Onkologie und Versorgung in Fach- und Publikumsmedien

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Use of ultrasound for spinal anesthesia in a super morbidly obese patient

We report the application of ultrasound prescans for spinal anesthesia to morbid obesity patient. A 38-year-old woman with a body mass index (BMI) of 50 (weight: 110 kg; height: 148 cm) was scheduled to undergo pilonidal cyst resection at the bottom of the tailbone. Spinal anesthesia was selected for the procedure, because the patient's position during the surgery was prone and the patient had morbid obesity. To determine the spinal needle insertion point and the distance between the skin and dura, we planned to use ultrasound.

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Magnesium sulfate accelerates the onset of low-dose rocuronium in patients undergoing laryngeal microsurgery

We evaluated the effect of magnesium sulfate—an enhancer of neuromuscular blockade—on onset and duration of low dose of rocuronium, and on operating conditions during laryngeal microsurgery.

http://ift.tt/2gN3m6a

Monitoring of the intraoperative analgesia by pupillometry during laparoscopic splenectomy for splenic hydatid cyst

Echinococcosis causes a hydatid cyst, a worldwide disease. Human beings are intermediate hosts, but dogs complete the life cycle of the cestode. The most common presentation sites are the liver and lungs. We present an unusual case of a primary splenic hydatid cyst. Open splenectomy has traditionally been the treatment of choice for splenic hydatid cysts. In recent years, minimally invasive laparoscopic surgery has been used in appropriate cases. A healthy 48-year-old woman was scheduled for laparoscopic splenectomy.

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Effect of total intravenous vs volatile anesthetics on intraoperatively acquired electrically evoked compound action potential in children undergoing cochlear implant surgery: A randomized prospective study

The purpose of the present study was to compare the effects of inhalational anesthesia to those of total intravenous anesthesia on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in children undergoing cochlear implantation.

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Medical students’ understanding of oral and maxillofacial surgery: an Irish perspective

Publication date: Available online 30 November 2016
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): P.G.C. Kielty, B.R. O'Connor, C.J. Cotter, A.M.C. Goodson, K.F.B. Payne, A. Tahim
Oral and Maxillofacial Surgery (OMFS) remains an enigmatic specialty in Irish medicine and many students are unaware of its scope and the unique career pathway involved. We performed a multicentre cross-sectional study to identify their ability to identify the requirements for entry to specialty training year 3 (ST3) in OMFS, to assess their awareness of OMFS surgeons, and their general awareness of, and exposure to, the specialty. Data were collected through an electronic questionnaire. Participants were asked to select the most suitable surgical specialty to treat a number of common conditions in the head and neck, and to choose the requirements they deemed essential for specialist training. Knowledge was measured by the number of correct responses. A total of 443 medical students participated (University College Cork (UCC) n=328, 74%; Royal College of Surgeons in Ireland (RCSI) n=113, 26%). A total of 318/374 (85%) had had no previous experience of OMFS, 38/374 (10%) had had theoretical teaching only, and 18/374 (5%) had had clinical experience. A total of 212/329 (64%) wished for greater exposure as a student, but only 34/329 (9%) would consider a career in the specialty. The median (IQR) number of correct responses for OMFS procedures was 3.0/10 (2.0), with women, direct entrants, and RCSI students scoring highest. Only 11/367 (3%) could identify the minimum entry requirements for a post of specialist registrar. This study has identified a potential gap in the undergraduate curriculum. Although medical students are rarely taught about OMFS, they show an interest in learning more.



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Minimally invasive endoscopic treatment for pediatric combined high grade stenosis as a laryngeal manifestation of epidermolysis bullosa

Publication date: January 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 92
Author(s): Dora Palinko, Vera Matievics, Ilona Szegesdi, Balazs Sztano, Laszlo Rovo
Epidermolysis bullosa refers to a clinically and genetically heterogeneous group of inherited mucocutaneous diseases. Laryngotracheal lesions are momentous regarding the risk of sudden airway obstruction. The traditional treatment is tracheostomy. This case report highlights the advantages of minimally invasive interventions. A successful combined endoscopic management of a life-threatening respiratory crisis is presented in a 4-year-old child. Combined commissure stenosis with supraglottic spread was treated by CO2 laser dissection and bilateral endoscopic arytenoid abduction lateropexy, supplemented with mitomycin C application. Due to expectable less scarring, the combination of these modern methods may be an efficient solution in these vulnerable respiratory tracts.



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School entry level tele-hearing screening in a town in South India – Lessons learnt

Publication date: January 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 92
Author(s): Saleth D Monica, Vidya Ramkumar, Mark Krumm, Nitya Raman, Roopa Nagarajan, Lakshmi Venkatesh
IntroductionSchool screening is warranted in developing countries that do not have newborn hearing screening as schools provide access to a large number of young children between 3 and 5 years of age. Due to scarcity of technical manpower and equipment, hearing screening programs are not often conducted in developing countries. In these circumstances, telehealth services appear to be a reasonable solution. Consequently, the purpose of this study was to assess the feasibility of school hearing screening using telehealth technology operated by a practitioner located 400 kms away at a distant hospital.MethodThirty one children received hearing screening procedures in their school. Each child was screened for both in-person and telehealth conditions to assess screening results. Remote computing software was employed for the telehealth condition in order for the practitioner to remotely operate an audiometer, DPOAE system and a video otoscope interfaced to a personal computer at the school site.Teamviewer version 10 was used to provide encrypted videoconferencing and synchronous hearing screening services between the hospital and school sites. All screening was conducted using a mobile phone hotspot or dongle device based internet connection to insure reliable connectivity.ResultsThe outcome revealed no significant difference between PTA and DPOAE performed in-person and tele-hearing screening methods. Concurrence of greater than 87% was achieved between in-person and tele-video-otoscopy. Strengths and challenges were documented for tele-hearing screening in three different dimensions: technical issues, child related and school related. Understanding these challenges may provide more effective tele-audiology services.DiscussionThe results of the study indicate synchronous hearing screening services can be provided in a school setting using mobile hotspot or dongle connectivity in locations where Internet bandwidth is otherwise restricted.



