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19
JUL
2018

StatPearls

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StatPearls

Book. 2018 01

Authors:

Abstract
Basic airway management in both the pediatric and adult populations includes assessing and managing airway patency, oxygen delivery, and ventilation. All efforts should be taken to maintain a patient’s airway via non-invasive methodology unless indications for invasive airway management are apparent. Non-invasive airway supplementation includes passive oxygenation (nasal cannula, non-rebreather, among others), bag-valve-mask (BVM), non-invasive positive pressure ventilation (BVM with positive-pressure valve, CPAP, BIPAP), and supraglottic airways (King Tube, LMA. among others). Invasive airway management involves establishing a secure airway and placing patients on a ventilator via intubation (nasal or endotracheal), needle jet ventilation (in pediatric patients younger than 8 years old, cricothyroidotomy in pediatric patients older than 8 years old, and adults), and tracheostomy. Proper airway management begins by looking at the patient visually for trauma, obesity, cervical collar, macroglossia, among other factors to determine the type of airway approach best suited for each patient. Most important is positioning via the head tilt-chin lift maneuver, which involves extending the patient’s neck by putting one hand on the forehead and the other hand on the neck to allow for the extension of the head in relation to the neck. This maneuver puts the patient into sniffing position, with the nose pointed upward and forward. Then a chin lift can be performed by taking the hand from underneath the neck to underneath the chin (mandible) and lifting the mandible until the teeth barely touch. Another airway positioning method involves the jaw thrust maneuver, which is safer in potential cervical spinal cord injury patients. This method involves maintaining the spine in a neutral position and grabbing the sides of the angle of the mandible and lifting it forward to lift the jaw and open the airway. There are some differences between the pediatric and adult populations. For example, the large occiput of the pre-pubescent pediatric patient can lead to too much flexion of the neck and can cause tracheal obstruction. This is addressed by utilizing the head tilt-chin lift maneuver, but care must be taken to avoid overextension in the pediatric population as it can cause airway obstruction due to a weak trachea in the pediatric patient. However, the head tilt-chin lift may not be adequate to maintain a patent airway, and the jaw thrust maneuver may need to be employed to prevent the pediatric, large, floppy tongue from obstructing the airway. Once properly positioned, the rescuer has the best shot at delivering effective breaths either via mouth to mouth or BVM. If there is continued difficulty at delivering breaths, then airway adjuncts like an oral pharyngeal airway (OPA) device or nasopharyngeal airway (NPA) can be useful for maintaining a patent airway to allow delivery of breaths in an unresponsive patient. NPA devices can be useful at maintaining the airway in an awake patient as well, which is beneficial if intubation is not the goal, intubation needs to be delayed, or an awake intubation is necessary. NPA devices are plastic hollow or soft rubber tubes that a healthcare provider can utilize to help with patient oxygenation and ventilation when the patient is difficult to oxygenate or ventilate via BVM, for example. NPAs are passed into the nose and pass through to the posterior pharynx. NPAs do not cause patients to gag and are, therefore, the best airway adjunct route in an awake patient and the better choice in a semiconscious patient that may not tolerate an OPA due to the gag reflex. NPAs are also helpful when a patient's mouth is difficult to open, for example, if there are angioedema, trismus, or other factors. While NPAs are airway adjuncts for difficult patient ventilation and oxygenation, they only act as a bridge to either an eventually stabilized patient that is breathing without aid or a patient that requires a secure airway via endotracheal or nasotracheal (NT) intubation. The NT route for intubation was the preferred route among critical care and emergency physicians up until several decades ago. However, today, the majority of clinicians prefer the endotracheal route for intubation as it has been shown to have better results and fewer complications. Some of the complications of NT intubation include sinusitis, nasal structure destruction due to localized pressure and decreased perfusion of nasal cartilage, and local abscesses. Furthermore, NT intubation requires narrow tubes making pulmonary toilet very difficult due to the increased airway resistance. However, there are clear advantages to NT intubation. NT intubation can be performed in the sitting position, which is valuable, especially in the pre-hospital setting when needing to intubate a patient in acutely decompensated heart failure that cannot lay flat. Other advantages include the patient’s inability to bite or manipulate the tube, better patient tolerance, decrease salivation, and better access to patient oral care. In addition, the NT tube is much more stable as it has the entire nasal tract holding it in place versus the endotracheal tube that flops out the mouth and can easily dislodge or become right mainstemmed. NT intubation can be performed blind or with a flexible bronchoscope. Blind NT intubation is difficult and requires expertise and skill. However, when indicated, can be a very useful skill both in the prehospital and hospital setting. Blind NT intubation decreases the need for neck movement and mouth opening, but can only be done in the awake and ventilating patient. NT intubation via a flexible bronchoscope also requires lots of expertise and skill, and it is useless if there is blood, vomitus, or fluid that will obscure the bronchoscopes camera.


