with 10% HES 130/0.4 as compared to 10% HES 200/0.5 (P=0.025) with this difference being statistically significant only in the per-protocol analysis (P=0.02). Treatment groups were comparable concerning other safety parameters and the incidence of adverse drug reactions. In particular, renal function was well preserved in both groups. CONCLUSION: Ten percent HES 130/0.4 was equally effective and safe as compared to 10% HES 200/0.5 for volume therapy in patients undergoing cardiovascular surgery. Postoperative coagulation and renal function, as measured by standard laboratory tests, were similar among groups.

In vitro interactions between amphotericin B and other antifungal agents and rifampin against Fusarium spp.

Fusarium species are common hyaline soil saprophytes and plant pathogens that are opportunistic fungal pathogens of immunocompromised patients. The treatment for fusariosis remains uncertain with an unfavourable prognosis; new possibilities for treatment, such as various synergistic drug interactions, must be uncovered. In this study, we evaluated the in vitro interactions of amphotericin B with caspofungin, ketoconazole, 5-flucytosine, itraconazole, miconazole, rifampin, fluconazole, terbinafine and voriconazole against isolates of Fusarium spp. using the chequerboard method with interactions evaluated by fractional inhibitory concentration indices. The highest percentages of synergistic interactions were observed for the combinations of amphotericin B and caspofungin (68.7%), amphotericin B and rifampin (68.7%), amphotericin B plus 5-flucytosine (59.3%) and amphotericin B with voriconazole (37.5%). The pattern of susceptibility to antifungal agents among Fusarium species and their consequence on the effects of drug combinations are also discussed.

Variabilidade intra e interobservador no diagnóstico radiográfico de lesões periapicais de origem inflamatória / Intra and interobserver variability in radiographic diagnosis of inflammatory periapical lesions

Para avaliar a concordância e a acurácia no diagnóstico da situação do periápice de molares e prémolaresinferiores portadores ou não de patologia periapical, quarenta radiografias periapicais, vinte de dentescom vitalidade pulpar e sem radiolucências periapicais e vinte de dentes com necrose pulpar foram selecionadas,digitalizadas em scanner no modo 8 bits, com resolução de 300 dpi e armazenadas no formatoJPEG 12. As imagens digitalizadas foram apresentadas no formato de slides com fundo preto no programaPowerPoint, sendo projetadas em equipamento multimídia para vinte observadores, alunos de dois gruposde pós-graduação de uma mesma instituição de ensino, simultaneamente, com repetição de 20% dos casos.Os observadores apresentaram ampla variação do percentual de concordância entre diagnósticos repetidos,contudo, quando agrupados por especialidade, endodontistas e radiologistas apresentaram percentuais deconcordância de 62,50 e 66,25%, respectivamente. A concordância interobservadores foi superior entre osalunos de Radiologia, comparados aos de Endodontia (Kendall´s W= 0,816 e 0,662 respectivamente). Emrelação à especificidade, observou-se desempenho idêntico para os dois grupos (70 a 95%), contudo os alunosde Radiologia apresentaram sensibilidade ligeiramente superior (70 a 95%). A variabilidade, tanto intraquanto inter observador, verificada pelas analises realizadas pelos alunos da mesma especialidade sugereque os critérios de interpretação de imagens radiográficas devam ser enfatizados e um maior treinamentoaplicado nos cursos de pós-graduação.

In order to assess agreement and diagnostic accuracy in lower molars and premolars periapical radiographs,with or without apical radiolucences, in periapical region, forty radiographs, twenty of teeth withpulp vitality and without periapical radiolucences and twenty with nonvital pulp teeth were selected. Theradiographs were digitized in a scanner at 8 bits, 300 dpi and saved in JPEG 12 format. The images werepresented simultaneously to two groups of ten observers, which were post-graduation students at the sameinstitution, utilizing multimedia equipment and a PowerPoint program to project the black background slides.Twenty percent of the images were reanalyzed. The observers presented a significant agreement variationin the reanalysis; however, when grouped by of expertise, endodontists and radiologists agreed in theirdiagnosis in 62.50% and 66.25%, respectively. The interobserver agreement was higher among Radiologystudents compared to the Endodontics students (Kendall´s W= 0.816 e 0.662, respectively). In reference tospecificity, both demonstrated equal performance (70 to 95%), nonetheless the Radiology students demonstratedslightly higher sensibility (70 to 95%). Both intra and interobserver variability verified throughout theanalyses done by the students, of the same of expertise, suggest that the radiographic image interpretationcriterions should be emphasized and a better training applied in the post-graduations courses.

Evaluation by digital subtraction radiography of induced changes in the bone density of the female rat mandible.

