Τετάρτη 28 Σεπτεμβρίου 2022

Evaluation of an Opt-Out Protocol for Antibiotic De-escalation in Patients with Suspected Sepsis: a multicenter randomized controlled trial

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Abstract
Background
Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. This randomized controlled trial evaluated an opt-out protocol to decrease unnecessary antibiotics in patients with suspected sepsis.
Methods
We evaluated non-ICU adults on broad-spectrum antibiotics despite negative blood cultures at ten U.S. hospitals from September 2018 through May 2020. A 23-item safety check excluded patients with ongoing signs of systemic infection, concerning or inadequate microbiologic data, or high-risk conditions. Eligible patients were randomized to the opt-out protocol vs. usual care. The primary outcome was 30-day post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted to encourage antibiotic discontinuation using opt-out language. If antibiotics were continued, clinicians discussed rationale for continuing antibiotics and de-escalation plans. To evaluate those with zero post-enrollment DOT, hurdle models provided two measures: 1) the odds ratio of antibiotic continuation and 2) ratio of mean DOT among those who continued antibiotics.
Results
Among 9606 patients screened, 767 (8%) were enrolled. Intervention patients had 32% lower odds of antibiotic continuation (79% vs. 84%, OR 0.68, 95% confidence interval (CI) [0.47, 0.98]). DOT among those who continued antibiotics were similar (ratio of means 1.06, 95% CI [0.88-1.26]). Few er intervention patients were exposed to extended-spectrum antibiotics (36% v. 44%. Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%). Thirty-day safety events were similar.
Conclusions
An antibiotic opt-out protocol targeting patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm.
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The effect of adjuvant radiotherapy on clinical outcomes in early major salivary gland cancer

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Abstract

Background

This study investigated the effects of adjuvant radiotherapy on outcomes in early-stage major salivary gland cancers.

Methods

A total of 655 patients were identified, including 355 (54.2%) received adjuvant radiotherapy and 300 (45.8%) had surgery alone. The effect of adjuvant radiotherapy on 5-year locoregional recurrence and disease-specific survival (DSS) was calculated using the Kaplan–Meier method, Wilcoxon rank sum test, and Cox proportional hazards model.

Results

There were no significant differences in locoregional recurrence and DSS between patients receiving adjuvant radiotherapy and those not in both univariate and multivariable analysis. Although patients with positive margin status had a higher locoregional recurrence and those with moderate/poor differentiation had a worse DSS, stratified analysis still indicated there were no protective effects from the use of adjuvant radiotherapy.

Conclusions

The use of adjuvant radiation therapy was not associated with improved locoregional recurrence and DSS, even for those with high-risk histopathological factors.

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Prolonged neutropenia is a risk of oral adverse events-related sepsis but is not associated with prognosis of tooth extraction in hematopoietic stem cell transplant recipients: a retrospective study

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Publication date: Available online 27 September 2022

Source: Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology

Author(s): Yasuyuki Shimada, Yuki Shiko, Akira Hangaishi, Yohei Kawasaki, Yutaka Maruoka

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Reconstruction of the Obliterated Eustachian Tube: A Pilot Case Series

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Reconstruction of the Obliterated Eustachian Tube: A Pilot Case Series

Complete occlusion of the cartilaginous ET can be associated with intractable mucoid effusion; endoscopic examination should be considered in such cases. In this pilot study, ET reconstruction was done and found to be a safe and possibly effective procedure in patients with total obliteration of the ET from various etiologies.


Objective

To investigate the safety and early efficacy of a procedure for reconstruction of the obliterated Eustachian tube (ET).

Study Design

Retrospective case series.

Methods

Patients with total obliteration of the cartilaginous ET, with intractable mucoid effusion causing repeated occlusion of tympanostomy tubes were included. Patients underwent endoscopic transnasal/transoral reconstruction of the obliterated ET using transtympanic illuminated guidewire guidance. A temporary stent (angiocatheter filled with bonewax) was placed to maintain patency while healing. In four cases an additional steroid-eluting propel stent was placed in the ET orifice. Main outcome measures were otomicroscopy results, absence of middle ear effusion, and nasopharyngoscopy showing patency of the ET orifice.