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The utility of early developmental assessments on understanding later nonverbal IQ in children who are deaf or hard of hearing

Publication date: January 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 92
Author(s): Jareen Meinzen-Derr, Susan Wiley, Jannel Phillips, Mekibib Altaye, Daniel I. Choo
ObjectiveIn children who are deaf or hard of hearing (DHH), it is helpful to have meaningful early measures of development in order to provide effective interventions and offer benchmarks that help recognize varied developmental trajectories. The main objective of this study was to compare results of an early developmental assessment prior to 3 years of age to later nonverbal IQ assessed between 3 and 6 years of age in children who are DHH.MethodsThis study included children 3–6 years of age with bilateral permanent hearing who were enrolled in a prospective cohort study on developmental outcomes. As part of the study, children received the Leiter International Performance Scale-Revised, which provided a nonverbal Brief IQ, as well as standardized language assessment and behavioral checklists. Children were included in this analysis if they had received an early developmental assessment with the Gesell Developmental Schedules-Revised as part of a clinical visit with a developmental pediatrician. Correlation coefficients and multiple regression analysis were used to associate the scores on the Gesell (using a developmental quotient) with scores on the Leiter-R Brief IQ.ResultsForty-five participants who enrolled in the observational study had available evaluation results from the Gesell and complete Brief IQ results from the Leiter-R. The adaptive domain of the Gesell had good correlation (r = 0.61, p < 0.0001) with the Brief IQ on the Leiter-R. Children who had stable developmental or intelligence classifications based on scores (<70, 70 to <85, 85 to <100, ≥100) over time were older (>24 months) at the early Gesell assessment. Degree of hearing loss or maternal education did not appear to confound the relationship between the Gesell and the Leiter-R.ConclusionsThe adaptive domain of the Gesell Developmental Schedules – Revised administered in early childhood (under 3 years of age) has good correlation with the nonverbal Brief IQ on the Leiter International Performance Scale-R. Because children who are DHH have a higher likelihood of having a developmental disability compared to the general population, early developmental assessments are often important. Although early developmental assessments have their limitations, our results indicate that they are fairly robust indicators of later development. Such early indicators can be extremely useful in the clinical and educational management of children who are DHH.



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A mini-survey of moulds and mycotoxins in locally grown and imported wheat grains in Nigeria

Abstract

A preliminary survey involving limited sample size was conducted to determine the spectrum of moulds and mycotoxins in wheat grains from flour mills and local markets in Nigeria. Fourteen wheat samples were analyzed for moulds using standard mycological methods and for toxic fungal metabolites using a liquid chromatography-tandem mass spectrometric method. Fusarium (range of incidence 12.5–61.7%) dominated in the wheat grains though species of Aspergillus (range of incidence 2.24–3.86%) were also recovered from the samples. The identified fungal species were Aspergillus flavus (7.7%), Aspergillus niger clade (2.6%), Fusarium avenaceum (10.9%), Fusarium culmorum (22.4%) and Fusarium graminearum (56.4%). A total of 54 microbial metabolites were detected in the samples at concentration ranging between 0.01 μg/kg for macrosporin and 2560 μg/kg for deoxynivalenol. Among the four mycotoxins addressed by regulations in the European Union (EU) found in the samples, deoxynivalenol (incidence 100%) dominated in the samples and its levels exceeded the maximum acceptable EU limit (750 μg/kg) in 36% of the samples. This report underscores the need for more robust surveys with larger sample sizes and across several agro-ecologies in the country.

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Under-Treatment of Patients with Moderate to Severe Psoriasis in the United States: Analysis of Medication Usage with Health Plan Data

Abstract

Introduction

Psoriasis is a chronic inflammatory disorder with significant morbidity and mortality, but a persistent gap appears to exist for the adequate treatment of patients with moderate to severe disease. As the extent of under-treatment is unknown, we attempted to determine overall treatment patterns and estimate under-treatment using a large database.

Methods

Data from the US National Health and Wellness Survey was used to estimate the proportion of patients with mild, moderate or severe psoriasis. The proportion with moderate to severe disease was estimated by excluding those with mild disease, and projecting this to the total insured US population, weighted by age and gender. Using US health plan claims data, patient totals by treatment type were determined between October 1, 2007 and September 30, 2012. Patients had to be continuously enrolled in a health plan and be ≥18 years at the end of the analysis window. Psoriasis was confirmed if patients had at least one claim of any type of psoriasis except psoriatic arthropathy (ICD-9 code 696.1). A monthly treatment history, classified by biologic, traditional oral systemic, phototherapy and topical therapy, was recorded for each patient.

Results

There were an estimated 1.7 million insured US patients with moderate to severe psoriasis. Of these, 1 million (59%) were not treated for their condition in the preceding year. Among 695,488 patients who were treated for psoriasis in the preceding year, 346,201 were currently receiving treatment and 349,287 had lapsed treatment. Of the patients lapsed and currently treated in this period, the numbers who received each treatment type were 156,409 (biologic), 222,657 (traditional oral systemic), 22,911 (phototherapy), and 293,511 (topical). A limitation of the study was that only insurance claims were analyzed.

Conclusion

Moderate to severe psoriasis remains persistently untreated or under-treated. We suggest that potential barriers preventing access to care be explored.

Funding

This study was sponsored by Pfizer Inc.

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Fixed-Combination Gels of Adapalene and Benzoyl Peroxide Provide Optimal Percutaneous Absorption Compared to Monad Formulations of These Compounds: Results from Two In Vitro Studies

Abstract

Introduction

Adapalene 0.1%/benzoyl peroxide 2.5% (0.1% A/BPO) and adapalene 0.3%/BPO 2.5% (0.3% A/BPO) gels are fixed-combination options for the topical treatment of acne. However, the active compounds of these combinations are also available as monads, to be used in association or as monotherapy. These two in vitro studies determined the effect of different treatment regimens on the percutaneous absorption of adapalene (0.1% and 0.3%) gels and BPO 2.5% gel in ex vivo human skin.

