Daniel J. Lenihan, MD

• Professor of Medicine
• Director, Clinical Research
• Division of Cardiovascular Medicine
• Vanderbilt University
• Nashville, Tennessee

Transfusion Requirements in Critical Care Investigators symptoms jaw bone cancer discount lariam 250mg, Canadian Critical Care Trials Group symptoms 3 weeks pregnant purchase lariam without a prescription. The use of a blood conservation device to reduce red blood cell transfusion requirements: before and after study medications jejunostomy tube buy 250 mg lariam otc. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion symptoms 4dpiui cheap 250mg lariam amex. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Optimal hemoglobin concentration in patients with subarachnoid hemorrhage symptoms pancreatitis discount lariam amex, acute ischemic stroke and traumatic brain injury medicine of the wolf discount 250mg lariam with amex. Laryngitis may be acute or chronic, infective or inflammatory, an isolated disorder, or part of systemic disease, and often includes symptoms such as hoarseness. Commonly, laryngitis is related to an upper respiratory tract infection and can have a major impact on physical health, quality of life, and even psychological wellbeing and occupation if symptoms persist. Consequently diagnosis can be difficult and requires correlation of history, examination, and, if necessary, specialised assessment, including visualisation of the larynx and stroboscopy. In at risk populations, or those with persisting symptoms, referral to a specialist otolaryngologist should be considered. The aim of this review is to assist nonspecialists in assessing and managing people with laryngitis and to identify the cohort that requires specialist input. A review conducted by the Royal College of General Practitioners in the United Kingdom in 2010 reported an average incidence of 6. They are usually driven by four broad disease processes: inflammation, neoplastic and structural abnormalities, imbalance in muscle tension, and neuromuscular dysfunction. A careful history and examination is crucial in determining the primary factor and helping to identify other factors leading to persisting symptoms. The first consideration in the initial assessment of patients with laryngeal symptoms should be airway patency. Patients with stridor or respiratory distress need urgent assessment in a setting where airway support can be provided quickly if needed. In addition to the description of vocal problems, it is important to ask about associated symptoms of dysphagia, odynophagia, otalgia, reflux, globus pharyngeus, weight loss, pulmonary health, and choking. Box 1 outlines the red flag symptoms that should prompt an urgent referral to exclude malignancy. Contributing medical conditions or the effects of treatment should be considered, as should lifestyle factors, including smoking, diet, and hydration. The impact on quality of life and psychosocial wellbeing should also be addressed. This can be done by way of a simple scale: grade 1 (subjectively normal voice), grade 2 (mild dysphonia), grade 3 (moderate dysphonia), grade 4 (severe dysphonia), and grade 5 (aphonic), with additional qualifiers used as necessary- for example, breathy, strained. This tool grades hoarseness, roughness, breathiness, aesthenia (weakness), and strain on a scale of 0-3, with 0 representing normal, 1 mild degree, 2 moderate degree, and 3 high degree. Acute laryngitis is commonly caused by infection (viral, bacterial, or fungal) or trauma. The larynx is a complex organ that is important for airway protection and maintaining safe swallowing and positive pressure in the pulmonary system. It is integral to cough, straining, and swallowing, and has immunological2 and even hormonal3 functions. It is typically used to describe acute infective laryngitis, one of the most common diseases of the larynx. Typically, laryngitis includes dysphonia, air wasting (excessive loss of air through the incompletely closed glottis resulting in a breathy voice), and pain or discomfort in the anterior neck, and it may include other symptoms such as cough, throat clearing, globus pharyngeus (feeling of a lump in the throat), fever, myalgia, and dysphagia. In addition we searched for specific conditions: "laryngopharyngeal reflux", "sarcoidosis", "pemphigoid", and "tuberculosis". Studies were limited to adult populations and where possible included systematic reviews and randomised controlled trials; we also included case reports to emphasise important problems. The larynx may be affected directly by inhaled material or by haematogenous spread, infective secretions, or as a consequence of irritation from contact trauma-for example, coughing. Symptoms may persist but are usually self limiting, with a duration of less than two weeks. In general practice, treatment is generally supportive, with voice rest, adequate hydration, and mucolytics. Other viruses should be considered, particularly in patients who are immunocompromised (for example, due to herpes species, human immunodeficiency virus, coxsackievirus). Rarely, severe infections such as herpes simplex can result in laryngeal erosion and necrosis. The two may coexist, with viral illness allowing opportunistic bacterial superinfection to occur. Commonly identified bacteria include Haemophilus influenzae B (HiB), Streptococcus pneumoniae, Staphylococcus aureus, haemolytic streptococci, Moraxella catarrhalis, and Klebsiella pneumoniae. Historically, diphtheria was associated with a pathognomonic grey membranous cast that could actually cause airway obstruction. Viral illness may manifest blisters, particularly herpes zoster, and can be associated with nerve paresis involving the lower cranial nerves. Equally, erythema and pain disproportionate to the mucosal appearances can be representative of viral disease. Reaction to antibiotics can indicate viral disease in retrospect-for example, production of rash when amoxicillin is given in the presence of Epstein Barr virus infection. Unusual causes of bacterial laryngitis in developed nations include mycobacterial and syphilitic disease, although these are still seen in developing countries or areas with large immigrant populations. Ultimately tissue diagnosis is essential to assess for tumour, which is considerably common, or to identify acid-fast bacilli on microscopy. Suspicion should be high in patients from developing countries with high rates of tuberculosis and those who are immunocompromised. This constellation of symptoms indicates a high risk of impending airway compromise and requires emergency 64 assessment and airway management. Treatment for less severe cases includes humidification through nebulised normal saline, or constant humidified oxygen, corticosteroids, intravenous antibiotics, and nebulised adrenaline. HiB vaccination has altered the epidemiology and incidence of supraglottitis and epiglottitis, most notably in the paediatric population, with a substantial decrease in presentations. At times, diffuse laryngeal erythema and oedema may be seen without these plaques. Candidiasis may mimic other disorders, particularly hyperkeratosis, leucoplakia, and malignancy, and these must be ruled out by biopsy or imaging. Although such infections most often occur in immunocompromised patients, they can occur in patients with normal immunity when there are alterations to the mucosal barrier,16 