PMID: 30020592

19
JUL
2018

Are metals involved in tattoo-related hypersensitivity reactions? A case report.

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Are metals involved in tattoo-related hypersensitivity reactions? A case report.

Contact Dermatitis. 2017 Dec;77(6):397-405

Authors: de Cuyper C, Lodewick E, Schreiver I, Hesse B, Seim C, Castillo-Michel H, Laux P, Luch A

Abstract
BACKGROUND: Allergic reactions to tattoos are not uncommon. However, identification of the culprit allergen(s) remains challenging.
OBJECTIVES: We present a patient with papulo-nodular infiltration of 20-year-old tattoos associated with systemic symptoms that disappeared within a week after surgical removal of metal osteosynthesis implants from his spine. We aimed to explore the causal relationship between the metal implants and the patient's clinical presentation.
METHODS: Metal implants and a skin biopsy of a reactive tattoo were analysed for elemental contents by inductively coupled plasma mass spectrometry and synchrotron-based X-ray fluorescence (XRF) spectroscopy.
RESULTS: Nickel (Ni) and chromium (Cr) as well as high levels of titanium (Ti) and aluminium were detected in both the skin biopsy and the implants. XRF analyses identified Cr(III), with Cr(VI) being absent. Patch testing gave negative results for Ni and Cr. However, patch tests with an extract of the implants and metallic Ti on the tattooed skin evoked flare-up of the symptoms.
CONCLUSION: The patient's hypersensitivity reaction and its spontaneous remission after removal of the implants indicate that Ti, possibly along with some of the other metals detected, could have played a major role in this particular case of tattoo-related allergy.

PMID: 28795428 [PubMed - indexed for MEDLINE]

19
JUL
2018

Apolipoprotein E epsilon 4 (APOE-?4) genotype is associated with decreased 6-month verbal memory performance after mild traumatic brain injury.

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Apolipoprotein E epsilon 4 (APOE-?4) genotype is associated with decreased 6-month verbal memory performance after mild traumatic brain injury.

Brain Behav. 2017 Sep;7(9):e00791

Authors: Yue JK, Robinson CK, Burke JF, Winkler EA, Deng H, Cnossen MC, Lingsma HF, Ferguson AR, McAllister TW, Rosand J, Burchard EG, Sorani MD, Sharma S, Nielson JL, Satris GG, Talbott JF, Tarapore PE, Korley FK, Wang KKW, Yuh EL, Mukherjee P, Diaz-Arrastia R, Valadka AB, Okonkwo DO, Manley GT, TRACK?TBI Investigators

Abstract
INTRODUCTION: The apolipoprotein E (APOE) ?4 allele associates with memory impairment in neurodegenerative diseases. Its association with memory after mild traumatic brain injury (mTBI) is unclear.
METHODS: mTBI patients (Glasgow Coma Scale score 13-15, no neurosurgical intervention, extracranial Abbreviated Injury Scale score ?1) aged ?18 years with APOE genotyping results were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study. Cohorts determined by APOE-?4(+/-) were assessed for associations with 6-month verbal memory, measured by California Verbal Learning Test, Second Edition (CVLT-II) subscales: Immediate Recall Trials 1-5 (IRT), Short-Delay Free Recall (SDFR), Short-Delay Cued Recall (SDCR), Long-Delay Free Recall (LDFR), and Long-Delay Cued Recall (LDCR). Multivariable regression controlled for demographic factors, seizure history, loss of consciousness, posttraumatic amnesia, and acute intracranial pathology on computed tomography (CT).
RESULTS: In 114 mTBI patients (APOE-?4(-)=79; APOE-?4(+)=35), ApoE-?4(+) was associated with long-delay verbal memory deficits (LDFR: B = -1.17 points, 95% CI [-2.33, -0.01], p = .049; LDCR: B = -1.58 [-2.63, -0.52], p = .004), and a marginal decrease on SDCR (B = -1.02 [-2.05, 0.00], p = .050). CT pathology was the strongest predictor of decreased verbal memory (IRT: B = -8.49, SDFR: B = -2.50, SDCR: B = -1.85, LDFR: B = -2.61, LDCR: B = -2.60; p < .001). Seizure history was associated with decreased short-term memory (SDFR: B = -1.32, p = .037; SDCR: B = -1.44, p = .038).
CONCLUSION: The APOE-?4 allele may confer an increased risk of impairment of 6-month verbal memory for patients suffering mTBI, with implications for heightened surveillance and targeted therapies. Acute intracranial pathology remains the driver of decreased verbal memory performance at 6 months after mTBI.