Methods

In vitro percutaneous absorption studies were conducted using full-thickness human skin from six donors. Treatment regimens included the application of 0.1% A/BPO, 0.3% A/BPO, or four free-combination regimens of the monads. Skin samples were incubated for 24 h. Concentrations of adapalene and BPO equivalent (BPO-eq) (i.e. benzoic acid after chemical transformation of BPO) were measured using high-performance liquid chromatography. Comparison of regimens was performed using a bioequivalence criterion (estimated ratio bewteen 0.8 and 1.25).

Results

The fixed combination 0.3% A/BPO regimen demonstrated more than three times higher absorption of adapalene versus the fixed-combination 0.1% A/BPO. Based on the bioequivalence acceptance criterion, all four free-combination regimens were different from 0.1% A/BPO and 0.3% A/BPO, with higher adapalene release delivered by the fixed combinations versus the free combinations. For BPO-eq, the results showed that the free-combination regimens where adapalene 0.1% was applied first were different from 0.1% A/BPO, with lower BPO-eq release delivered by these regimens compared to the fixed combination. The regimen adapalene 0.3% for 10 h followed by BPO 2.5% delivered lower BPO-eq release compared to the fixed combination.

Conclusion

The fixed-combination A/BPO gels provide optimal percutaneous absorption of the active compounds compared to free combinations of adapalene 0.1%, adapalene 0.3%, and BPO 2.5%. The higher concentration of adapalene in the 0.3% A/BPO gel and the resulting higher absorption may explain higher clinical efficacy.

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Komplementäre Medizin und Prävention

Zusammenfassung

Hintergrund

Die Auswirkungen von Lebensstilfaktoren wie körperliche Aktivität und Ernährung auf Entstehung und Verlauf von Krebs ist seit über 60 Jahren Gegenstand klinischer und epidemiologischer Forschung. Obwohl viele Fragen noch offen bleiben, ermöglichen aktuelle Studien evidenzbasierte Empfehlungen für die primäre und tertiäre Krebsprävention.

Methoden

Im Rahmen einer Literaturrecherche wurden Übersichtsarbeiten zum Einfluss von körperlicher Aktivität und Ernährung auf Krebs sowie Studien zu aktuellen Entwicklungen in diesen Themengebieten identifiziert.

Ergebnisse

Körperliche Aktivität trägt zur primären Prävention von Kolonkarzinomen, postmenopausalem Brustkrebs und Endometriumkarzinomen bei. Der vermehrte Verzehr von rotem Fleisch und verarbeiteten Fleischprodukten ist mit einer Erhöhung des Krebsrisikos assoziiert. Eine obst-, gemüse- und ballaststoffreiche Ernährung hängt demgegenüber mit einer Senkung des Krebsrisikos zusammen. Körperliche Aktivität kann während jeder Therapiephase unter Berücksichtigung der individuellen Probleme durchgeführt werden. Studienergebnisse berichten von verbesserter Leistungsfähigkeit und Lebensqualität, einer Verminderung von therapieassoziierten Nebenwirkungen sowie Senkung des Rezidivrisikos durch eine körperliche Aktivität.

Schlussfolgerungen

Evidenzbasierte Empfehlungen zur Krebsprävention durch körperliche Aktivität und Ernährung sollen in die Behandlung von onkologischen Patienten und in die Versorgung der Allgemeinbevölkerung integriert werden. Innovative Programme wie „Jetzt aktiv!", die kompetente Beratung bezüglich Ernährung und körperlicher Aktivität nach einer Krebserkrankung anbieten, werden an Krebsberatungsstellen entwickelt und erfolgreich eingesetzt.

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Körperliche Beschwerden und psychosoziale Belastungen bei Endometriumkarzinom

Zusammenfassung

Hintergrund

Das Endometriumkarzinom ist in Deutschland die vierhäufigste gynäkologische Tumorerkrankung. Dank der Früherkennung sowie verbesserter medizinischer Therapien liegt das Fünfjahresüberleben für die betroffenen Patientinnen bei 74–91 %. Bei sinkender Mortalität und steigender chronischer Morbidität steigt auch die Zahl der Patientinnen, die an Überlebenszeit gewinnen.

Ziele und Fragestellungen

Ziel dieses Artikels ist es, körperliche und psychische Belastungsfaktoren bei Patientinnen mit Endometriumkarzinom zu benennen und Unterstützungsbedürfnisse aufzuzeigen.

Ergebnisse

Bei der Einschätzung des subjektiven Bedarfs an psychosozialer Beratung, Begleitung oder Behandlung korrelieren der körperliche Zustand und das subjektive Befinden der betroffenen Frauen kaum. Potenziell belastende Kontextfaktoren sollten im Arzt-Patienten-Gespräch aktiv erfragt werden. Zu allen Zeitpunkten im individuellen Krankheits- und Behandlungsverlauf können psychosoziale Belastungen bei Patientinnen, ihren Partnern und Angehörigen auftreten. Ein erleichterter Zugang zu psychoonkologischen/psychosozialen Versorgungsangeboten sollte über alle Behandlungs- und Nachsorgezeiträume bereitgestellt werden. Die Art der Behandlung beeinflusst die Lebensqualität der Betroffenen. Frauen in höherem Lebensalter leiden eher an somatischen Funktionsstörungen, jüngere dagegen häufiger unter psychosozialen Belastungen. Die spezifischen körperlichen Beschwerden umfassen postoperative Schmerzen, Dysurie, Harn- und Stuhlinkontinenz, Scheidentrockenheit und Dyspareunie. Klimakterische Beschwerden treten häufig auf. Im Langzeitverlauf kommen behandlungsbedürftige psychische Belastungen wie Ängste, Anpassungsstörungen und Depressionen hinzu.

Schlussfolgerungen

Je selbstverständlicher und offener mögliche Probleme, z. B. Therapiefolgen, im Arzt-Patienten-Gespräch vom Arzt oder Behandlerteam proaktiv angesprochen werden, desto leichter wird es für die Patientinnen, ihre Schwierigkeiten oder Ängste zu verbalisieren. Dies ist gerade bei gynäkologischen Tumorerkrankungen mit ihren spezifischen Therapiefolgen, die sich unmittelbar auf Körperbild und -erleben sowie Intimität und Sexualität der Betroffenen auswirken, von großer Bedeutung.