such as after chemoradiotherapy, prolonged use of inhalers, or laryngopharyngeal reflux. Biopsy can be difficult to obtain and culture may take several weeks, although fungal elements may be detected more rapidly on Gram stains. Consequently some experts have recommended the diagnosis is implied from a combination of strong clinical suspicion with adequate treatment response to oral antifungal tablets and antifungal solution. Phonotrauma Laryngeal inflammation can arise from collision forces of the vocal folds. The larynx may be traumatised in other ways, including blunt or penetrating trauma, chronic coughing, or habitual throat clearing. Patients with acute airway compromise or presumed epiglottitis should be referred for urgent management. Most cases of acute laryngitis are self limiting and typically resolve within two weeks. Vocal hygiene refers to measures such as voice rest, hydration, humidification, and limiting caffeine intake. These measures are invaluable in the symptomatic treatment of laryngeal inflammation. Care of the voice should be recommended to all presenting with vocal difficulties as this provides symptomatic relief and is good practice to carry forward, even as laryngitis resolves. Periods of voice rest may be as short as 48 hours or as long as a week, and a simple rule of thumb can be to recommend voice rest until patients find it comfortable to hum. Hydration may be achieved just by chewing sugar-free gum, or increasing total fluid intake during waking hours (250 mL per waking hour). Caffeine is dehydrating and increases reflux and therefore exacerbates both snoring and pharyngolaryngeal irritation. The vocal folds are rarely involved · Biopsy is required to confirm the diagnosis · Treated with systemic corticosteroids; or more rarely intralesional injections or laser resection28 Vocal difficulties can result from hyperfunctional vocal behaviours, which in professional voice users can limit or even end their career. Most programmes focus on four main tenets: dealing with the amount and type of voice use, reducing phonotraumatic behaviours, improving hydration, and enhancing lifestyle to improve vocal health, such as reducing caffeine and alcohol intake, smoking cessation, and managing medical conditions. The role of local lubrication, systemic hydration, control of laryngopharyngeal reflux, and allergies are often addressed. The second study compared erythromycin with placebo and found a subjective reduction in voice disturbance at one week and a reduction in cough at two weeks in the erythromycin group. Signs and symptoms such as persistent fever (>48 hours), purulent sputum, membrane formation, or associated distant disease should prompt consideration of antibiotic treatment. Patients with acute airway compromise or suspected epiglottitis or supraglottitis should be assessed in hospital as an emergency. The persistence of laryngeal symptoms beyond three weeks is defined as chronic laryngitis. Acute laryngitis may become chronic, with a shift in the underlying pathophysiology. It may be a direct consequence of the initial acute laryngitis episode or have a completely different or concomitant or superimposed cause. A recent retrospective study found that three quarters of patients referred to an otolaryngologist with an initial diagnosis of acute laryngitis had a different final laryngeal diagnosis. This highlights the need for adequate laryngeal examination by an otolaryngologist in all patients with persisting symptoms, or in those who generate a high degree of suspicion, such as heavy smokers. There is debate as to how long dysphonia may be present before warranting laryngoscopy. Many otolaryngologists would recommend laryngoscopy if dysphonia is present for more than three weeks without an obvious cause, such as acute illness or intubation. Interestingly, guidelines from the American Academy currently state that direct laryngeal 65 examination is warranted for dysphonia that is present for up to three months, or sooner if there are concerns. If symptoms persist for longer than three weeks, we recommend that patients should be referred to an otolaryngologist to exclude malignancy. It can be due to a range of different disease processes, ranging from inflammatory processes, such as allergic laryngitis and laryngopharyngeal reflux, to autoimmune disorders such as rheumatoid arthritis, and granulomatous disease such as sarcoidosis. Chronic laryngitis is less prevalent in primary practice but is the primary indication for referral. By definition, chronic laryngitis implies persistent laryngeal problems, and the glottis should be directly visualised in this situation. While a detailed description of each cause of chronic laryngitis is outside the scope of this review, box 2 summarises the features of the common causes of chronic laryngitis. Furthermore, laryngopharyngeal reflux has been associated with other conditions, such as vocal cord nodules, both premalignant and malignant changes in the larynx, and even sinusitis and otitis media. The results of dual probe pH monitoring have varied,32 with some studies showing, particularly in chronic cough, that the pH of refluxate is not important. Impedance allows consideration of non-acid and mixed reflux episodes in relation to symptom generation. This improves temporal association of symptoms with reflux episodes of any pH, which may be relevant in atypical symptoms of reflux such as cough or globus pharyngeus. Furthermore, it is not inactivated until the pH is greater than 8 and retains around 20% activity at a pH of 6. Antisecretory drugs also present an important side effect profile, including bloating, epigastric discomfort, inhibition of calcium and magnesium absorption, atrophic gastritis, and drug induced acid hypersecretion. Where symptoms remain, further investigation should be considered, including pH-metry, impedance, laryngoscopy, gastroscopy, manometry, and videofluoroscopic swallowing study, depending on the cluster of symptoms. Hyperacidity, association of symptoms with or after meals should prompt pH study with impedance. Where there is associated solid food dysphagia, gagging, or choking a videofluoroscopic assessment of swallowing is recommended. If symptoms are dyspeptic in nature (bloating, belching, food triggered) then gastroscopy may help. Overall, the treatment of extraoesophageal reflux should include dietary and behaviour modification, with judicious use of antisecretory drugs. Some investigators recommend antireflux surgery for patients with laryngeal symptoms. Less than half in this group benefited from surgery, and patients should be counselled appropriately if this option is being considered. Clinicopathological review of tubercular laryngitis in 32 cases of pulmonary Kochs. Epiglottitis in Sydney before and after the introduction of vaccination against Haemophilus influenzae type b disease. The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Diagnosis change in voice-disordered patients evaluated by primary care and/or otolaryngology: a longitudinal study. The larynx as an immunological organ: immunological architecture in the pig as a large animal model. Laryngeal mucous membrane pemphigoid: a systematic review and pooled-data analysis. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Extra-esophageal manifestations of gastroesophageal reflux disease: diagnosis and treatment.

