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Introduction: Iron deficiency is one of the most common deficiencies that may occur after Roux-en-Y gastric bypass (RYGB). Little is known about the optimal treatment of post-RYGB iron deficiency.Aim: The aim of this study is to evaluate the changes in iron absorption characteristics after RYGB for two oral iron formulations, one presented in tablet form and one as in the form of a solution.Method: Iron absorption in 24 obese women was studied before and 1 month after RYGB. Twelve patients were tested with a single dose of 600 mg ferrous fumarate in tablet form (195 mg of elementary iron, group 1), and 12 patients received a single dose of 1390 mg ferrous gluconate as a solution (160 mg of elementary iron, group 2). Serum iron levels were measured before (T0) and every hour after ingestion of the supplement (T1-T9).Results: Before surgery, iron absorption was similar for the two supplements (P = 0.71). However, RYGB was associated with a decrease in fumarate iron absorption (P < 0.001) but did not affect gluconate iron absorption (P = 0.13). Postoperative absorption of fumarate iron was significantly lower than gluconate iron at T1 (P < 0.05), but the overall difference over 9 h did not reach statistical significance (P = 0.53).Conclusion: RYGB adversely affects the absorption of ferrous fumarate tablets but not that of solubilized ferrous gluconate. A solubilized supplement is therefore preferred as the supplement of first choice after RYGB. [ABSTRACT FROM AUTHOR]

Summary: Background: After reversal of a rocuronium‐induced neuromuscular blockade with sugammadex, the recovery of train‐of‐four ratio to 0.9 is faster than recovery of first twitch of the train‐of‐four to 90% in adults. These findings after reversal of neuromuscular blockade with sugammadex have not yet been investigated in pediatric patients. Aims: The aim of this retrospective analysis was to investigate the relationship of the recovery of first twitch of the train‐of‐four height and train‐of‐four ratio after reversal of rocuronium‐induced neuromuscular blockade with sugammadex in pediatric patients. Methods: Patients ASA I‐III, aged 2‐11 years, and who underwent abdominal and/or perineal surgery were included in the analysis. After extracting the necessary data from the hospital database, the patients were divided into 2 groups based on the dose of sugammadex received: group A: 2 mg.kg−1 for reversal of moderate neuromuscular blockade and group B: 4 mg.kg−1 for reversal of deep neuromuscular blockade. The relationship of the recovery of first twitch of the train‐of‐four height and train‐of‐four ratio in these 2 groups were analyzed. Results: Data from 43 pediatric patients aged 2‐11 years could be analyzed. The first twitch of the train‐of‐four height at the recovery of train‐of‐four ratio to 0.9 in group B was statistically significantly lower compared with group A. This height 3 and 5 minutes after the train‐of‐four ratio reached 0.9 showed no statistically significant differences between groups. Conclusion: The results were in line with the results found in adults and showed that the train‐of‐four ratio recovered to 0.9 was faster than first twitch of the train‐of‐four height recovered to the same level. [ABSTRACT FROM AUTHOR]

Background: Hypophosphatemia occurs in about 25% of patients admitted to the intensive care unit. To date, a safe and validated phosphate replacement protocol is not available. Objective: To evaluate an individualized phosphate replacement regimen. Design: Fifty consecutive intensive care unit patients with a serum phosphate level <0.6 mmol/L were treated with sodium-potassium-phosphate intravenously at a rate of 10 mmol/h. The dose was calculated according to the following equation: Phosphate dose in mmol = 0.5 × Body Weight × (1.25 - [serum Phosphate]). Phosphate levels were measured immediately upon completion of the infusion, as well as the next morning at 8 AM. Results: Post-infusion phosphate levels were >0.6 mmol/L in 98% of the patients. Hyperphosphatemia, hyperkalemia or a decrease in serum calcium were not observed. In about a third of patients serum phosphate decreased to <0.6 mmol/L within the next 24 hours after infusion. The phosphate distribution volume calculated from the results of infusion and corrected for renal phosphate loss during the infusion period was 0.51 L/kg (95% CI 0.42-0.61 L/kg). Conclusion: This study shows that phosphate replacement with dose calculation based on serum phosphate levels and a Vd of 0.5 L/kg is effective and safe. [ABSTRACT FROM AUTHOR]