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Analysis of feline and canine allergen components in patients sensitized to pets

Component resolved allergen diagnosis allows for a precise evaluation of the sensitization profiles of patients sensitized to felines and canines. An accurate interpretation of these results allows better insi...

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Factors associated to post-operative nausea and vomiting following oral and maxillofacial surgery: a prospective study

Abstract

Aim

This study aims to address and assess possible factors associated with nausea and vomiting (NV) following oral and maxillofacial surgery.

Material and methods

A prospective study was carried out in the period from December 2013 to January 2016 targeting all attended cases in that period. For statistical analysis, Pearson chi-square and Fisher tests were used to verify association and ANOVA and Student's t tests to test for significant difference, p was defined as ≤0.05. The sample group consisted of 207 patients with an average age of 33.56 years (±13.23), and 70.5% of subjects were male.

Results

Calculations based on the predictive model showed that a female patient with prior history of nausea and vomiting who used opioids and had intra-oral surgical access would have a 96% chance of experiencing a nausea and vomiting episode.

Other factors like age, being overweight, anesthesia, surgery duration, and duration of hospital stay also contribute so that these aspects must be paid careful attention prior to surgery to ensure a suitably orientated treatment that will avoid disturbances caused by post-operative nausea and vomiting.

Conclusion

The occurrence of post-operative nausea and vomiting after oral and maxillofacial surgery was found to be more higher incidence associated to female patients who used opioids, who had a prior history of NV, whose surgery involved intra-oral access, who were in the second or third decades of their lives, who have above average weight, and who have long anesthesia when undergoing surgery, resulting in a long hospital stays.

http://ift.tt/2gL5Fa3

Botulinum Toxin Type A Block of the Sphenopalatine Ganglion in Chronic Rhinosinusitis With Nasal Polyposis

Conditions:   Chronic Disease;   Nasal Polyposis;   Rhinitis
Intervention:   Drug: botox injection Multiguide
Sponsors:   Norwegian University of Science and Technology;   St. Olavs Hospital
Recruiting - verified November 2016

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Adrenal Cushing syndrome with detectable ACTH from an unexpected source

Mixed corticomedullary adrenal tumours (MCMT) are rare. We describe the second reported case of a male patient presenting with hypertension and Cushing syndrome with MCMT. A man aged 48 years presented with hypertension and signs of Cushing syndrome. 24-hour urine cortisol was elevated, with detectable adrenocorticotropic hormone (ACTH). A high-dose dexamethasone suppression test indicated an adrenal or ectopic Cushing syndrome. Plasma metanephrines were normal. A 3 cm left adrenal mass was identified without potential ectopic sources of ACTH on imaging. After induction of anaesthesia for laparoscopic adrenalectomy, the patient developed resistant hypertension with stress-dose hydrocortisone administration. Surgery was cancelled and repeat testing revealed elevated plasma metanephrines. α-Blockade was administered for a presumed coexisting pheochromocytoma, and the patient underwent adrenalectomy. Pathology revealed an MCMT. This case highlights the importance of a thorough biochemical evaluation in patients with adrenal masses to rule out multiple hormone producing tumours.

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Medium-chain acyl-Coenzyme A dehydrogenase deficiency (MCADD): a cause of severe hypoglycaemia in an apparently well child

Medium-chain acyl-Coenzyme A dehydrogenase deficiency (MCADD) is a disorder of fatty acid β oxidation inherited in an autosomal recessive manner. The enzyme is useful in hepatic ketogenesis, a major source of energy once hepatic glycogen stores become depleted during prolonged fasting. It is a cause of hypoketotic hypoglycaemia in a previously well child. MCADD is not part of newborn screening in Ireland; children are likely to be missed if routine hypoglycaemic screen is not instituted when blood glucose level is below 2.6 mmol/L. This is a case of an otherwise healthy 23-month-old baby girl who presented with severe hypoglycaemia with some initial diagnostic dilemma.

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First reported case of peroneal tenosynovitis caused by Coccidioides immitis successfully treated with fluconazole

Coccidioidomycosis is an insidious infection caused by Coccidioides spp (C. immitis and C. posadasii). Disseminated disease occasionally involves tendon sheaths and synovium of the joints leading to tenosynovitis. Here, we describe the case of a 72-year-old woman from southern Arizona, who presented with right ankle pain, redness and swelling for 2 months. Her serum IgG was positive for C. immitis on complement fixation, and her MRI of the right ankle joint showed extensive tenosynovitis of the right peroneal tendons, and subtalar joint effusions with associated synovitis. The purpose of this case is to report an extremely rare manifestation of disseminated C. immitis, that is, peroneal tenosynovitis and challenges involved with diagnosis and treatment. We also document that azole therapy is an effective treatment option for peroneal tenosynovitis caused by C. immitis, and we had to double the dose for slow symptom resolution with 4-week trial with usual 400 mg oral dose of fluconazole.

http://ift.tt/2gGgoGn

Acute promyelocytic leukaemia: looking through 'gums

Description

Examination of the oral cavity provides valuable clues to a large number of systemic disorders. Gum hypertrophy is usually associated with myelomonocytic and monocytic subtypes of acute myeloid leukaemia.1 Its occurrence in a case of acute promyelocytic leukaemia (APL) is unusual.1

We describe a 28-year-old man from India who presented to our hospital with a 2-week history of easy fatiguability and gum bleeding. Examination revealed pallor and marked gum hypertrophy (figure 1). Blood investigations showed haemoglobin 50 g/L, white cell count 5.4x10⁹/L, differential counts 95% promyelocytes, 3% myelocytes, 1% metamyelocytes and 1% neutrophils, platelets 30x10⁹/L, prothrombin time 18 s (control 14 s), activated partial thromboplastin time 42 s (control 34–36 s) and fibrinogen 1.5 g/L (2–4 g/L). Examination of the bone marrow aspirate smears revealed typical Faggot cells (figure 2A, B). Conventional karyotyping revealed t(15;17). PML-RARα was detected in the bone marrow aspirate by reverse...