There is also a small risk of subintimal dissection of the arteries during catheter or guidewire manipulation medications blood donation order lariam toronto, with a reported prevalence of 1­6 symptoms vomiting diarrhea cheap 250mg lariam amex. There are usually no symptoms or problems related to the subintimal dissection symptoms zinc toxicity cheap lariam 250 mg with visa, and it can be managed conservatively symptoms 20 weeks pregnant cheap lariam online amex. There is also a case report of iatrogenic rupture of the descending thoracic aorta during bronchial artery embolization which was treated by implantation of an endovascular stent graft in the thoracic aorta [14] medicine to increase appetite buy 250mg lariam amex. One of the most devastating complications of bronchial artery embolization is spinal cord ischaemia due to occlusion of the spinal arteries medicine doctor 250 mg lariam overnight delivery. Therefore, when it is visualized at angiography, embolization should not be performed. A final word from the expert Bronchial artery embolization is an effective treatment for haemoptysis caused by various diseases. Provided that meticulous attention paid to the anatomy and technical details, it is a safe and life-saving procedure for the patient. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. In J Butler (ed), the Bronchial Circulation (New York: Marcel Dekker); 1992: 667­723. Bronchial artery embolization: the importance of preliminary thoracic aortography. Comparison of the effectiveness of embolic agents for bronchial artery embolization: Gelfoam versus polyvinyl alcohol. Bronchial and nonbronchial systemic artery embolization in patients with major hemoptysis: safety and efficacy of n-butyl cyanoacrylate. Successful stent-grafting for iatrogenic aortic rupture and life-threatening hemoptysis. He described mild occasional abdominal discomfort but no significant pain, nausea, vomiting, or weight loss. Significant past medical history included a traumatic head injury with resultant right hemiparesis and chronic hydrocephalus managed by a ventriculo-peritoneal shunt. On endoscopy, stigmata of previous haemorrhage can manifest as active bleeding, non-bleeding but a visible vessel, fresh blood clot, or black spots [1]. Various endoscopic methods for controlling haemorrhage are available, including local epinephrine injection, thermal coagulation, and mechanical clips, bands, and ligation. The various modalities appear to be equivalent in efficacy for haemostasis, rebleeding rates, and emergency surgery [3], with a combination of two or more therapies giving the best results. A colonoscopy was performed to the ascending colon, which confirmed blood within the transverse and ascending colon. Evidence base If endoscopy is unsuccessful, is surgery or embolotherapy more effective? The embolotherapy group were older, had a higher incidence of cardiovascular disease, and were more likely to be anticoagulated. The patients treated surgically were more likely to require additional surgery, usually for surgical complications rather than rebleeding, although this was not statistically significant (16. Learning point Predictors of positive angiography include [9]: Clinical signs of bleeding Active bleeding on endoscopy Bleeding >0. The use of coils alone was significantly associated with an early rebleeding rate. In this particular patient, coils were probably not the appropriate choice of embolic agent. We then tried large particles (700­900m Embospheres) in an attempt to decrease pulse pressure in the feeding artery, but this did not provide a lasting result. Finally, when the patient bled for the third time a decision was made to use glue. The particular form of glue used was Glubran (Gem Srl, Italy), which is different from the cyanoacrylate Histoacryl (B. Expert comment the more dilute the glue solution, the more distally it will embolize. In this patient, a distal embolization was required; therefore, the glue was mixed with lipiodol in a 1:3 ratio. It was planned to perform embolization in two or three sessions to avoid small bowel ischemia, but two sessions were adequate for complete embolization. For this reason both sides of the arcade should be embolized (back-door) and being very selective is not as crucial. All were embolized with endoscopy guiding the location of embolization when contrast extravasation was not demonstrated, i. Coil embolization was exclusively used in this study, with two patients requiring colectomy due to ischaemic complications. Overall, embolotherapy has good technical success but more variable clinical success. Secondary clinical success of arresting haemorrhage after all interventions is high at 85­100%. Handbook of Interventional Radiologic Procedures (4th edn) (Philadelphia: Lippincott-Williams & Wilkins); 2011. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. Therapeutic decision-making in endoscopically unmanageable nonvariceal upper gastrointestinal hemorrhage. Shock index correlates with extravasation on angiographs of gastrointestinal hemorrhage: a logistics regression analysis. Transcatheter arterial embolization of acute upper gastrointestinal tract bleeding with N-butyl-2-cyanoacrylate. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. The patient was in a good general state, complaining only of mild left upper quadrant abdominal pain. No relevant past medical history was mentioned by either the patient or his close relatives who escorted him to the hospital. An hour later he started complaining of worsening abdominal pain on the left side. Learning point Focused abdominal ultrasonography is considered a reliable imaging method for detection of free intra-abdominal fluid in poly-trauma patients. In addition, it is a valid method for assessing possible specific organ injury [1]. Because of the persistence of abdominal pain and the drop in the Hb level a decision was made to immediately transfer the patient to the angiographic suite for embolization in order to control the bleeding. The patient was haemodynamically stable during the whole process, complaining solely of abdominal pain. The branch was selectively catheterized and embolized using a microcatheter and microcoils. Learning point the spleen is the most frequently injured solid organ as a result of either blunt or penetrating trauma [3]. Transcatheter embolization plays an important role in the non-operative management of these cases. In the case of proximal embolization, coils are usually deployed approximately 2cm distal to the origin of the dorsal pancreatic artery, but ideally proximal to the origin of the pancreatica magna artery [3]. Distal embolization or superselective embolization can be applied when the patient is haemodynamically stable and time allows it, especially if there is a small peripheral vessel or single arterial injury [3]. When superselective embolization is performed, as in the case described here, it is important to remember to obtain a