PMID: 28948085 [PubMed - indexed for MEDLINE]

19
JUL
2018

Predictors of symptomatic myelopathy in degenerative cervical spinal cord compression.

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Predictors of symptomatic myelopathy in degenerative cervical spinal cord compression.

Brain Behav. 2017 Sep;7(9):e00797

Authors: Kadanka Z, Adamova B, Kerkovsky M, Kadanka Z, Dusek L, Jurova B, Vlckova E, Bednarik J

Abstract
OBJECTIVES: To update a previously established list of predictors for neurological cervical cord dysfunction in nonmyelopathic degenerative cervical cord compression (NMDCCC).
MATERIAL AND METHODS: A prospective observational follow-up study was performed in a cohort of 112 consecutive NMDCCC subjects (55 women and 57 men; median age 59 years, range 40-79 years), either asymptomatic (40 subjects) or presenting with cervical radiculopathy or cervical pain (72 subjects), who had completed a follow-up of at least 2 years (median duration 3 years). Development of clinical signs of degenerative cervical myelopathy (DCM) as the main outcome was monitored and correlated with a large number of demographic, clinical, electrophysiological, and MRI parameters including diffusion tensor imaging characteristics (DTI) established at entry.
RESULTS: Clinical evidence of the first signs and symptoms of DCM were found in 15 patients (13.4%). Development of DCM was associated with several parameters, including the clinical (radiculopathy, prolonged gait and run-time), electrophysiological (SEP, MEP and EMG signs of cervical cord dysfunction), and MRI (anteroposterior diameter of the cervical cord and cervical canal, cross-sectional area, compression ratio, type of compression, T2 hyperintensity). DTI parameters showed no significant predictive power. Multivariate analysis showed that radiculopathy, cross-sectional area (CSA) ? 70.1 mm2, and compression ratio (CR) ? 0.4 were the only independent significant predictors for progression into symptomatic myelopathy.
CONCLUSIONS: In addition to previously described independent predictors of DCM development (radiculopathy and electrophysiological dysfunction of cervical cord), MRI parameters, namely CSA and CR, should also be considered as significant predictors for development of DCM.

PMID: 28948090 [PubMed - indexed for MEDLINE]

19
JUL
2018

Effects of forced, passive, and voluntary exercise on spinal motoneurons changes after peripheral nerve injury.

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Effects of forced, passive, and voluntary exercise on spinal motoneurons changes after peripheral nerve injury.

Eur J Neurosci. 2017 Dec;46(12):2885-2892

Authors: Arbat-Plana A, Navarro X, Udina E

Abstract
After peripheral nerve injury, there are important changes at the spinal level that can lead to disorganization of the central circuitry and thus compromise functional recovery even if axons are able to successfully regenerate and reinnervate their target organs. Physical rehabilitation is a promising strategy to modulate these plastic changes and thus to improve functional recovery after the damage of the nervous system. Forced exercise in a treadmill is able to partially reverse the synaptic stripping and the loss of perineuronal nets that motoneurons suffer after peripheral nerve injury in animal models. The aim of this study was to investigate whether passive exercise, by means of cycling in a motorized bicycle, or voluntary free running in a wheel is able to mimic the effects induced by forced exercise on the changes that axotomized motoneurons suffer after peripheral nerve injury. Partial preservation of synapses and perineuronal nets was observed only in axotomized motoneurons from animals subjected to high-intensity cycling and the ones that freely ran long distances, but not when low-intensity exercise protocols were applied. Therefore, the intensity but not the type of exercise used is the key element to prevent synaptic stripping and loss of perineuronal nets in motoneurons after axotomy.

PMID: 29044770 [PubMed - indexed for MEDLINE]

19
JUL
2018

Granulocyte Colony-Stimulating Factor (G-CSF) for the Treatment of Spinal Cord Injury.

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Granulocyte Colony-Stimulating Factor (G-CSF) for the Treatment of Spinal Cord Injury.