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Course of membranous nephropathy during multiple gestations

Description

The physiological adaptations in pregnancy can unmask underlying occult proteinuric renal disease. However, the effect of multiple pregnancies on the course of the disease is variable. We report the clinical course of a case of idiopathic membranous nephropathy through multiple pregnancies.

A 25-year-old Hispanic woman was referred to our institution for worsening generalised swelling of the body, uncontrolled hypertension and 21 g/day of proteinuria at 34 weeks' gestation during her third pregnancy. There were no stigmata suggestive of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. She was previously seen at our institution 5 years ago during her 1st pregnancy when 13 g/day of proteinuria was recorded at 25 weeks of gestation. At that time, she was treated with oral steroids and delivery was induced at 35 weeks due to intrauterine growth restriction. Placental biopsy revealed focal, tightly adherent blood clot, consistent with possible abruption. Renal biopsy performed in the postpartum period...

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Early severe coronary artery disease and aortic coarctation in a child with familial hypercholesterolaemia

An 11-year-old boy presented with easy fatigability, multiple xanthomas, and absent pedal pulsations. Laboratory workup showed severe hypercholesterolaemia and non-invasive imaging revealed 'normally functioning' bicuspid aortic valve and tight aortic coarctation. Coronary angiography showed severe right coronary artery (RCA) stenosis. Medical treatment resulted in significant improvement of dyslipidaemia. We successfully performed balloon dilation and stenting of his coarctation, as well as percutaneous coronary intervention for RCA lesion.

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Effect of an early supervised rehabilitation programme compared with home-based exercise after temporomandibular joint condylar discopexy: a randomized controlled trial

Publication date: Available online 29 November 2016
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): N. Capan, S. Esmaeilzadeh, A. Karan, D. Dıracoglu, U. Emekli, A. Yıldız, A. Baskent, C. Aksoy
The goal of rehabilitation after temporomandibular joint (TMJ) surgery is to achieve a normal range of motion. The aim of this study was to compare the impact of a comprehensive and early supervised rehabilitation programme with home-based exercise after TMJ condylar discopexy. Patients diagnosed with disc displacement without reduction were randomized to the study and control groups. After baseline assessments, the same surgical condylar discopexy procedure was applied to both groups. Following surgery, the study group patients underwent a supervised exercise programme conducted by a physiotherapist in the outpatient clinic. This comprised 30-min sessions 3 days per week for 8 weeks in the hospital. The control group patients performed the same exercise programme at home. Maximum mouth opening (MMO), protrusion, and right and left lateral movements were measured. Based on the results, the supervised rehabilitation programme yielded significantly better outcomes for pain at rest and with activity, MMO, and protrusion compared with the home-based exercise programme. Also certain parameters of quality of life improved significantly in the study group. In conclusion, exercise therapy is the cornerstone of rehabilitation of the TMJ, and a supervised rehabilitation programme after TMJ surgery is effective in improving functional parameters.



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To the Editor: Combined immunodeficiency and hypoglycemia associated with mutations in hypoxia up-regulated 1

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Emma M. Haapaniemi, Christopher L. Fogarty, Salla Keskitalo, Shintaro Katayama, Helena Vihinen, Mette Ilander, Satu Mustjoki, Kaarel Krjutškov, Markku Lehto, Timo Hautala, Ove Eriksson, Eija Jokitalo, Vidya Velagapudi, Markku Varjosalo, Mikko Seppänen, Juha Kere

Teaser

We describe recessive mutations in hypoxia up-regulated 1 (HYOU1) in a patient that presented with generalized susceptibility to bacterial and herpetic infections as well as hypoglycemic episodes.


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Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Brittany T. Straka, Claudia E. Ramirez, James B. Byrd, Elizabeth Stone, Alencia Woodard-Grice, Hui Nian, Chang Yu, Aleena Banerji, Nancy J. Brown
BackgroundThe B2 receptor antagonist icatibant is approved for treatment of attacks of hereditary angioedema. Icatibant has been reported to decrease time-to-resolution of angiotensin-converting enzyme (ACE) inhibitor-associated angioedema in one study of European patients.MethodsPatients with ACE inhibitor-associated angioedema (defined as swelling of lips, tongue, pharynx or face during ACE inhibitor use and no swelling in the absence of ACE inhibitor use) were enrolled at Vanderbilt University Medical Center from October 2007 through September 2015 and at Massachusetts General Hospital in 2012. C1 inhibitor deficiency and patients with bowel edema only were excluded. Patients were randomized within six hours of presentation to subcutaneous icatibant 30 mg or placebo at zero and six hours later. Patients assessed severity of swelling using a visual analog scale serially following study drug administration or until discharge.ResultsThirty-three patients were randomized and 31 received treatment, with 13 receiving icatibant and 18 receiving placebo. One patient randomized to icatibant did not complete the visual analog scale and was excluded from analyses. Two-thirds of patients were African American and two-thirds were women. Time-to-resolution of symptoms was similar in placebo and icatibant treatment groups (p=0.19 for the primary symptom and p>0.16 for individual symptoms of face, lip, tongue, or eyelid swelling). Frequency of administration of H1 and H2 blockers, corticosteroids, and epinephrine was similar in the two treatment groups. Time-to-resolution of symptoms was similar in black and white patients.ConclusionsThis study does not support clinical efficacy of a bradykinin B2 receptor antagonist in ACE inhibitor-associated angioedema.

Teaser

This randomized, placebo-controlled double-blind study does not shown any benefit of administration of the bradykinin B2 receptor antagonist icatibant in patients presenting with angiotensin-converting enzyme inhibitor-associated angioedema. This contrasts studies in hereditary angioedema.