completion angiogram from the proximal splenic artery in order to identify any additional culprit branches that may have been missed on the initial angiograms. Expert comment Use of endovascular techniques in order to control active haemorrhage originating from the spleen as a consequence of either blunt or penetrating trauma has been a major contributor to the conservative management of allowing preservation of the spleen. The aim of endovascular embolization is to improve the results of the non-operative management of patients with splenic injury and to reduce the rates of splenectomy [4,5]. Splenic vascular trauma management usually consists of proximal embolization of the splenic artery resulting in decreased perfusion of the spleen which controls the bleeding and in addition prevents secondary rupture by reducing the overall pressure. Alternatively, more distal superselective embolization of the suspect arterial branch may be performed. Superselective embolization techniques, if applicable, can be used in order to minimize organ injury and preserve most of the target organ function. Nevertheless, superselective techniques must only be used in cases where the clinical condition of the patient allows sufficient time for this procedure. There were no further signs of pain or embolization-related complications (post-embolization syndrome). He had an otherwise uneventful recovery and was discharged from hospital three days later. Complications of splenic artery embolization include splenic artery injury, non-targeted embolization, infraction of splenic parenchyma, and most importantly abscess formation and sepsis. Interventional radiology and endovascular procedures Expert comment the aim of transcatheter embolization for management of splenic artery injuries is to preserve the spleen, which is a key solid organ in the immunological system. Complications of transcatheter embolization can be avoided with experience or, if present, can usually be managed conservatively. Non-target embolization may be the result of improper sizing of the coils or failure to successfully recognize the responsible arterial branch. Abscess formation may occur either immediately after the procedure or in a delayed manner. Discussion Trauma is a major healthcare problem as it is the primary cause of death in young patients. Interventional radiology plays an increasing role in management of trauma patients, especially via percutaneous transcatheter treatment of sites of active haemorrhage that contribute to haemodynamic instability. Patients eligible for endovascular management of traumatic arterial injuries are those who are haemodynamic stable or sufficiently resuscitated to allow enough time for both cross-sectional imaging evaluation and angiographic identification and arrest of the bleeding site. Endovascular treatment for haemorrhage control was first described in the early 1970s [8]. Since then, the increasing experience of interventional radiologists in the delivery of transcatheter therapies, together with developments in endovascular instruments, has expanded the role of minimally invasive options in the polytrauma patient. This approach is applicable to almost all vascular territories of the human body that may be injured by either blunt or penetrating trauma, including the thoracic or abdominal aorta, the pelvic and upper or lower extremity arteries, the lumbar arteries, and the major visceral branches feeding the spleen, liver, and kidneys [3,9]. Endovascular techniques can be applied to manage bleeding in all these arterial territories. The following endovascular options are applicable to the poly-trauma patient: balloon occlusions, embolization using all available embolic agents, and implant of covered metal stents or stent grafts [3,9]. It is essential that the operator involved must have the appropriate catheter skills and knowledge to carry out an effective and safe percutaneous embolization procedure. Knowledge of the arterial anatomy, including the collateral networks, is essential for a successful embolization procedure. The most widely used embolic agents in the trauma setting are coils and Gelfoam [3,9]; coils are more precise but Gelfoam produces quicker arrest of flow. A final word from the expert Over the last few decades the role of endovascular treatment of traumatic arterial injuries has emerged and evolved to allow non operative management of such cases. By using embolic agents, occlusion balloons, and stent grafts radiologists have produced a paradigm shift in the management of such cases. No matter where the injury is located, Case 19 Endovascular approach to the trauma patient 169 radiologists can often offer a less invasive therapeutic option. The spleen, which is the most frequently injured solid organ [3], is being preserved in an increasing number of cases (up to 94%) thanks to application of modern imaging and endovascular techniques [6,7]. Liver injuries can involve the hepatic arteries, the portal venous system, or the hepatic veins. Surgical repair of liver injuries can have than mortality rates in excess of 33%, making transcatheter management a more appealing approach [10]. In kidney injuries embolization must be performed as selectively as possible in order to minimize the extent of organ infarction. Gelfoam is preferred because it offers the option of recanalization; however, coils can also be used [3]. Pelvic haemorrhage can be the result of fractured bones or disrupted pelvic veins, and in about 10­20% of cases the source of bleeding is severe arterial injury [13]. Transcatheter embolization is a highly effective procedure to control bleeding with success rates ranging from 85% to 100%. The introduction and widespread use of a variety of endografts and stent grafts have altered the management of such cases, favouring the transcatheter endovascular approach whenever this is possible mainly because of its inherent advantages over open surgery. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Nonoperative salvage of computed tomographydiagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. Effectiveness of transcatheter embolization in the control of hepatic vascular injuries. Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization. Place of arterial embolization in severe blunt hepatic trauma: a multidisciplinary approach. Leto Maili and Aneeta Parthipun Expert commentary Irfan Ahmed Case history A 40-year-old woman, who was previously fit and well, presented to her gynaecologist with a long-standing history of menorrhagia and dysmenorrhea. There was no endometrial abnormality or additional supply to the uterus via the ovarian arteries. She was also sent for routine blood tests (full blood count, coagulation screen, and renal function tests), which were all normal. Transcervical expulsion of leiomyomas: this is the most common serious complication and is defined as the detachment of fibroid tissue from the uterine wall and subsequent transvaginal passage.