Background: Hypophosphatemia and bone disease are common in HIV-positive (HIV+) patients on tenofovir disoproxil fumarate-containing antiretroviral therapy (TDF-containing ART). The underlying etiology is not completely understood. Objective: To examine the effects of treatment of calcium and vitamin D deficiency on phosphate metabolism and bone disease in HIV+ patients on tenofovir. Methods: This was an open-label, pilot study of calcium and phosphate metabolism, bone turnover, and bone density in 24 HIV+ patients on TDF, who were receiving a 1-year treatment for vitamin D and/or calcium deficiency according to a predefined protocol. Eight patients without calcium or vitamin D deficiency served as controls. Results: One-year treatment improved vitamin D levels, decreased serum parathyroid hormone (PTH), and improved calcium balance and bone mineral density. It did not affect the serum levels of PTH-related peptide (PTH-rp) or fibroblast growth factor 23 (FGF-23) nor did it raise serum phosphate levels or decrease renal phosphate loss. Conclusion: Treatment of calcium or vitamin D deficiency in HIV+ patients on ART including TDF has favorable effects on bone density, but it does not improve serum phosphate levels. Renal phosphate wasting in these patients is not caused by excess PTH, PTH-rp, or FGF-23 nor by vitamin D or calcium deficiency. [ABSTRACT FROM AUTHOR]

Purpose: A new system for software-controlled, highly automated correction of intrafraction prostate motion,' intrafraction stereographic targeting' (iSGT), is described and evaluated. Methods: At our institute, daily prostate positioning is routinely performed at the start of treatment beam using stereographic targeting (SGT). iSGT was implemented by extension of the SGT software to facilitate fast and accurate intrafraction motion corrections with minimal user interaction. iSGT entails megavoltage (MV) image acquisitions with the first segment of selected IMRT beams, automatic registration of implanted markers, followed by remote couch repositioning to correct for intrafraction motion above a predefined threshold, prior to delivery of the remaining segments. For a group of 120 patients, iSGT with corrections for two nearly lateral beams was evaluated in terms of workload and impact on effective intrafraction displacements in the sagittal plane. Results: SDs of systematic (Σ) and random (σ) displacements relative to the planning CT measured directly after initial SGT setup correction were <0.5 and <0.8 mm, respectively. Without iSGT corrections, effective Σ and σ for the 11-min treatments would increase to Σeff < 1.1 mm and σeff < 1.2 mm. With the iSGT procedure with an action level of 4 mm, effective positioning errors were reduced to Σeff < 0.8 mm and σeff < 1.0 mm, with 23.1% of all fractions requiring a correction. Computer simulations demonstrated that with an action level of 2 mm, the errors would have been reduced to Σeff < 0.6 mm and σeff < 0.7 mm, requiring corrections in 82.4% of the fractions. Because iSGT is highly automated, the extra time added by iSGT is <30 s if a correction is required. Conclusions: Without increasing imaging dose, iSGT successfully reduces intrafraction prostate motion with minimal workload and increase in fraction time. An action level of 2 mm is recommended. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of the No Action Level (NAL) off-line correction protocol in the reduction of systematic prostate displacements as determined from electronic portal images (EPI) using implanted markers. Methods and Materials: Four platinum markers, two near the apex and two near the base of the prostate, were implanted for localization purposes in patients who received fractionated high dose rate brachytherapy. During the following course of 25 fractions of external beam radiotherapy, the position of each marker relative to the corresponding position in digitally reconstructed radiographs (DRRs) was measured in EPI in 15 patients for on average 17 fractions per patient. These marker positions yield the composite displacements due to both setup error and internal prostate motion, relative to the planning computed tomography scan. As the NAL protocol is highly effective in reducing systematic errors (recurring each fraction) due to setup inaccuracy alone, we investigated its efficacy in reducing systematic composite displacements. The analysis was performed for the center of mass (COM) of the four markers, as well as for the cranial and caudal markers separately. Furthermore, the impact of prostate rotation on the achieved positioning accuracy was determined. Results: In case of no setup corrections, the standard deviations of the systematic composite displacements of the COM were 3-4 mm in the craniocaudal and anterior-posterior directions, and 2 mm in the left-right direction. The corresponding SDs of the random displacements (interfraction fluctuations) were 2-3 mm in each direction. When applying a NAL protocol based on three initial treatment fractions, the SDs of the systematic COM displacements were reduced to 1-2 mm. Displacements at the cranial end of the prostate were slightly larger than at the caudal end, and quantitative analysis showed this originates from left-right axis rotations about the prostate apex. Further analysis revealed that significant time trends are present in these prostate rotations. No significant trends were observed for the prostate translations. Conclusions: The NAL protocol based on marker positions in EPI halved the composite systematic displacements using only three imaged fractions per patient, and thus allowed for a significant reduction of planning margins. Although large rotations of the prostate, and time trends therein, were observed, the net impact on the measured displacements and on the accuracy obtained with NAL was small. [ABSTRACT FROM AUTHOR]

