Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

Assessment and characterization of gut microbiota has become a major research area in human disease, including type 2 diabetes, the most prevalent endocrine disease worldwide. To carry out analysis on gut microbial content in patients with type 2 diabetes, we developed a protocol for a metagenome-wide association study (MGWAS) and undertook a two-stage MGWAS based on deep shotgun sequencing of the gut microbial DNA from 345 Chinese individuals. We identified and validated approximately 60,000 type-2-diabetes-associated markers and established the concept of a metagenomic linkage group, enabling taxonomic species-level analyses. MGWAS analysis showed that patients with type 2 diabetes were characterized by a moderate degree of gut microbial dysbiosis, a decrease in the abundance of some universal butyrate-producing bacteria and an increase in various opportunistic pathogens, as well as an enrichment of other microbial functions conferring sulphate reduction and oxidative stress resistance. An analysis of 23 additional individuals demonstrated that these gut microbial markers might be useful for classifying type 2 diabetes.

/pdf/a-metagenome-wide-association-study-of-gut-microbiota-in-4gng2ouuna.pdf

A metagenome-wide association study of gut microbiota in type 2 diabetes

Infectious Diseases Society of America.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

/pdf/european-position-paper-on-rhinosinusitis-and-nasal-polyps-mj734vsl7p.pdf

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

Medical and surgical errors are very common in the hospital setting. They increase the number of malpractice lawsuits, the cost of medical care, the length of patients’ hospital stays, and morbidity and mortality. As an infectious diseases specialist for more than 40 years, I was not aware how common these errors are until I became a patient myself after being diagnosed with hypopharyngeal carcinoma. My initial cancer was successfully removed, but there was a local recurrence 20 months later. I underwent pharyngolaryngectomy with flap reconstruction after attempts to remove the cancer by laser failed. Although the care I received was generally very good, I realized that mistakes occurred at all levels of my care. I am sharing my personal experiences about the medical and surgical errors that occurred during my hospitalizations at 3 different hospitals. My inability to speak after surgery made it difficult for me to prevent all these mistakes. Fortunately, I was able to abort many of them. I realized that my surgeons had failed to diagnose the recurrence of my cancer in a timely fashion although they examined me periodically after my initial surgery. I had been complaining of sharp and persistent pain in the right side of my throat for 7 months. The recurrence was finally observed by an astute resident who was the first to ask me to perform a valsalva maneuver (exhale while closing my mouth) during the endoscopic examination. This allowed visualization of the pyriform sinus where the tumor was located. I had wondered why my experienced surgeons never performed such a basic procedure. If they had done so earlier, my tumor (4 × 2 cm) most likely would have been observed and removed much earlier. Subsequently, my surgeons, using laser equipment, mistakenly removed scar tissue instead of the cancerous lesion. A week after the surgery pathological studies revealed that the tumor was actually farther down in the pyriform sinus. This error could have been avoided if frozen sections of the lesion itself, not just its margins, had been analyzed in the operating room. Accordingly, I had to undergo an additional surgeries to remove the tumor. The prior surgery made the repeat attempts more difficult because of swelling and postsurgical changes at the surgical site. I also experienced hazardous situations because of nursing errors. One day after my laryngectomy, while still in the surgical intensive care unit, I experienced airway obstruction and reached for the call button. It was not to be found as it had fallen to the floor. I tried to call the attention of the staff but, even though I was only a few feet away from the nurses’ station, I was ignored until, luckily, my wife arrived 10 minutes later. Without a voice, I was helpless to ask for assistance and was in need of air while medical personnel passed by me. A similar incident took place on the otolaryngology floor a week later when the nurse did not respond to my call to suction my airway. I had difficulty in breathing as mucus in my trachea obstructed my airway. The nurse came to assist me only after 15 minutes. I learned that she was on the phone ordering supplies during all that time. Two physicians and several nursing assistants were on the floor, yet no one responded. Incredibly, even on a ward dedicated to people with airway issues, there were many distractions that prevented physicians and nurses from paying attention to their patients’ immediate needs. The most serious error after my major surgery was prematurely feeding me by mouth with soft food far too soon. Early feeding by mouth after laryngectomy with free flap reconstruction can lead to failure of integration by the flap. Only my persistent questioning brought this to the attention of a senior surgeon, who discontinued the feeding after it had gone on for 16 hours. The error occurred because the order to start feeding was intended for another patient and was erroneously transcribed into my chart. I wonder what would have happened if I had not continued to question the feeding and when (or if) the error would have been discovered. Some of the errors by nursing and other staff included the following: not cleaning or washing their hands, not