Results

Nine ETs (seven patients), ages 17–68 years (mean 37.9) underwent ET reconstruction. Follow-up ranged from 4 to 56 months (mean 30.9 months). 89% of operated ears had no effusion at last follow-up. Two patients (three Eustachian tubes) underwent successful reoperation. There were no complications directly related to the procedure. Etiologies of obliteration included scarring after sinus surgery, obstruction after maxillo-mandibular advancement surgery (two patients), bullous pemphigus, gunshot trauma, and previous patulous obliteration (two patients).

Conclusions

Complete occlusion of the cartilaginous ET can be associated with intractable mucoid effusion; endoscopic examination should be considered in such cases. In this pilot study, ET reconstruction was found to be a safe and possibly effective procedure in patients with total obliteration of the ET from various etiologies. Larger studies with long term follow up are indicated.

Level of Evidence

4 Laryngoscope, 2022

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The Effect of Subglottic Steroid injection on Blood Glucose in a Cohort of Patients With Subglottic Stenosis

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The Effect of Subglottic Steroid injection on Blood Glucose in a Cohort of Patients With Subglottic Stenosis

Intralesional subglottic steroid injections are commonly used for patients with subglottic stenosis. This prospective study shows that these injections have a transient effect on blood glucose that peaks at 1 day after the injection and normalizes within 72 h.


Objective

The objective of this work was to assess the effect of a single intralesional subglottic steroid injection on fasting blood glucose over 7 days in a cohort of patients with subglottic stenosis.

Methods

A prospective cohort study of patients undergoing intralesional steroid injections at a tertiary academic center. Patients had baseline bloodwork performed, including fasting blood glucose (FBG), and hemoglobin A1C levels. Demographic data and risk factors were collected. Fasting capillary glucose (FCG) was measured using a capillary glucometer and performed by patients daily from days 0 to 7 after a single injection of Triamcinolone into the subglottic airway. Data were analyzed using descriptive and comparative statistics.

Results

Eleven patients were enrolled, and 10 completed data collection over 7 days. All were female, with a mean age of 52.6 years (SD 17.5). Two patients were diabetic (non-insulin dependent). There was a statistically significant increase in FCG on day 1 post-injection (mean = 122.4 mg/dl compared to 100.7 mg/dl) that normalized for all patients within 24–72 h. The mean increase in FCG was 21.5% (SD 22.5%) of the initial value for the cohort. The diabetic group had statistically significant higher glucose values on day 1 compared to the non-diabetic group (146.5 mg/dl compared to 117.0 mg/dl).

Conclusion

A single subglottic steroid injection appears to cause a transient increase in FCG 1 day post injection, which resolves after 24–72 h and can be more pronounced in diabetic patients.

Level of Evidence

4 Laryngoscope, 2022

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Bone characteristics in condylar hyperplasia of the temporomandibular joint: a microcomputed tomography, histology, and Raman microspectrometry study

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Unilateral condylar hyperplasia (UCH) of the temporomandibular joint is a progressive deformation of the mandibular condyle of unknown origin. UCH is characterized by excessive growth of the condylar head and neck, leading to an increase in size and volume. The aim of this study was to investigate the characteristics of the bone in patients with UCH using microcomputed tomography (micro-CT), histology, and Raman microspectroscopy. The mandibular condyles of six patients with UCH were analysed using micro-CT, histology, and Raman microspectrometry and imaging, and the results were compared with those obtained for a normal control subject. (Source: International Journal of Oral and Maxillofacial Surgery)
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A complete digital approach for facially generated full arch diagnostic wax up, guided surgery, and implant‐supported interim prosthesis by integrating 3D facial scanning, intraoral scan, and CBCT

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Abstract

Continuous innovation in digital dental technology offers new prospects for creating a complete virtual environment. This technique described adds a facial approach to the conventional digital workflow by incorporating 3D face scans to cone beam computed tomography and intraoral scans. Thus, obtaining a complete virtual patient for facially generated diagnostic wax up and planning to implement a predictable implant placement and interim prosthesis. It provides a full digital workflow by restoratively driven computer-aided implant planning, guided surgery, and 3D printing of an interim complete-arch fixed implant-supported prosthesis.