CNS Drugs. 2017 Nov;31(11):911-937

Authors: Khorasanizadeh M, Eskian M, Vaccaro AR, Rahimi-Movaghar V

Abstract
Spinal cord injury (SCI) is a common medical condition with a poor prognosis for recovery and catastrophic effects on a patient's quality of life. Available treatments for SCI are limited, and the evidence suggesting their harmful side effects is more consistent than any suggestion of clinical benefit. Developing novel safe and effective therapeutic options for SCI is crucial. Granulocyte colony-stimulating factor (G-CSF) is a hematopoietic cytokine with known multifaceted effects on the central nervous system. Herein, we review the accumulating preclinical evidence for the beneficial effects of G-CSF on functional and structural outcomes after SCI. Meanwhile we present and discuss multiple mechanisms for G-CSF's neuroprotective and neuroregenerative actions through the results of these studies. In addition, we present the available clinical evidence indicating the efficacy and safety of G-CSF administration for the treatment of acute and chronic traumatic SCI, compression myelopathy, and SCI-associated neuropathic pain. Our review indicates that although the quality of clinical evidence regarding the use of G-CSF in SCI is inadequate, the encouraging available preclinical and clinical data warrant its further clinical development, and bring new hope to the longstanding challenge that is treatment of SCI.

PMID: 29063471 [PubMed - indexed for MEDLINE]

19
JUL
2018

The Stanmore Nursing Assessment of Psychological Status (SNAPS): not just for spinal cord injury rehabilitation?

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The Stanmore Nursing Assessment of Psychological Status (SNAPS): not just for spinal cord injury rehabilitation?

Pain Manag. 2018 Jan;8(1):5-8

Authors: Ikkos G, Gall A, Smyth C

Abstract
Spinal cord injury is an uncommon condition, potentially causing a wide range of consequences and requiring specialist rehabilitation to optimize health, activity and participation. Early psychological response to injury and relations with staff, as well as family, may set the foundations for long-term emotional adjustment, healthcare utilization and quality of life. The Stanmore Nursing Assessment of Psychological Status has been developed at the London Spinal Cord Injury Centre to empower nurses to adopt a consistently empathic approach to patient care, as part of a comprehensive range of rehabilitation team skills. Its use in other spinal cord injury centers and a broader range of clinical environments (hospital and community) should therefore be considered.

PMID: 29182036 [PubMed - indexed for MEDLINE]

19
JUL
2018

Lentivirus-mediated silencing of the PTC1 and PTC2 genes promotes recovery from spinal cord injury by activating the Hedgehog signaling pathway in a rat model.

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Lentivirus-mediated silencing of the PTC1 and PTC2 genes promotes recovery from spinal cord injury by activating the Hedgehog signaling pathway in a rat model.

Exp Mol Med. 2017 Dec 15;49(12):e412

Authors: Zhang YD, Zhu ZS, Zhang D, Zhang Z, Ma B, Zhao SC, Xue F

Abstract
This study aimed to investigate the effect of Patched-1 (PTC1) and PTC2 silencing in a rat model, on Hedgehog (Hh) pathway-mediated recovery from spinal cord injury (SCI). An analytical emphasis on the relationship between the sonic hedgehog (Shh) pathway and nerve regeneration was explored. A total of 126 rats were divided into normal, sham, SCI, negative control (NC), PTC1-RNAi, PTC2-RNAi and PTC1/PTC2-RNAi groups. The Basso, Beattie and Bresnahan (BBB) scale was employed to assess hind limb motor function. Quantitative real-time polymerase chain reaction and western blotting were performed to examine the mRNA and protein levels of PTC1, PTC2, Shh, glioma-associated oncogene homolog 1 (Gli-1), Smo and Nestin. Tissue morphology was analyzed using immunohistochemistry, and immunofluorescent staining was conducted to detect neurofilament protein 200 (NF-200) and glial fibrillary acidic protein (GFAP). The PTC1/PTC2-RNAi group displayed higher BBB scores than the SCI and NC groups. Shh, Gli-1, Smo and Nestin expression levels were elevated in the PTC1/PTC2-RNAi group. PTC1 and PTC2 mRNA and protein expression was lower in the PTC1/PTC2-RNAi group than in the normal, sham and SCI groups. Among the seven groups, the PTC1/PTC2-RNAi group had the largest positive area of NF-200 staining, whereas the SCI group exhibited a larger GFAP-positive area than both the normal and the sham groups. The Shh pathway may provide new insights into therapeutic indications and regenerative recovery tools for the treatment of SCI. Activation of the Hh signaling pathway by silencing PTC1 and PTC2 may reduce inflammation and may ultimately promote SCI recovery.