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An mTORC1/AKT1/Cathepsin H axis controls filaggrin expression and processing in skin, a novel mechanism for skin barrier disruption in Atopic Dermatitis

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Aishath S. Naeem, Cristina Tommasi, Christian Cole, Stuart J. Brown, Yanan Zhu, Benjamin Way, Saffron AG. Willis Owen, Miriam Moffatt, William O. Cookson, John I. Harper, Di WL, Sara J. Brown, Thomas Reinheckel, Ryan F.L. O'Shaughnessy
BackgroundFilaggrin, encoded by the FLG gene, is an important component of the skin's barrier to the external environment and genetic defects in FLG strongly associate with Atopic Dermatitis (AD). However, not all AD patients have FLG mutations.ObjectiveWe hypothesised that these patients may possess other defects in filaggrin expression and processing, contributing to barrier disruption and AD, and therefore present novel therapeutic targets for this disease.ResultsWe describe the relationship between the mTORC1 protein subunit RAPTOR, the serine/threonine kinase AKT1 and the protease cathepsin H, for which we establish a role in filaggrin expression and processing. Increased RAPTOR levels correlated with decreased filaggrin expression in AD. In keratinocyte cell culture, RAPTOR up-regulation or AKT1 shRNA knockdown reduced the expression of the protease cathepsin H. Skin of cathepsin H-deficient mice and CTSH shRNA knockdown keratinocytes showed reduced filaggrin processing and the mouse showed both impaired skin barrier function and a mild proinflammatory phenotype.ConclusionOur findings highlight a novel, potentially treatable, signalling axis controlling filaggrin expression and processing which is defective in AD.

Graphical abstract

Teaser

Capsule:FLG mutations strongly associate with Atopic Dermatitis (AD). However, not all AD patients have FLG mutations. An mTORC/AKT1 signalling axis controls both filaggrin expression and processing by controlling expression of the protease Cathepsin H.


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Oral Immunotherapy–Induced Gastrointestinal Symptoms and Peripheral Blood Eosinophil Responses

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Michael R. Goldberg, Arnon Elizur, Liat Nachshon, Michael Y. Appel, Michael B. Levy, Keren Golobov, Robert Goldberg, Miguel Stein, Marc E. Rothenberg, Yitzhak Katz

Teaser

Capsule Summary: Oral immunotherapy-induced gastrointestinal and eosinophilic responses (OITIGER) is an adverse response to OIT in ∼8% of patients and is typically reversible by decreasing dosage administration. The peripheral blood eosinophil count serves as a biomarker marker for susceptibility and the medical course.


http://ift.tt/2gxKOrh

Effects of nongenetic factors on immune cell dynamics in early childhood: The Generation R Study

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Diana van den Heuvel, Michelle A.E. Jansen, Kazem Nasserinejad, Willem A. Dik, Ellen G. van Lochem, Liesbeth E. Bakker-Jonges, Halima Bouallouch-Charif, Vincent W.V. Jaddoe, Herbert Hooijkaas, Jacques J.M. van Dongen, Henriëtte A. Moll, Menno C. van Zelm
Background. Numbers of blood leukocyte subsets are highly dynamic in childhood and differ greatly between individuals. Inter-individual variation is only partly accounted for by genetic factors.ObjectiveDetermine which nongenetic factors affect the dynamics of innate leukocytes, and naive and memory lymphocyte subsets.Methods. We performed six-color flow cytometry and linear mixed effect modeling to define the dynamics of 62 leukocyte subsets from birth to 6 years of age in 1,182 children with one to five measurements per individual. Subsequently, we defined the impact of prenatal maternal lifestyle-related or immune-mediated determinants, birth characteristics and bacterial/viral exposure-related determinants on leukocyte subset dynamics.Results. Functionally similar leukocyte populations were grouped by unbiased hierarchical clustering of patterns of age-related leukocyte dynamics. Innate leukocyte numbers were high at birth and were predominantly affected by maternal low education level. Naive lymphocytes peaked around 1 year, while most memory lymphocyte subsets more gradually increased during the first 4 years of life. Dynamics of CD4⁺ T cells were predominantly associated with gender, birth characteristics, and persistent infections with cytomegalovirus (CMV) or Epstein Barr virus (EBV). CD8⁺ T cells were predominantly associated with CMV and EBV infections, and TCRγδ⁺ T cells with premature rupture of membranes and CMV infection. B-cell subsets were predominantly associated with gender, breastfeeding and Helicobacter pylori carriership.Conclusions. Our study identifies specific dynamic patterns of leukocyte subset numbers, as well as nongenetic determinants that affect these patterns, thereby providing new insights into the shaping of the childhood immune system.

Graphical abstract

Teaser

Capsule Summary: Human inter-individual immunological diversity can only partly be explained by genetic factors, indicating an important contribution of nongenetic factors. We here analyzed leukocyte dynamics in 1,182 children of the Generation R Study and determined the effect of 26 nongenetic factors on inter-individual immunological diversity.


http://ift.tt/2fR7952

Predictive factors and treatment outcome of laryngeal carcinoma recurrence

Abstract

Background

Up to 30% of patients with laryngeal squamous cell carcinoma (SCC) present with recurrence after treatment. We analyzed factors associated with the risk of cancer recurrence and prognosis after recurrence.

Methods

A nationwide laryngeal SCC cohort from Finnish university hospitals during 2001 to 2005 with initial successful therapy (n = 316) was analyzed.

Results

Laryngeal SCC recurred in 22% of patients. The median time to recurrence was 9 months, with 90% occurring within 36 months after treatment. The World Health Organization (WHO) performance status >0, neck metastasis at presentation, and nonsurgical treatment were independent prognostic factors for recurrence. Patients with local recurrence had a 5-year overall survival (OS) of 53% compared with 5% in patients with regional/distant recurrences. OS for glottic and nonglottic laryngeal SCC recurrence was 45% and 0%, respectively.