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Case 25 Tracheobronchial stenting: covered versus uncovered 215 Expert comment In cases of very tight stenosis a balloon predilatation may be necessary in order to allow accurate the advancement of the appropriate stent over the wire deployment under fluoroscopic guidance treatment 002 buy 250mg lariam visa. Various peri- and post-procedural complications following tracheobronchial stent insertion have been reported: stent fracture or collapse xerostomia medications that cause cheap lariam 250mg, occlusion treatment low blood pressure buy generic lariam from india, migration medicine remix lariam 250mg with mastercard, stent intolerance medications kosher for passover purchase lariam 250mg line, infection medicine world nashua nh cheap 250mg lariam mastercard, and haemoptysis. Other complications, such as fracture and migration, can be managed with stent removal. In the past, biopsy forceps were used to remove expandable metallic stents [12,13] with potential risk of mucosal bleeding. When the hook grasps the stent drawstring, the wire is withdrawn to obtain proximal stent collapse. A final word from the expert Minimally invasive palliative stenting, under bronchoscopic and fluoroscopic guidance, for the management of symptomatic malignant airway disease is a safe and effective procedure. Rigid bronchoscope access is valuable for accurate stent positioning, taking biopsies, and allowing adequate suction of airways. The role of airwaystent placement in the management of tracheobronchial stenosis caused by inoperable advanced lung cancer. Silicone stents in the management of benign tracheobronchial stenoses: tolerance and early results in 63 patients. Treatment of inoperabile tracheobronchial obstructive lesions with the Palmaz stent. Bronchoscopic balloon dilatation of tracheobronchial stenosis: long-term follow-up. Tracheobronchial stenting for malignant airway disease: long-term outcomes from a single-centre study. A rounded hypodensity, which did not enhance on arterial phase, is present in segment 6. In this case the patient had cirrhotic liver with significant background nodularity and a dominant nodule that could easily be identified on imaging. Hepatic angiography and chemoembolization with doxorubicin and lipiodol was chosen as the next step in clinico-radiological management as it is useful not only for characterizing atypical lesions but also for identifying other lesions which are not detected on axial imaging. Knowledge of the broad variation in enhancement features is essential for early diagnosis and management. Tumours with diameters <2cm showed a wide variation in enhancement characteristics. It was important to obtain a histological diagnosis, as that would dictate further management. Although the risk is small, tumour seeding would have a significant negative impact and preclude the patient from having a liver transplantation in future, which would offer her the best chance of long-term survival. Coaxial needles are preferred as they allow more than one sample to be taken in case the first sample is inadequate or fragmented. A coaxial needle also allows tract embolization if bleeding occurs and, more importantly, if the patient is a potential candidate for transplantation, both tumour and biopsy tract can be treated with ablation or ethanol injection to minimize the risk of tumour seeding. Currently there are no prospective randomized trials evaluating the effect of these therapies prior to liver transplantation. Most studies have demonstrated a reduction in the dropout rate compared with historical controls. This compares favourably with a historical dropout rate of 10­30% with waiting times of 6­12 months [5]. Prognosis is very poor in the latter group, with five-year survival reported to be less than 10% [11]. Classical cross-sectional imaging characteristics are usually satisfactory for diagnosis without the need for histology, which may be reserved for less clear-cut cases or for patients without signs of chronic liver disease on imaging. This staging system takes into account liver function, portal pressure studies, and radiological findings, and determines the best treatment modality and the expected prognosis. Surgical approaches, either resection or liver transplantation, have the best prognosis. Resection is best reserved for a select population who have either little or no chronic liver disease, i. The absence of portal hypertension, as determined by a hepatic vein pressure gradient <10mmHg, and normal bilirubin are associated with better clinical outcomes [11]. However, recurrence rates in resected patients are as high as 70% and include de novo tumours [11]. The Milan Criteria were previously used, but have largely been replaced according to geographical location. For patients who are not suitable for resection there are a variety of percutaneous approaches which can be used as treatments in their own right or as a bridge to liver transplantation. In particular, they are useful for preventing dropout from liver transplantation by keeping the tumour burden under control. Curative treatments have a five-year survival of 50­70%; Palliative treatments have a three-year survival of 20­40% and symptomatic treatments have a one-year survival of only 10­20%. This procedure is generally well tolerated, but is less frequently performed because of the better efficacy of the other approaches. It results in tumour necrosis in approximately 50% of patients and improves survival [14]. It can be performed with or without chemotherapy agents depending on whether the patient can tolerate this. Conventional chemoembolization involves injection of the chemotherapeutic agent doxorubicin in combination with lipiodol into the lobar or segmental hepatic artery. These allow slow release of the cytotoxic agent into the tumour, inflicting local ischaemia while reducing systemic concentrations [15]. Contraindications to treatment include extrahepatic tumour, Child­Pugh B or C liver disease, and macroscopic portal vein thrombus or poor portal flow for any other reason, as a potential complication is acute liver failure secondary to the procedure. The aim is to inject yttrium-90 microspheres bound to glass beads or resin which provide radiotherapy locally into the tumour circulation without the harmful effects of radiation necrosis to the remainder of the liver. It is used as a first-line treatment when other potentially more effective therapies, as discussed in this case, cannot be used. Radiologists play an integral role, from screening to diagnosis, and can provide a variety of treatments. Asymptomatic patients with large-volume confined hepatic disease, no evidence of macrovascular invasion, and preserved liver function (Child­Pugh A) are treated with transarterial embolization with or without chemotherapy. Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver. Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation. Current opinion on the role of resection and liver transplantation for hepatocellular cancer. Hepatocellular carcinoma: natural history, current management, and emerging tools. Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. The decision was made on the basis of the size of the lesion, the general condition of the patient, and local expertise. Overall survival, cancer-specific survival, local recurrence-free survival, overall disease-free survival, and metastasis-free survival were compared. Expert comment Outpatient consultations are an important part of the management of patients prior to image-guided tumour ablation. The proposed treatment should be put into context relative to alternative options, such as radiotherapy and surgery. During these consultations, the procedure is carefully explained to the patient, ideally with the help of diagrams or other images. The possible complications are outlined, as well as pre- and post-procedure care and follow-up arrangements. It is particularly important to explain that there may be a need for repeat treatment if there is local recurrence. The patient was referred by the urology consultant to the Interventional radiology oncological outpatient clinic. The day before the procedure the patient was admitted and a full blood count and biochemical analysis were ordered. The interventional radiologist who had countersigned the consent form visited the patient again. The procedure was performed under conscious sedation using midazolam 6mg and fentanyl 100g administered intravenously. The energy output is adjusted based on the impedance of the tissue which is monitored continuously. The electrodes are internally cooled with saline to enhance the homogenous heating of the adjacent tissue and to reduce charring and vaporization. At the end of the procedure the patient was transferred to the radiology recovery area and monitored haemodynamically for four hours. If the first scan shows complete response, but enhancement is detected in the follow-up scan, recurrence of the tumour should be considered. Discussion Historically, surgical oncology followed the guidance of its founder, William Stewart Halstead, aiming for wide en bloc resection of the organ and the tumour that the organ contained. Therefore minimally invasive in situ needle-guided treatments have been introduced and developed in the last 15 years, offering tumour treatment based on the destruction of tumour cells. The alternating current causes water molecules in the biological tissue to vibrate, and the vibration is transmitted to adjacent molecules. The kinetic energy is transformed into thermal energy, leading to hyperthermia and coagulation necrosis of the biological tissue. Disease-specific survival and overall survival were calculated and stratified by tumour stage. Twenty-four patients (13%) were re-treated for residual disease and there were 12 local recurrences. Tumour stage was the only significant predictor of disease-specific survival on multivariate analysis. Secondary endpoints were the deterioration of renal function and overall survival rate. Evidence base Combined percutaneous radiofrequency ablation and ethanol injection of renal tumours: midterm results [16] Single-centre prospective study. Twenty-seven of the 28 tumours were completely ablated following either one (21/27) or two (6/27) treatment sessions. No evidence of local recurrence or metastatic disease was seen during the follow-up period. A final word from the expert Percutaneous ablation is a useful alternative to surgery in carefully selected patients with small renal masses. This nephron-sparing technique produces satisfactory long-term oncological outcomes in patients with lesions up to 3cm in diameter. Ideally, this will be done through randomized comparative studies, although recruitment of patients may prove problematic and good registry data may make a significant contribution. In the meantime, percutaneous ablation seems particularly appropriate in patients with multiple tumours, chronic kidney disease, or tumours in solitary kidneys, and in those who are poor surgical candidates. Radiofrequency ablation versus partial nephrectomy in patients with solitary clinical T1a renal cell carcinoma: comparable oncologic outcomes at a minimum of 5 years of follow-up. Survival analysis of 130 patients with papillary renal cell carcinoma: prognostic utility of type 1 and type 2 subclassification. Long-term oncologic outcomes after radiofrequency ablation for T1 renal cell carcinoma. The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. Seven years after laparoscopic radical nephrectomy: oncologic and renal functional outcomes. Effect of warm ischemia time during laparoscopic partial nephrectomy on early postoperative glomerular filtration rate. The impact of warm ischaemiaonrenal function after laparoscopic partial nephrectomy. Multivariate analysis of the factors involved in loss of renal differential function after laparoscopic partial nephrectomy: a role for warm ischemia time. Percutaneous radiofrequency ablation of small renal tumours in patients with a single functioning kidney: long-term results. Combined percutaneous radiofrequency ablation and ethanol injection of renal tumours: midterm results. Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours. Comparison of percutaneous radiofrequency ablation and open partial nephrectomy for the treatment of size- and location-matched renal masses. Midterm results of radiofrequency ablation versus nephrectomy for T1a renal cell carcinoma. Management of renal masses with laparoscopic-guided radiofrequency ablation versus laparoscopic partial nephrectomy. Miltiadis Krokidis Expert commentary Adam Hatzidakis Case history An 87-year-old man presented with moderate melaena in the A&E department of a tertiary care centre. He was not significantly anaemic and he was transferred to a ward with a view to endoscopic examination the following day. There is significant dilatation of the intra- and extra-hepatic ducts and the pancreatic duct. Contrast injection should be performed at a rate of 4­5ml/sec, preferably with low osmolality contrast at an iodine dose of 1. It is important to obtain images when the enhancement of the background gland is maximal in order to reveal the attenuation difference between tumour and gland [3]. Expert comment the type of approach adopted for malignant biliary obstruction mainly depends on local expertise. In the majority of the tertiary care centres with experienced endoscopists and interventional radiologists the endoscopic approach should be tried first, and the percutaneous route will usually follow if the failed endoscopic attempt fails. The percutaneous approach is the first approach for patients with a Roux-en-Y loop or when severe oesophageal stenosis is present.

