Postoperative analgesic effect, of preoperatively administered dexamethasone, after operative fixation of fractured neck of femur: randomised, double blinded controlled study.

Background: Fractured neck of femur is a common cause of hospital admission in the elderly and usually requires operative fixation. In a variety of clinical settings, preoperative glucocorticoid administration has improved analgesia and decreased opioid consumption. Our objective was to define the postoperative analgesic efficacy of single dose of dexamethasone administered preoperatively in patients undergoing operative fixation of fractured neck of femur. Methods: Institutional ethical approval was granted and written informed consent was obtained from each patient. Patients awaiting for surgery at Cork University Hospital were recruited between July 2009 and August 2012. Participating patients, scheduled for surgery were randomly allocated to one of two groups (Dexamethasone or Placebo). Patients in the dexamethasone group received a single dose of intravenous dexamethasone 0.1 mg kg -1 immediately preoperatively. Patients in the placebo group received the same volume of normal saline. Patients underwent operative fixation of fractured neck of femur using standardised spinal anaesthesia and surgical techniques. The primary outcome was pain scores at rest 6 h after the surgery. Results: Thirty seven patients were recruited and data from thirty patients were analysed. The groups were similar in terms of patient characteristics. Pain scores at rest 6 h after the surgery (the principal outcome) were lesser in the dexamethasone group compared with the placebo group [0.8(1.3) vs. 3.9(2.9), mean(SD) p = 0.0004]. Cumulative morphine consumption 24 h after the surgery was also lesser in the dexamethasone group [7.7(8.3) vs. 15.1(9.4), mean(SD) mg, p = 0.04]. Conclusions: A single dose of intravenous dexamethasone 0.1 mg kg -1 administered before operative fixation of fractured neck of femur improve significantly the early postoperative analgesia. Trial registration: ClinicalTrials.gov identifier: NCT01550146, date of registration: 07/03/2012

AN INVESTIGATION ON ROUTINE FOLLOW-UP CARE FOR HEAD AND NECK CANCER

BACKGROUND: Follow-up care aims to provide surveillance with early detection of recurring cancers and to address treatment complications and other health issues in survivorship. It is assumed that follow-up care fulfills these aims, however little evidence supports routine surveillance detecting curable disease early enough to improve survival. Cancer survivors are a diverse patient population, suggesting that a single follow-up regimen may not meet all patients’ follow-up needs. Little is known about what effective follow-up care should include for head and neck cancer patients in a Canadian setting. Identification of subgroups of patients with specific needs and current practices would allow for hypotheses to be generated for enhancing follow-up care. OBJECTIVES: 1a) To describe the follow-up needs and preferences of head and neck cancer patients, 1b) to identify which patient characteristics predict needs and preferences, 1c) to evaluate how needs and preferences change over time, 2a) to describe follow-up care practices by physician visits and imaging tests, and 2b) to identify factors associated to the delivered follow-up care. METHODS: 1) 175 patients who completed treatment between 2012 and 2013 in Kingston and London, Ontario were recruited to participate in a prospective survey study on patients’ needs and preferences in follow-up care. Bivariate and multivariate analyses were employed to describe patient survey responses and to identify patient characteristics that predicted needs and preferences. 2) A retrospective cohort study of 3975 patients on routine follow-up from 2007 to 2015 was carried out using data linkages across registry and administrative databases to describe follow-up practices in Ontario by visits and tests. Multivariate regression analyses assessed factors related to follow-up care. RESULTS: 1) Patients’ needs and preferences were wide-ranging with several characteristics predicting needs and preferences (ORECOG=2.69 and ORAnxiety=1.13). Needs and preferences declined as patients transitioned into their second year of follow-up (p<0.05). 2) Wide variation in practices was found, with marked differences compared to existing consensus guidelines. Multiple factors were associated with follow-up practices (RRTumor site=0.73 and RRLHIN=1.47). CONCLUSIONS: Patient characteristics can be used to personalize care and guidelines are not informing practice. Future research should evaluate individualized approaches to follow-up care.

The Role of Perceived Social Support, Resilience, and Depression on Communicative Participation in Head and Neck Cancer Survivors

Thesis (Master's)--University of Washington, 2016-08

Assurance qualité en dissection virtuelle des faisceaux de la matière blanche par tractographie

Ce mémoire est divisé en quatre chapitres. D’abord, une introduction initie le lecteur au domaine des neurosciences. Ensuite, le chapitre 1 décrit les étapes de la dissection virtuelle par tractographie, à partir du phénomène physique de la diffusion jusqu’aux mesures statistiques des structures de la matière blanche. Le chapitre 2 présentera une nouvelle méthode d’assurance qualité, basée sur l’analyse volumique des faisceaux de la matière blanche, la contribution principale de ce mémoire. Finalement, la conclusion contient une discussion des problématiques non résolues ainsi que des perspectives d’avenir pour la tractographie.

Sternoclavicular Septic Arthritis Caused by Acupuncture over the Posterior Neck

Acupuncture has been used therapeutically for thousands of years and is considered a relatively safe procedure. Sternoclavicular joint (SCJ) arthritis is a rare joint infection and has never been reported as an adverse event of acupuncture. We report the case of a 50-year-old woman who presented with progressive left neck, shoulder and upper chest pain after acupuncture. A computerized tomography (CT) scan revealed septic arthritis over the left sternoclavicular joint (SCJ) and methicillin-sensitive Staphylococcus aureus bacteraemia was noted. The patient was discharged uneventfully after intravenous antibiotic treatment. SCJ septic arthritis should be considered if unilateral neck and upper chest pain occurs after acupuncture.

Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome.

Embolisation of Vertebral Artery Damaged Following Cervical Disc Removal

Introduction: The incidence of vertebral artery (VA) injury during cervical spine surgery is rare. Even though tamponade is effective in many cases, early consultation of an endovascular team is recommended if bleeding cannot be controlled. We report a case of emergent endovascular embolisation of left VA due to iatrogenic injury during anterior cervical disc removal and fusion. Case: A 47-year-old woman was admitted to our emergency department with serious arterial bleeding from the neck only hours after undergoing anterior cervical disc removal and fusion surgery. She was intubated and mechanically ventilated, however hemorrhage could not be successfully controlled by packing with surgical hemostatic agents. Cranial computed tomography, computed tomography of the cervical spine and CT angiography confirmed the suspected diagnosis of injury to the VA. Emergent endovascular embolisation successfully stopped the bleeding. Occlusion of the vessel was achieved by vascular plugging. The patient was discharged from our hospital 14 days after the intervention, receiving a revision surgery of the cervical spine on the day of embolisation. At the date of discharge she presented without any focal neurological deficit. Conclusion: Pre-operative radiographic imaging of the cervical spine should be used routinely to identify anatomic abnormalities of the vertebral arteries. Endovascular embolisation appears to be effective in treating acute iatrogenic dissection of the vertebral arteries.

CAREGIVING FOR A FAMILY MEMBER WITH HEAD AND NECK CANCER

Objective: To know the perception of informal caregivers regarding the care for a family member with head and neck cancer. Methods: Qualitative study conducted between March and May 2014 in the radiotherapy outpatient center of the Centro de Alta Complexidade em Oncologia – CACON (Oncology High Complexity Center) of the Hospital Universitário de Brasília – HUB (University Hospital of Brasília) using semi-structured interviews with nine caregivers about the experience of caring for family members. Data underwent Content Analysis and four units of meaning were identified: “Representation of cancer in the Family”, “The care as debt, individual reward or reconstruction of family ties”, “Repercussions of cancer on the caregiver’s personal life” and “Social support and network used by caregivers”. Results: Feelings of sadness and surprise at the moment of diagnosis were attributed to cancer, as well as the idea of punishment. The care was seen as personal satisfaction, accomplishment and opportunity for family rapprochement. Work overload and change in routine were altered functions. Religiosity, exchange of experience in the waiting room and institutional support appeared as coping strategies. Conclusion: The experience of caring for family members with head and neck cancer directly interferes in the lives of caregivers. Pointing out the institutional embracement as a strategy within the social network reinforces the importance of integrating the caregivers as a significant part of the health care plan developed by the health team.

Computed Tomography Perfusion Can Guide Endovascular Therapy in Bilateral Carotid Artery Dissection

Carotid artery dissection (CAD) is a major cause of stroke in those under age 45, accounting for around 20% of ischaemic events[1,2]. In the absence of known connective tissue disorders, most dissections are traumatic[2]. First-line management is comprised of antiplatelet or anticoagulation therapy, but many traumatic dissections progress despite this and carry the risk of long-term complications from embolism or stenosis[3]. We report a case of traumatic bilateral carotid dissection leading to progressive neurological symptoms and hypoperfusion on computed tomography perfusion (CTP), despite escalation in anticoagulation, which led to emergency carotid stenting.

From genes to radioresistance in head and neck squamous cell carcinoma

Head and Neck Cancers (HNC) are a group of tumours located in the upper aero-digestive tract. Head and Neck Squamous Cell Carcinoma (HNSCC) represent about 90% of all HNC cases. It has been considered the sixth most malignant tumour worldwide and, despite clinical and technological advances, the five-year survival rate has not improved much in the last years. Nowadays, HNSCC is well established as a heterogeneous disease and that its development is due to accumulation of genetic events. Apart from the majority of the patients being diagnosed in an advanced stage, HNSCC is also a disease with poor therapeutic outcome. One of the therapeutic approaches is radiotherapy. However, this approach has different drawbacks like the radioresistance acquired by some tumour cells, leading to a worse prognosis. A major knowledge in radiation biology is imperative to improve this type of treatment and avoid late toxicities, maintaining patient quality of life in the subsequent years after treatment. Then, identification of genetic markers associated to radiotherapy response in patients and possible alterations in cells after radiotherapy are essential steps towards an improved diagnosis, higher survival rate and a better life quality. Not much is known about the radiation effects on cells, so, the principal aim of this study was to contribute to a more extensive knowledge about radiation treatment in HNSCC. For this, two commercial cell lines, HSC-3 and BICR-10, were used and characterized resorting to karyotyping, aCGH and MS-MLPA. These cell lines were submitted to different doses of irradiation and the resulting genetic and methylation alterations were evaluated. Our results showed a great difference in radiation response between the two cell lines, allowing the conclusion that HSC-3 was much more radiosensitive than BICR-10. Bearing this in mind, analysis of cell death, cell cycle and DNA damages was performed to try to elucidate the motifs behind this difference. The characterization of both cell lines allowed the confirmation that HSC-3 was derived from a metastatic tumour and the hypothesis that BICR-10 was derived from a dysplasia. Furthermore, this pilot study enabled the suggestion of some genetic and epigenetic alterations that cells suffer after radiation treatment. Additionally, it also allowed the association of some genetic characteristics that could be related to the differences in radiation response observable in this two cell lines. Taken together all of our results contribute to a better understanding of radiation effects on HNSCC allowing one further step towards the prediction of patients’ outcome, better choice of treatment approaches and ultimately a better quality of life.