OBJECTIVES: To verify whether changes in bone mass induced by glucocorticoid and bisphosphonate can be detected by digital subtraction radiography of lateral X-rays in female rat mandibles. METHODS: 36 Rattus norvegicus (Wistar) females were randomly allocated to three groups: Group 1, control (n = 12); Group 2, induced osteopaenia (n = 12); and Group 3, induced osteopaenia plus risedronate (n = 12). Group 1 received subcutaneous saline solution (2 ml kg(-1)) injections for 12 weeks. Group 2 received 1 mg kg(-1) methylprednisolone acetate for 12 weeks. Group 3 received the same treatment as Group 2, plus 3 mg kg(-1) risedronate sodium for a further 12 weeks. A radiograph of the left mandible was taken on day 0 and after 12 weeks. A third radiograph was taken in Group 3 after risedronate treatment. Digital subtraction of the radiographs was used to compare the intensity of pixels in the control area and the test area. The animals were killed and the same area assessed by subtraction was histologically evaluated. RESULTS: ANOVA revealed statistically significant histological differences between the three groups. Tukey's multiple comparisons test showed that Group 2 had the smallest mean proportion of bone trabeculae per field and Group 3 the largest (F = 37.56; P < 0.01). Radiographic subtraction revealed a higher mean pixel intensity in Groups 1 and 3 vs Group 2. In Group 3, glucocorticoid caused a significant loss in radiographic density, and risedronate restored that loss (Friedman's non-parametric test). CONCLUSIONS: Subtraction radiography was able to detect changes in bone mass induced by glucocorticoid and bisphosphonate.

Optimal parameters for lateral oblique radiographs of rat mandibles.

OBJECTIVE: To establish optimal exposure parameters for lateral oblique radiographs of rat mandibles using an intraoral X-ray machine. METHODS: A positioning apparatus, previously tested for its reproducibility, was used to obtain radiographs of four heads of formaldehyde-preserved Wistar rats. Radiographs were exposed at 50 kV and 8 mA using four size 2 films (Insight, Ektaspeed Plus, Ultraspeed and D-Speed; Eastman Kodak Co., Rochester, NY), two focal distances (30 cm and 60 cm) and seven exposure times (0.6 s, 0.7 s, 0.8 s, 1.0 s, 1.5 s, 2.0 s and 2.5 s). The radiographs were evaluated by two examiners and scored for image quality: 1, very poor; 2, poor; 3, fair; 4, good; and 5, excellent. The evaluations were repeated at 30 days. RESULTS: Intraobserver reproducibility was substantial (kappa = 0.798 and 0.667). Also, the two examiners showed substantial agreement (kappa = 0.726). There was a significant difference (alpha = 1%) between the scores for the films under study. At a 30 cm distance, E-speed films had mean scores of 4 and 5 at 0.8 s and 1 s exposure times, and D-speed films, at 1.5 s, 2 s and 2.5 s exposure times. At a 60 cm distance, the best results were found for E-speed films at 2.0 s and 2.5 s exposure times. CONCLUSION: The films under study did not show any significant difference in the quality of rat mandible images as long as exposure times were adequate to their sensitivity and focal distance.

[A rare cause of myocarditis in a 30-year-old patient]. / Seltene Ursache einer Myokarditis bei einem 30-jährigen Patienten.

CASE REPORT: A 30-year-old male was admitted to hospital because of chest pain and raised cardiac enzymes. Coronary heart disease was excluded by coronary angiography. Assuming myocarditis serological testing was performed and showed markedly raised antibody titers against Coxiella Burnetii. We treated the patient with doxycycline, 2 times 100 mg daily for 5 months. CONCLUSION: Acute Q-fever should be considered as a possible cause of myocarditis, especially in rural areas.

Mechanical restitution and recirculation fraction in cardiac myocytes and left ventricular muscle of adult rats.

Unloaded cell shortening was measured in electrically stimulated myocytes from adult rat hearts to compare the contractile response to stimulation with that in isometrically contracting left ventricular papillary muscles under similar experimental conditions, but preloaded to produce maximum twitch tension. Mechanical restitution in cells followed a biexponential function with time constants of 0.19 +/- 0.03 s and 36.4 +/- 10.2 s (7 cells from 5 hearts, n = 7/5). The time constants for papillary muscles were 0.58 +/- 0.05 s and 14.6 +/- 1.0 s (n = 6/6). In myocytes, maximum post-rest potentiation occurred after 30 to 60 s of rest. The potentiation after 60 s of rest was 2.48 +/- 0.31 times the steadystate in cells and 2.63 +/- 0.16 in papillary muscles. Recirculation fraction of C2+ as calculated from the decay of post-rest potentiation was 0.84 +/- 0.04 in single cells and 0.59 +/- 0.02 in papillary muscles (p < 0.005). Caffeine (3mM) abolished post-rest potentiation in both types of preparations. The numerical values for the time constants of mechanical restitution, potentiation factor and recirculation fraction in papillary muscles did not depend on preload. It is concluded that interval-dependent changes of contractility are preserved in single cardiac cells but the kinetics of decay of potentiation appear to have changed quantitatively.

Pars plana vitrectomy for subfoveal macular hemorrhage and choroidal neovascular membranes.

