Harrison G. Weed

Preoperative identification of patients at risk for delirium after major head and neck cancer surgery

This study was performed to determine preoperative criteria for identifying patients at risk for delirium after major head and neck cancer surgery. The authors prospectively evaluated 138 consecutive patients undergoing head and neck cancer surgery lasting more than 2 hours at the Arthur G. James Cancer Hospital and Research Institute, Ohio State University, Columbus, from July 1993 through May 1994.

Antimicrobial prophylaxis in the surgical patient

The primary prophylactic measure against postoperative infection is antiseptic technique in patient preparation, during surgery, and in postoperative patient care. Antimicrobial prophylaxis against postoperative infection is not indicated for procedures with a low infection rate because the expected benefit of antimicrobial treatment is less than the risk of an adverse medication reaction. Antimicrobial prophylaxis has been demonstrated to be of greater benefit than risk in some procedures with higher infection rates; however, because the problem is complex and the data are limited, extra-polating these findings to the practitioners setting and the individual patient remains a challenge (Table 1). Although antimicrobial prophylaxis for bacterial endocarditis is not effective for most patients, the seriousness of the potential infection has driven the creation of guidelines recommending prophylaxis for at-risk patients undergoing at-risk procedures. Applying these guidelines appropriately could help to reduce unwarranted use of antimicrobials. In the prophylactic use of antimicrobials, as in many medical interventions, the difficulty is balancing the risks of the intervention with the potential benefits. Although we do not have either the randomized, controlled trials or the detailed, patient-specific information to estimate this balance precisely, there are general guidelines to help the clinician choose treatment for most patients.

Factors influencing cotinine half-life during smoking abstinence in African American and Caucasian women

Cotinine, the proximate metabolite of nicotine, has been identified as an indicator of smoke constituent exposure. Higher cotinine levels in African American cigarette smokers have been identified. Because African Americans experience disproportionate smoking-related morbidity and mortality, it is important to examine potential factors influencing these higher levels of cotinine. The current study examined selected factors of ethnicity, menthol cigarette preference, body composition and alcohol-use history on cotinine half-life in 6 days of smoking abstinence in African American and Caucasian women. A 7-day inpatient protocol was conducted in the General Clinical Research Center, in which day 1 was ad lib smoking and days 2-7 were smoking abstinence (n = 32). Plasma cotinine was measured every 8 h throughout. Average cotinine half-life was 21.3 h, similar to previously reported 18-20 h. Three women exhibited >14 ng/ml cotinine after 136 h of smoking abstinence. Host factors explaining 52.0% of variance in cotinine half-life and associated with longer half-life were being an African American menthol smoker, fewer years of alcohol use and greater lean body mass. Among menthol smokers, baseline cotinine level and cotinine half-life were not significantly different in Caucasian and African American women. Intra-individual cotinine half-life variation and CYP2A6 genotype were examined in substudies. To improve accuracy in correctly classifying non-smokers with cotinine levels, a period of at least 7 days of smoking abstinence may be warranted.

Lean body mass gain in patients with head and neck squamous cell cancer treated perioperatively with a protein- and energy-dense nutritional supplement containing eicosapentaenoic acid.

Cancer‐associated weight loss may be mediated by an inflammatory response to cancer. Eicosapentaenoic acid (EPA) may suppress this response.

Adherence to American Society of Health-System Pharmacists Surgical Antibiotic Prophylaxis Guidelines in Iran

We assessed the appropriateness of surgical antibiotic prophylaxis in 6 teaching hospitals in Shiraz, Iran, using the American Society of Health-System Pharmacists guideline as a reference. We reviewed the medical records of 1,000 patients who underwent 1 of 9 different surgical procedures (1 procedure per patient). The proportion of procedures in which there was compliance with all guideline recommendations was 0.3%. The most common mistakes were overuse and misuse of antibiotics.

Candida laryngitis appearing asleukoplakia and gerd

The symptoms and physical findings of reflux laryngopharyngitis are characteristic, but the mucosal alterations evident in the larynx are not exclusive to reflux. When conventional reflux management produces an equivocal response, other etiologic factors such as mycotic laryngitis, need consideration. The differential diagnosis of dysphonia in an immunocompromised patient always includes mycotic infections, but mycotic laryngitis can also occur in the immunocompetent host. Laryngeal candidiasis can produce physical findings, such as erythema and leukoplakia, that are similar to reflux laryngopharyngitis. Predisposing factors include previous radiation therapy, antibiotic therapy, corticosteroids, and any alteration in the mucosal barrier. Diagnosis is established by mucosal biopsy with special staining of the tissue to identify the characteristic hyphae. Treatment of mycoses can be difficult and long-term therapy is often required.

Levels of cigarette availability and exposure in Black and White women and efficient smokers

Purposes of this investigation were to examine differences in smoke exposure and smoking topography across three smoking conditions: usual number of cigarettes, restricted (50%) and increased (167%) simulating restricted and unrestricted cigarette availability. A repeated-measures counterbalanced design with a sample of 25 women (13 African Americans; 12 Caucasians) was implemented with a 6-day inpatient protocol conducted in the General Clinical Research Center (GCRC). There were significantly larger percentage increases in carbon monoxide (CO) postcigarette in the restricted condition compared to usual and increased condition. Women with baseline cotinine/cigarette ratios >20 ng/ml/cigarette, considered efficient smokers, had significantly higher CO increases postcigarette at baseline than participants with lower cotinine/cigarette ratios, yet increased this exposure further during the restricted condition. Efficient smokers had significantly higher nicotine boost in the restricted condition compared to less efficient smokers. Differences by ethnicity were also noted with significantly higher CO percentage increases pre- to postcigarette in African Americans across all conditions, compared to Caucasians. Levels of smoke exposure postcigarette in persons who reduce cigarettes per day in response to restricted cigarette availability may be substantial.

A programme of accelerated medical education in Taiwan

Background: Graduates of the 7-year undergraduate medical curriculum in Taiwan are often deficient in clinical skills. Aims: To implement and assess a programme of accelerated clinical education. Method: The Department of Primary Care Medicine at the National Taiwan University College of Medicine implemented a programme shortening the undergraduate clinical curriculum from 3 to 2 years and giving students more clinical responsibility. Students were prepared for clinical rotations with a 1-month clinical skills course. Core clinical rotations were redesigned to be more participatory. The programme included 1 year of a postgraduate, rotating residency. Self-selected students with adequate grades, recommendations and performance on an interview participated in the programme. None of them dropped out. Results: Compared with their traditionally instructed cohorts, graduates of the accelerated programme (∼10% of each class) were more likely to pass national boards (100% versus 80–97%) and were rated as more proficient on 9 of the 10 different clinical performance parameters (p < 0.01 by sign test). Sixty-nine percent reported being satisfied or very satisfied with the programme. Conclusion: A pilot programme of accelerated medical education at National Taiwan University that included clinical skills instruction, mentor-style classes and active learning techniques resulted in satisfactory outcomes for the students selected for the programme.

Perioperative issues in patients with cancer

The perioperative care of patients with cancer can be an exciting challenge. The physician must consider many factors, including the cancer diagnosis, the extent of disease, treatment received, the presence of comorbid conditions, and the patients prognosis and must understand the impact of these factors on the planned surgical procedure. In this setting, the physician has the opportunity to perform an essential role in the perioperative management of patients with cancer.

Review: Probiotics prevent C. difficile–associated diarrhea in patients using antibiotics

Source Citation Goldenberg JZ, Ma SS, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013;(5):CD006...