Conclusion

The type of treatment affected the risk of recurrence in this retrospective series. Local recurrences carried a chance for successful salvage treatment. Routine follow-up beyond 36 months remains controversial. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Rhinosporidiosis: A Rare Cause of Proptosis and an Imaging Dilemma for Sinonasal Masses

Background. Rhinosporidiosis is a common disease entity in tropical countries; however, it can be encountered in other parts of the world as well due to increasing medical tourism. It may mimic other more malignant and vigorous pathologies of the involved part. Case Report. We present a case of a 36-year-old male presenting with proptosis due to involvement of nasolacrimal duct which is rare. We will discuss typical CT and MRI features of the disease which were present in the case. Conclusion. For a surgeon and a radiologist, this is a necessary differential to be kept in mind for sinonasal masses. CT and MRI are invaluable investigations. However, FNAC is confirmatory. Both clinical and radiological aspects are required to reach correct diagnosis.

http://ift.tt/2g6dh76

“The Crossroad between Dentistry and Medicine” at ADEE & AMEE

By Prof. Rui Amaral Mendes and Dr. Seema Biswas

In August, taking advantage of having our annual meetings in the same city – the beautiful Barcelona – ADEE (the Association for Dental Education in Europe) and its medical counterpart, AMEE (the Association for Medical Education in Europe), convened efforts to hold a joint scientific and business meeting under the topic of: "The crossroad between Dentistry and Medicine".

More than a mere morning workshop's theme, this is a major trend worldwide and should be regarded as one of the major challenges pending upon two of the major stakeholders as far as Heathcare providing is concerned.

According to the World Health Organization, Interprofessional Education (IPE) is a necessary step in planning a "collaborative practice-ready" health workforce that is better prepared to respond to local and global health needs. A similar opinion is shared by ADEE's American colleagues from ADEA.

Still, the important thing is how we, educators, can use a potentially good idea and put in to good use, ensuring that our students get the best possible training, in line with the most recent FDI definition of oral health, as an "integral part of general health and well-being".

Hence, being, as we are, well-aware and committed to this evolving educational paradigm of Interprofessional Education and Learning and Interprofessional Collaborative Practice (IPCP), one must also consider the prospects of a partnership that makes the best out of each other's know-how, while keeping in mind that the European Directive 2005/36/EC, issued by the European Parliament and by the Council, establishing the EU legal foundations for the recognition of professional qualifications, makes it even more pertinent, not to say imperative, that both ADEE and AMEE join efforts in a combine approach advocating for new European Directives calling for a competencies-based approach for the education of dentists and physicians.

We often forget that according to the World Health Organisation, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".
Hence, when we think about Dental Education and overall services's provision, we can not help to feel that we are currently at a crossroad: one that demands us to move "outside the box" of our Dental Schools and Dental offices, while engaging with the needs of our communities at home and vulnerable communities across the world.

Education, even at the undergraduate level, and service provision are, therefore, intricately linked. We have to accept that we need to train dentists who are far more than just competent technicians, but rather health professionals responsible for oral health and health in general. Dentists need to get to know their patients and their communities better if they are to provide truly effective care.

There is a need for those involved in Dental Education to take the lead on incorporating global health into the undergraduate dental curriculum and to boost global health in postgraduate practice. The key focus should be to provide better dental care to patients at home, work on improving access (for free or at low cost) for patients at home and to fill the gap where dentists are scarce.

Due to socio-economic, cultural and political reasons, large segments of the world's population have limited or no access to regular dental care. Assisting the development of dental services in these areas should be regarded as a win- win strategy for both the developed and developing world as opportunities for training, practice and research lend themselves to twinning established successful programs at home with programmesfor the world's most vulnerable communities.

It's within this context, that, as we look through the feedback of the ADEE and AMEE meetings and workshops in global health, it becomes clear the enthusiasm for global health across all the medical disciplines. This enthusiasm seems centred on clinical practice: global health in the workplace, renewed focus on ensuring that the most vulnerable of our patients receive the best of clinical care, setting an example in the workplace to trainees who are going the extra mile to ensure that they address ALL the health needs of their patients and moving forward together to address the determinants of health in our undergraduate teaching programmes.

Thus, as ADEE and AMEE discuss the modern teaching agenda, we remind ourselves that global health is comprehensive healthcare and research. At BMJ Case Reports, we have the opportunity to put together the input of authors from across the world and emphasise priorities in addressing health disparities and access to healthcare. We have case reports from Trinidad in the West Indies (link) to Queensland in Australia (link). What is key is not so much the reach across the globe as the fact that authors are clinicians writing about patients they see locally daily.

As clinicians write about global health issues, we encourage students to do this, too. Global health problems cannot be tackled without a strong evidence base. Our cases are hugely valuable for teaching and to assist students as they begin to write. These case are also a powerful tool in bringing about improvements in health and should be used again and again as we advocate for our patients. There is extensive guidance on our website, and, as editors we are always to eager to engage with authors on how to make BMJ Case Reports more accessible to our readers and promote excellence in research and education.

http://ift.tt/2fLgzLT

Laryngeal tumours and radiotherapy dose to the cricopharyngeus are predictive of death from aspiration pneumonia

Publication date: January 2017
Source:Oral Oncology, Volume 64
Author(s): Jolyne O'Hare, Julia Maclean, Michal Szczesniak, Rashmi Gupta, Peter Wu, Harry Quon, Ian Cook, Peter Graham
ObjectivesAspiration pneumonia is an under-reported treatment sequelae following radiotherapy for head and neck cancer (HNC) patients. This study aims to investigate its incidence and risk factors in this population.Materials and methodsA retrospective review of all HNC patients that had received radiotherapy or chemo radiotherapy with radical intent at a single institution was undertaken (n=206). Dose delivered to the pharyngeal constrictors, base of tongue and cricopharyngeus was calculated and compared between those patients who had died from aspiration pneumonia and those who are alive or had died from other causes.ResultsIn a cohort of 206 patients, the median time of follow up was 3.5years (IQR 1.8–4.9years). The cause of death was known in 80 and one of the leading causes of non-cancer related mortality was aspiration pneumonia (n=12) equating to an annual incidence of 0.016. Patients with a tumour located in the larynx had a higher risk of death compared to other sites (p=0.005). The mean cricopharyngeal dose was significantly higher in those patients who died of aspiration pneumonia (p=0.023) compared to those who were still alive or had died from other causes. In a multivariate regression analysis, maximum cricopharyngeal dose is a significant predictor of death from aspiration pneumonia.ConclusionDose to the cricopharyngeus and tumours located within the larynx is associated with an increased mortality due to aspiration pneumonia. Clinical awareness of high risk groups and more studies into causative nature are needed.