A physician's personal experiences as a cancer of the neck patient: errors in my care.

Overview:This article presents my personal experiences as a physician who underwent laryngectomy for hypopharyngeal squamous cell carcinoma. I describe the numerous medical and surgical errors that...

Preventing errors in oncology: perspective of a physician who is also a cancer patient.

https://www.jenonline.org/article/S0099-1767(10)00289-8/pdf

Urgent care of neck breathers.

In Reply.—We read with interest the letter by Shambaugh, who has observed the occurrence of lung abscesses following tonsillectomy in the upright position, and the correlation he documented between the tonsillar flora and the organisms recovered in the lung abscesses. This important observation brought about the abandonment of the sitting-up position during that procedure. The observation by Shambaugh confirms the association between the normal aerobic-anaerobic oral flora and the ones recovered from lung abscesses.1-5The organisms that predominate in lung abscesses (ie,Bacteroidesspecies,Fusobacteriumspecies,Peptostreptococcusspecies, andStreptococcusspecies)2-5are the primary isolates recovered from the surface and core of tonsils.6Patients with recurrent tonsillitis may harbor organisms that are more pathogenic in forming abscesses than those recovered in normal tonsils.7Furthermore, these pathologic tonsils may contain more organisms per tonsil,8and more organisms that produce the enzyme β-lactamase.6,8These factors

Microbiology of the Tonsils and Adenoids-Reply

Paroxysmal hypertension can be associated with failure of the carotid artery baroreceptors due to past exposure to radiation treatment. This report describes a patient whose repeated paroxysmal hypertensive episodes were ameliorated following placement of a carotid artery stent for the treatment of carotid artery stenosis.A 79-year-old caucasian male was diagnosed with hypopharyngeal squamous cell carcinoma (T1, L0, M0) in 2006, and received 70 Gy intensity-modulated radiotherapy in 2006 and underwent a total laryngectomy in 2008. He experienced paroxysmal hypertensive episodes since 2010 that exacerbated in frequency in 2019. Eighty percent left internal carotid artery stenosis was demonstrated by ultrasound and arteriography. Angioplasty and stenting of the left carotid artery was performed. A Doppler ultrasound study performed 5 months after the stent placement did not reveal any hemodynamic stenosis in the left carotid artery. The patient experienced postprandial hypotension and had experienced only three episodes of paroxysmal hypertension in the following 24 months. He was able to abort paroxysmal hypertensive episodes by eating warm food.This is the first report of a patient whose paroxysmal hypertensive episodes that occurred following radiation of the neck subsided after placement of a stent in a stenotic carotid artery. The exact mechanism leading to this phenomena is unknown but may be due to several factors. The reversal of the carotid artery stent and improvement in blood flow to the carotid artery baroceptors may play a role in this phenomenon.The ability to ameliorate paroxysmal hypertensive episodes in a patient with carotid artery stenosis by stent placement may be a promising therapeutic intervention for paroxysmal hypertension. 

/pdf/correction-of-carotid-artery-stenosis-by-stent-placement-171n8uvz.pdf

Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma: a case report

Itzhak Brook

Papers

A physician's personal experiences as a cancer of the neck patient: errors in my care.

Preventing errors in oncology: perspective of a physician who is also a cancer patient.

Urgent care of neck breathers.

Microbiology of the Tonsils and Adenoids-Reply

Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma: a case report