This article is protected by copyright. All rights reserved

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Pterygoid muscle activity in speech: a preliminary investigation

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Abstract

Background

Speaking depends on refined control of jaw opening and closing movements. The medial pterygoid muscle (MPT), involved in jaw closing, and the lateral pterygoid muscle (LPT), involved in jaw opening, are two key mandibular muscles in mastication and are likely to be recruited for controlled movements in speech.

Objectives

Three hypotheses were investigated, that during speech the MPT and LPT: (1) are both active, (2) but exhibit different patterns of activity, (3) which fluctuate with the vowels and consonants in speech.

Methods

Intramuscular EMG recordings were made from the right inferior head of the LPT and/or the right MPT in five participants during production of 40 target nonsense words (NWs) consisting of three syllables in the form /V1 C 1 V 2 C2ə/ (V = vowel; C = consonant; ə = unstressed, reduced vowel), spoken by each participant 10 times per NW; analysis focussed on the target syllable, C 1 V 2 .

Results

Both MPT and LPT exhibited robust increases in EMG activity during utterance of most NWs, relative to rest. Peak LPT activation was time-locked to the final part of the target consonant (C1) interval when the jaw begins opening for the target vowel (V2), whereas peak MPT activation occurred around the temporal midpoint of V2, when the jaw begins closing for C2. EMG amplitude peaks differed in magnitude between "high" vowels, i.e., for which the tongue/jaw are high (e.g., in S EE K), and "low" vowels, i.e., for which the tongue/jaw are low (e.g., in S O CK).

Conclusion

These novel findings suggest a key role for the LPT and MPT in the fine control of speech production. They imply that speech may impose major synergistic demands on the activities of the MPT and the LPT, and thereby provide insights into the possible interactions between speech activities and orofacial activities (e.g. mastication) and conditions (e.g. Temporomandibular Disorders) that involve the masticatory muscles.

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Paediatric mandibular distraction: optimizing outcomes

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imagePurpose of review The purpose of this review is to summarize current evidence surrounding the use of mandibular distraction osteogenesis in children and to highlight recent advances in our knowledge of this subject. Recent findings Distraction osteogenesis of the mandible has gained in popularity since its initial description about 30 years ago. Its efficacy and safety have been well described. More recently, proper patient selection, technique modifications and long-term outcomes have been the subject of much discussion around this revolutionary technique. Summary Distraction osteogenesis of the mandible is a powerful tool for surgeons. Technological advances and high-quality research have allowed for optimization of this technique within the field of craniomaxillofacial surgery.
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Evaluation and management of paediatric vertigo

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imagePurpose of review This review summarizes the most current information on cause, evaluation and treatment of dizziness in children. Recent findings There has been an increased understanding of the multifactorial cause of dizziness in the paediatric population. Quantitative vestibular testing is increasingly used and valuable as a diagnostic adjunct. Vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals and/or surgery can be used as well tolerated and effective treatments for vertigo in children and adolescents when tailored to cause. Summary Paediatric vertigo can be effectively evaluated through careful history taking and physical examination along with adjunctive tests, such as vestibular testing and audiometry, when appropriate. Options for treatment of vestibular disorders in children and adolescents have greatly expanded in recent years allowing for the effective management of nearly all cases of paediatric vertigo, though a multimodal and/or multidisciplinary approach is often needed.
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