PMID: 29244790 [PubMed - indexed for MEDLINE]

19
JUL
2018

The use of the DTO™ hybrid dynamic device: a clinical outcome- and radiological-based prospective clinical trial.

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The use of the DTO™ hybrid dynamic device: a clinical outcome- and radiological-based prospective clinical trial.

BMC Musculoskelet Disord. 2018 Jun 21;19(1):199

Authors: Herren C, Sobottke R, Pishnamaz M, Scheyerer MJ, Bredow J, Westermann L, Berger EM, Oikonomidis S, Eysel P, Siewe J

Abstract
BACKGROUND: The purpose of this study was to assess the radiological and clinical outcome parameters following lumbar hybrid dynamic instrumentation with the focus on the adjacent segment degeneration (ASD) and adjacent segment disease (ASDi).
METHODS: In this prospective trial all patients presenting with degenerative changes to the lumbar spine have been included. Precondition was a stable adjacent level with/without degenerative alteration. The elected patients underwent a standardised fusion procedure with hybrid instrumentation (DTO™, Zimmer Spine Inc., Denver, USA). Patients' demographics have been documented and the follow-up visits were conducted after 6 weeks, and then stepwise after 6 up to 48 months. Each follow-up visit included assessment of quality of life and pain using specific questionnaires (COMI, SF-36, ODI) and the radiological evaluation with focus on the adjacent level alterations.
RESULTS: At a mean follow up of 24 months an incidence of ASD with 10.91% and for ASDi with 18.18% has been observed. In 9% a conversion to standardised fusion was needed. There was a high rate of mechanical complication: (1) screw loosening (52.73%), (2) pedicle screw breakage (10.91%), and (3) rod breakage (3.64%) after a follow up of a maximum of 60 months. There were no significant difference of COMI, ODI and SF-36(v2) in comparison to all groups but all 55 patients showed a clinical improvement over the time.
CONCLUSION: The dynamic hybrid DTO™ device is comparable to the long-term results after standardised fusion procedure, while a high rate of mechanical complication decreased the initial benefit.
TRIAL REGISTRATION: This trial was registered at the ClinicalTrials Register ( #NCT03404232 , 2018/01/18, registered retrospectively).

PMID: 30016956 [PubMed - in process]

19
JUL
2018

Designing patient-specific 3D printed devices for posterior atlantoaxial transarticular fixation surgery.

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Designing patient-specific 3D printed devices for posterior atlantoaxial transarticular fixation surgery.

J Clin Neurosci. 2018 Jul 13;:

Authors: Thayaparan GK, Owbridge MG, Thompson RG, D'Urso PS

Abstract
Atlantoaxial transarticular screw fixation is an effective technique for arthrodesis. Surgical accuracy is critical due to the unique anatomy of the atlantoaxial region. Intraoperative aids such as computer-assisted navigation and drilling templates offer trajectory guidance but do not eliminate screw malposition. This study reports the operative and clinical performance of a novel process utilising biomodelling and 3D printing to develop patient specific solutions for posterior transarticular atlantoaxial fixation surgery. Software models and 3D printed 1:1 scale biomodels of the patient's bony atlantoaxial spine were developed from computed tomography data for surgical planning. The surgeon collaborated with a local medical device manufacturer using AnatomicsC3D to design patient specific titanium posterior atlantoaxial fixation implants using transarticular and posterior C1 arch screws. Software enabled the surgeon to specify screw trajectories, screw sizes, and simulate corrected atlantoaxial alignment allowing patient specific stereotactic drill guides and titanium posterior fixation implants to be manufactured using 3D printing. Three female patients with unilateral atlantoaxial osteoarthritis were treated using patient specific implants. Transarticular screws were placed using a percutaneous technique with fluoroscopy and neural monitoring. No screw malposition and no neural or vascular injuries were observed. Average operating and fluoroscopy times were 126.0?±?4.1?min and 36.7?±?11.5?s respectively. Blood loss was <50?ml per patient and length of stay was 4-6?days. Clinical and radiographic follow up data indicate satisfactory outcomes in all patients. This study demonstrates a safe, accurate, efficient, and relatively inexpensive process to stabilise the atlantoaxial spine using transarticular screws.

PMID: 30017594 [PubMed - as supplied by publisher]