This probably means that transfusion is not needed for most patients at these haemoglobin concentrations symptoms 28 weeks pregnant buy cheap lariam 250mg on-line, but it could also be an indication of the insensitivity of available measures of oxygenation treatment bacterial vaginosis buy generic lariam on-line. Table 2 shows physiological and biochemical measures that can help guide blood transfusion decisions symptoms and diagnosis buy cheap lariam on-line, although they lack specificity as diagnostic tests and transfusion triggers treatment neuroleptic malignant syndrome order lariam mastercard. When faced with evidence of poor oxygenation treatment zone tonbridge purchase lariam with paypal, clinicians must decide whether to increase the cardiac output (with fluids or inotropic drugs symptoms 4 dpo bfp purchase generic lariam from india, or both) or improve the oxygen carrying capacity of blood (with red cells). The lack of reliable clinical or laboratory tests to indicate when transfusion is needed means that clinicians rely heavily on the haemoglobin concentration as the primary trigger for transfusion. The problem is that the correct trigger haemoglobin is usually unknown for an individual patient and might vary depending on their clinical condition. Table 2 Useful clinical symptoms, signs, and tests when deciding if red cell transfusion is needed Clinical symptom, sign, or test Most useful Considerations Lactic acidosis this is a useful indicator of inadequate oxygen delivery, especially early in critical illness (during the "resuscitation phase"). It commonly results from hypoxia or inadequate cardiac output rather than anaemia, so careful cardiorespiratory assessment is needed. Lactic acidosis can also result from poisoning and other conditions causing critical illness Low central venous oxygen saturations (from these measures are invasive, but low saturations a central venous catheter) (less than 70%) imply that the body is extracting more oxygen from arterial blood than normal. As for lactic acidosis, correct hypoxia and ensure that cardiac output is optimised before blood transfusion unless haemoglobin concentrations are <70-80 g/l or the patient is bleeding Haemoglobin value this is the most commonly used transfusion "trigger. Patients may also be unable to provide a history Pallor Pallor does not reliably predict the haemoglobin concentration and can also result from hypovolaemia and excessive adrenergic activity (eg, anxiety) High heart rate Many other factors, such as pain, anxiety, dehydration, hypovolaemia, and adrenergic drugs, can increase heart rate in critically ill patients What haemoglobin concentration should trigger blood transfusion in critically ill patients? Patients with a haemoglobin 90 g/l or less were randomised to either a relatively high haemoglobin transfusion trigger of less than 100 g/l with a target of 100-120 g/l (the "liberal" group) or a lower haemoglobin transfusion trigger of less than 70 g/l with a target of 70-90 g/l ("restrictive" group). The findings strongly support using red cells only to maintain a haemoglobin concentration of 70-90 g/l, especially in younger or less severely ill patients. The generalisability of these findings are unclear, however, and this might explain why clinical practice still varies. This trial has never been replicated in adult critical care, and a recent Cochrane systematic review noted the need for further trials. We consider a single unit transfusion followed by reassessment of the haemoglobin value before further transfusion to be best practice unless the patient is actively bleeding or has a haemoglobin concentration substantially lower than 70 g/l. Some evidence exists to support using a higher transfusion trigger than 70 g/l in the following clinical scenarios. Patients with chronic ischaemic heart disease Coronary blood flow occurs mainly during diastole. The heart muscle has a high metabolic rate and normally extracts 60-70% of available oxygen to meet its needs. If coronary stenoses limit blood flow it is logical to suppose that anaemia will increase the risk of myocardial ischaemia, especially if tachycardia and shock limit perfusion further. Several large cohort studies found that in patients with chronic ischaemic heart disease haemoglobin concentrations less than 90 g/l were associated with higher mortality during surgery and critical illness. Patients with acute coronary syndrome Several cohort studies have found associations between anaemia and higher mortality after acute coronary syndrome,22 w11-w13 but no evidence is available from randomised controlled trials to suggest what haemoglobin value should be targeted. The most recent highest quality cohort studies do not show benefit from transfusion when the haemoglobin concentration is more than 80 g/l, but the overall quality of evidence is low and controlled trials are needed, especially because bleeding and anaemia are both common in patients who are treated for acute coronary syndrome. Yes No need to consider red blood cell transfusion No Does patient have early severe sepsis with evidence of inadequate oxygen supply (high lactate or low ScvO2)? No Use a default haemoglobin transfusion trigger of 70 g/l with target haemoglobin range of 70 to 90 g/l Does the patient have an acute coronary syndrome? ScvO2=oxygen saturation of less than 70% in central venous blood 60 We agree with current recommendations to keep the haemoglobin concentration no lower than 80-90 g/l in patients with an acute coronary syndrome, although the supporting evidence is weak and based largely on physiological reasoning. Transfused leucocytes may have adverse effects in critically ill patients and most countries now routinely leucodeplete blood before storagew18 · the storage age of the blood was unknown. Longer storage times might affect patient outcomes, especially if the blood was not leucodepleted17 · the study could not prove that the restrictive approach was safe for all patient subgroups, especially those with heart disease and sicker older patients · Improvements in critical care and blood processing over the past decade might mean the findings would be different if the trial were repeated now Patients with early sepsis Patients with sepsis are at risk of inadequate oxygen delivery to the tissues, particularly during the first six to 12 hours after onset. After this time, abnormalities in the utilisation of cellular oxygen probably become more important than oxygen supply. One single centre, non-blinded, randomised controlled trial used oxygen saturation of less than 70% in central venous blood (measured via a central venous catheter) as a trigger for a resuscitation protocol that included giving red cells to keep the haemoglobin concentration more than 90-100 g/l. Until additional evidence emerges it is reasonable to consider transfusing patients with early sepsis to haemoglobin values of 90-100 g/l in addition to resuscitation with fluids and adrenergic drugs, but only if there is clear evidence that oxygen supply may be inadequate (oxygen saturation of <70% in central venous blood, or severe or worsening lactic acidosis). Once patients are haemodynamically stable, a haemoglobin of 70-90 g/l is probably adequate. Acute neurological disease the quality of evidence to guide transfusion in patients with intracerebral haemorrhage, thrombotic stroke, subarachnoid haemorrhage, and traumatic brain injury is low and no randomised trials exist. Several large well conducted randomised trials have evaluated the effect of using recombinant human erythropoietin, which is not currently licensed for use in this setting, to treat anaemia in people with critical illness. This treatment resulted only in a modest reduction in the use of red cells in early smaller trials, and in the largest most recent trial transfusion was not significantly reduced. Red cell requirements for intensive care units adhering to evidence-based transfusion guidelines. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Time course of hemoglobin concentrations in nonbleeding intensive care unit patients. Important role of nondiagnostic blood loss and blunted erythropoietic response in the anemia of medical intensive care patients. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Laparoscopic antireflux surgery in patients with throat symptoms: a word of caution. Mucosal changes in laryngopharyngeal reflux- prevalence, sensitivity, specificity and assessment. Long-term outcomes after laparoscopic Nissen fundoplication for reflux laryngitis. In the absence of a lumbar puncture, viral and bacterial meningitis cannot be differentiated with certainty, and all suspected cases should therefore be referred. Lumbar puncture and analysis of cerebrospinal fluid may be done primarily to exclude bacterial meningitis, but identification of the specific viral cause is itself beneficial. Viral diagnosis informs prognosis, enhances care of the patient, reduces the use of antibiotics, decreases length of stay in hospital, and can help to prevent further spread of infection. In this review we outline the changing epidemiology, discuss key clinical topics, and illustrate how identification of the specific viral cause is beneficial. Neonatal meningitis may be a component of perinatal infection and is not covered here. As a consequence of mumps, measles, and rubella vaccination, enteroviruses have supplanted mumps as the most common cause of viral meningitis in children (box 1). Enteroviruses were most common, accounting for 46%, followed by herpes simplex virus type 2 (31%), varicella zoster virus (11%), and herpes simplex virus type 1 (4%). Viral meningitis and bacterial meningitis are both characterised by acute onset of fever, headache, photophobia, and neck stiffness, often accompanied by nausea and vomiting. At initial presentation, no reliable clinical indicators are available to differentiate between acute viral meningitis and bacterial meningitis, so all suspected cases should be referred to hospital. Particular caution is warranted with young children, in whom meningitis is manifest as fever and irritability, without, as a rule, evidence of meningeal irritation. Suspected encephalitis warrants empirical antiviral treatment with intravenous aciclovir. Analysis of cerebrospinal fluid is needed, and lumbar puncture should be done unless it is contraindicated. Whether prior computed tomography imaging is needed is controversial, and guidance is now available (see box 2). In the largest reported study, a 1966 birth cohort of 12 000 children in Finland, the annual incidence of presumed viral meningitis was 219 per 100 000 in infants under 1 year and 27. We also consulted several formal medical, infectious diseases, and virological textbooks. A blood glucose concentration is essential and should be collected immediately before lumbar puncture. Although characteristically associated with a mononuclear pleocytosis, neutrophils may predominate initially in viral meningitis (table 1). In 138 children with aseptic meningitis, 57% had a polymorphonuclear predominance that persisted beyond 24 hours. Coxsackie B viruses and echoviruses account for most cases of enterovirus meningitis. Infants and young children with no immunity are most susceptible to enteroviruses, and the incidence decreases with age. Infection is seasonal in temperate climates-highest in summer and autumn-but high all year round in tropical and subtropical climates. Most cases that present clinically with meningitis are self limiting and carry a good prognosis. Nevertheless, enteroviral meningitis causes considerable morbidity, with moderate or high fever despite antipyretics and several days of severe headache warranting opiate analgesia. They can cause systemic infections, however, and have a proclivity to be neuroinvasive. Immunoglobulin replacement has a role in patients with hypogammaglobulinaemia, who are prone to severe and chronic enteroviral disease. Recognising that herpes simplex virus meningitis and encephalitis are discrete entities in the immunocompetent host, rather than part of a continuous spectrum, is essential. Whereas herpes simplex virus encephalitis is a life threatening medical emergency warranting empiric antiviral treatment, herpes simplex virus meningitis is a self limiting condition in patients with normal immunity. Herpes simplex virus now ranks second among the causes of viral meningitis in adolescents and adults in developed countries. Unlike primary infection, non-primary genital infection with herpes simplex virus is rarely accompanied by aseptic meningitis. She had been increasingly unwell over the preceding 10 days and had sought medical advice for severe dysuria on more than one occasion; she was receiving treatment for a presumptive urinary tract infection. Analysis of cerebrospinal fluid showed white cells 692Ч106/l (99% lymphocytes), protein 1. She was treated with intravenous aciclovir 10 mg/ kg eight hourly for six days, followed by oralvalaciclovir 1 g eight hourly for two weeks. Patient 2 A 32 year old woman presented with a three day history of headache, fever, and photophobia. She received oral valaciclovir 1 g eight hourly for seven days and opiates for severe headache. Patients with herpes simplex virus meningitis should be referred to a sexual health clinic after recovery. However, the diagnosis of herpes simplex virus meningitis and possible associations with genital herpes may come as a shock to the patient, and this needs to be discussed sensitively at the earliest appropriate opportunity. Many people harbour genital herpes simplex virus infection and intermittently shed virus without ever having symptoms. The timing of transmission is unpredictable; it may occur only after several years within a monogamous sexual relationship. It is more commonly seen in association with reactivation of varicella zoster virus (zoster) and can also occur in the absence of cutaneous lesions. Among 21 patients with varicella zoster virus meningitis, more than 50% had no skin manifestations. Before widespread immunisation, mumps was a common cause of meningitis, which occurred in 15% of patients with mumps. United States Department of Health and Human Services Centers for Disease Control and Prevention. Pathogenesis and pathophysiology of viral infections of the central nervous system. Incidence and prognosis of central nervous system infections in a birth cohort of 12,000 children. Diseases notifiable (to Local Authority Proper Officers) under the Public Health (Infectious Diseases) Regulations 1988. Early management of suspected bacterial meningitis and meningococcal septicaemia in immunocompetent adults. Impact of a diagnostic cerebrospinal fluid enterovirus polymerase chain reaction test on patient management. Enteroviruses: polioviruses, coxsackieviruses, echoviruses, and newer enteroviruses. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Identification of women at unsuspected risk of primary infection with herpes simplex virus type 2 during pregnancy. Influence of neurologic manifestations of primary human immunodeficiency virus infection on disease progression. Improving prevention of intracerebral haemorrhage in primary care and its outcome in secondary care is especially important in view of trends towards a rising incidence of intracerebral haemorrhage in an ageing population. No clinical scoring system has been shown to reliably differentiate intracerebral haemorrhage from ischaemic stroke. Computed tomography detects symptomatic intracerebral haemorrhage within minutes of symptom onset and up to one week thereafter; magnetic resonance imaging with gradient-recalled echo sequences reliably differentiates infarction from haemorrhage more than one week after onset of stroke.