Background: Sugammadex, a γ-cyclodextrin derivative, belongs to a new class of selective relaxant binding agents. Sugammadex was approved 10-years ago by the European medicines agency and today is used in clinical anesthesia and emergency medicine globally. In this review, indications for neuromuscular block, the challenge of neuromuscular monitoring and the practice of under-dosing of sugammadex as a potential cost-saving strategy are discussed. Main body: Reversal of neuromuscular block is important to accelerate the spontaneous recovery of neuromuscular function. Sugammadex is able to reverse a rocuronium- or vecuronium-induced neuromuscular block rapidly and efficiently from every depth of neuromuscular block. However, since sugammadex was introduced in clinical anesthesia, several studies have reported administration of a lower-than-recommended dose of sugammadex. The decision to under-dose sugammadex is often motivated by cost reduction concerns, as the price of sugammadex is much higher than that of neostigmine outside the United States. However, under-dosing of sugammadex leads to an increased risk of recurrence of neuromuscular block after an initial successful (but transient) reversal. Similarly, when not using objective neuromuscular monitoring, under-dosing of sugammadex may result in residual neuromuscular block in the postoperative care unit, with its attendant negative pulmonary outcomes. Therefore, an appropriate dose of sugammadex, based on objective determination of the depth of neuromuscular block, should be administered to avoid residual or recurrent neuromuscular block and attendant postoperative complications. Whether the reduction in perioperative recovery time of the patient can be translated into additional procedural cases performed, faster operative turnover times, or improved organizational resource utilization, has yet to be determined in actual clinical practice that includes verification of neuromuscular recovery prior to tracheal extubation. Conclusions: The current review addresses the indications for neuromuscular block, the challenge of neuromuscular monitoring, the practice of under-dosing of sugammadex as a potential cost-saving strategy in reversal of deep neuromuscular block, the economics of sugammadex administration and the potential healthcare cost-saving strategies. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 50-year-old woman with a history of chronic pulmonary disease presented with fatigue, nausea, and generalized bone pain who was administered with a human monoclonal antibody denosumab. It provides information that the efficacy of denosumab was determined for the treatment of severe tumor-induced hypercalcemia. It concludes that denosumab is a safe alternative for the treatment of tumor-induced hypercalcemia complicated by renal failure.

A letter to the editor is presented about the importance of releasing and luteinizing hormone to treat postmenopausal flushing.