1. Choroidal neovascular membranes (CNVM), the abnormal ingrowth of blood vessels from the choroid through Bruch's membrane, remain a major cause of treatable visual loss. 2. Laser photocoagulation is effective in destroying CNVM and preserving central vision in many affected patients. However, laser treatment of subfoveal CNVM irreversibly destroys foveal vision. 3. The utility of vitrectomy techniques for removal of subfoveal macular hemorrhage on CNVM remains unknown pending the results of a randomized, controlled prospective study. 4. Laser photocoagulation remains the treatment of choice for extra- and juxtafoveal CNVM caused by age-related macular degeneration (ARMD), ocular histoplasmosis and idiopathic causes, and for selected subfoveal CNVM caused by ARMD.

External argon laser choroidotomy versus needle drainage technique in primary scleral buckle procedures. A prospective randomized study.

PURPOSE: To compare the rates of intraoperative and postoperative complications of external argon laser choroidotomy and needle drainage techniques during scleral buckle procedures for primary retinal detachment. METHODS: A group of 175 patients undergoing scleral buckling for primary retinal detachment was randomly assigned to undergo either external argon laser choroidotomy or needle drainage. Complications associated with drainage of subretinal fluid were categorized as retinal break, retinal incarceration, or hemorrhage (dot, < or = 1 disc diameter [DD], or > 1 DD), and recorded during surgery and 24 hours after surgery. RESULTS: In the group that underwent laser choroidotomy, 12 (13%) of 92 patients had complications, including 4 dot hemorrhages, 3 hemorrhages 1 DD or smaller, 3 hemorrhages larger than 1 DD, 1 retinal incarceration, and 1 suprachoroidal hemorrhage. In the group that underwent needle drainage, 13 (16%) of 81 patients had complications, including 3 dot hemorrhages, 4 hemorrhages 1 DD or smaller, 5 hemorrhages larger than 1 DD, and 1 suprachoroidal hemorrhage. No significant difference was noted between the two groups in the incidence of complications (P = 0.657). CONCLUSION: External argon laser choroidotomy and needle choroidotomy are comparable, safe, and effective ways to drain subretinal fluid during scleral buckle surgery.

Choroidal malignant melanoma.

Choroidal nevi are found on routine fundus evaluations in 1% to 2% of patients. It is felt that these usually benign lesions are the precursors of choroidal malignant melanomas. The incidence of choroidal malignant melanoma in the United States is approximately 6 cases per 1 million persons per year. Diagnosis is multifactorial, based on the tumor's funduscopic, angiographic, and ultrasonographic appearance. Once a melanoma is diagnosed in a patient, a complete metastatic workup is performed. A small tumor is observed for change. Medium-sized tumors are treated with radioactive plaque therapy, external beam radiation, or enucleation. Large tumors are treated with enucleation with or without external beam radiation. Studies are underway to establish the optimum form of treatment.

Lenticular burns following argon panretinal photocoagulation.

Photocoagulation burns of the crystalline lens are a rare complication of posterior segment laser surgery. These burns occur more commonly in eyes with cataracts and with small, high-power, long-duration argon blue-green burns. We describe the first occurrence of lenticular burns caused by a fractured laser fibre optic cord.

Oculocutaneous manifestations observed in multisystem disorders.

Patients with multisystem disorders frequently present with or eventually manifest cutaneous disease. Many of these patients will also manifest ocular changes. In these disorders, the dermatologist or ophthalmologist may act as primary provider or consultant. Thus, familiarity with these conditions will enable the specialist to provide better care for these patients. This article reviews the oculocutaneous manifestations of sarcoidosis, Behçet's disease, Reiter's syndrome, and Sjögren's syndrome.

Retinal detachment and retinal holes in retinitis pigmentosa sine pigmento.

Retinal detachment and retinal holes in two family members with retinitis pigmentosa sine pigmento are reported. We believe these are the first such cases reported in the literature. We describe the presenting symptoms and management, including cryotherapy, scleral buckling procedure, and sulfur hexafluoride injection (SF6), resulting in stable visual acuity in one case and retinal reattachment and improved visual acuity in the other case.

Photocoagulation for serous detachment of the macula secondary to retinal astrocytoma.

Retinal astrocytomas are rare, usually asymptomatic, hamartomatous retinal tumors that are most commonly seen in patients with tuberous sclerosis. Serous detachment of the macula is a rare complication of retinal astrocytomas. The first successful treatment with laser photocoagulation of two eyes (two patients) with decreased vision due to a serous detachment of the macula from a retinal astrocytoma is described. Laser photocoagulation should be considered for retinal astrocytomas causing persistent or increasing exudation that is threatening the macula or causing visual loss.

Lacrimal outflow patency demonstrated by chemiluminescence.

A chemiluminescent material (Cyalume) was injected into the lacrimal excretory passages of eight normal monkeys (16 eyes). Patency was established by almost instantaneous observation of a yellowish-green glow in the nose and pharynx. No toxic effects of the chemical were noted in any of the monkeys.