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Three cases of interstitial pneumonia with anti-signal recognition particle antibody

Publication date: Available online 29 November 2016
Source:Allergology International
Author(s): Ryuichi Togawa, Yoshinori Tanino, Takefumi Nikaido, Naoko Fukuhara, Manabu Uematsu, Kenichi Misa, Yuki Sato, Nozomu Matsuda, Yoshihiro Sugiura, Sachiko Namatame, Hiroko Kobayashi, Yasuhito Hamaguchi, Manabu Fujimoto, Masataka Kuwana, Mitsuru Munakata




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Parvovirus B19 infection presenting concurrently as papular–purpuric gloves-and-socks syndrome and bathing-trunk eruption

Summary

Parvovirus B19 infection can cause a wide range of cutaneous manifestations, including papular–purpuric gloves-and-socks syndrome (PPGSS) and petechial bathing trunk eruption. We report a case of an immunocompetent woman with a primary parvovirus B19 infection presenting as concurrent PPGSS and petechial bathing trunk eruption. Parvovirus B19 seroconversion was confirmed several days after the onset of the clinical manifestations. The coexistence of these two cutaneous manifestations of primary parvovirus B19 infection has rarely been reported in the literature. It is important to recognize parvovirus B19 infection early, based on the cutaneous manifestations, to avoid potentially serious systemic complications in susceptible individuals.

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Mosaic NRAS Q61R mutation in a child with giant congenital melanocytic naevus, epidermal naevus syndrome and hypophosphataemic rickets

Summary

The association of hypophosphataemic rickets with verrucous epidermal naevus (EN) and elevated fibroblast growth factor 23 levels is known as cutaneous–skeletal hypophosphataemia syndrome (CSHS), and can be caused by somatic activating mutations in RAS genes. We report a unique patient with CSHS associated with giant congenital melanocytic naevus (CMN), neurocutaneous melanosis and EN syndrome, manifesting as facial linear sebaceous naevus, developmental delay and ocular dermoids. An activating mutation Q61R in the NRAS gene was found in affected skin and ocular tissue but not blood, implying that the disparate manifestations are due to a multilineage activating mutation (mosaic RASopathy). We speculate on the apparently rare association of CSHS with CMN compared with EN. We also report the favourable outcome of this patient at the age of 8 years after extensive neonatal curettage of the giant CMN and use of vitamin D and phosphate supplementation.

http://ift.tt/2fC8aPM

The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.

BACKGROUND: The Perioperative Surgical Home (PSH) seeks to remedy the currently highly fragmented and expensive perioperative care in the United States. The 2 specific aims of this health services research study were to assess the association between the preoperative and postoperative elements of an initial PSH model and a set of (1) clinical, quality, and patient safety outcomes and (2) operational and financial outcomes, in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A 2-group before-and-after study design, with a nonrandomized preintervention PSH (PRE-PSH group, N = 1225) and postintervention PSH (POST-PSH group, N = 1363) data-collection strategy, was applied in this retrospective observational study. The 2 study groups were derived from 2 sequential 24-month time periods. Conventional inferential statistical tests were applied to assess group differences and associations, including regression modeling. RESULTS: Compared with the PRE-PSH group, there was a 7.2% (95% confidence interval [CI] 4.0%-10.4%, P

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Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Christopher Schardt, Angela Schmid, Jens Bodem, Johannes Krisam, Jürgen Hoffmann, Christian Mertens
PurposeBone defects after resective tumor surgeries often require the use of microvascular reanastomized bone grafts for reconstruction. The decision as to which specific flap is most suitable for the particular patient is dependent on various factors. The aspects donor site morbidity and quality of life are rarely taken into account in this connection. The aim of this study was to analyze whether these factors, in the future, should influence the choice of donor site.Material and MethodsIn this study, the donor sites of 46 patients with respect to deep-circumflex iliac artery (DCIA) and fibula flaps were analyzed using subjective and objective parameters. The primary outcome was postoperative pain measured by VAS. Postoperative complication evaluations as well as 2 orthopedic scores were implemented (American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Harris Hip Score) and the patients' quality of life was assessed using the 36-Item Short Form (SF-36) questionnaire to quantify donor site impairment.ResultsPostoperative pain was rated with a mean value of 42.4 mm (SD 34.8) for the DCIA group and 36.9 mm (SD 37.1) for the fibula group (p=0.617). After a mean period of 13.72 months, pain was rated with a mean value of 15.3 mm (SD 21.7) for DCIA and 13.3 mm (SD 22.6mm) for the fibula (p=0.763). Persistent pain, however, was recorded only in 11.11% of DCIA patients and 5.26% of fibula patients. Furthermore pain intensity was higher in the DCIA group. A changed gait pattern was observed in 59.26% of DCIA patients and 21.05% of fibula patients. DCIA patients required walking aids for walking and stair climbing more often. Looking at the results of the 2 orthopedic scores, fibula patients showed slightly better results. Concerning quality of life, patients after reconstructive surgery with DCIA flaps showed slight better results than patients in the fibula group.ConclusionsTaking the results of this study into account, the outcome in terms of pain, morbidity and quality of life did not show a significant superiority of any donor site.



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Patient-specific Biodegradable Implant in Pediatric Craniofacial Surgery

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): H. Essig, D. Lindhorst, T. Gander, P. Schumann, D. Könü, S. Altermatt, M. Rücker
Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver. 3.0.5; Brainlab, Feldkirchen, Germany) to generate a 3D reconstruction. Virtual osteotomies and simulation of the ideal outer contour with reassembled bony segments were performed. Digital planning was transferred with a cutting guide, and an individually manufactured resorbable implant was used for rigid fixation. A resorbable patient-specific implant (Resorb X-PSI) allows precise surgery for FOA in craniosynostosis using a complete digital workflow and should be considered superior to manually bent resorbable plates.



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Patient-specific polymethylmethacrylate prostheses for secondary reconstruction of large calvarial defects: A retrospective feasibility study of a new intraoperative moulding device for cranioplasty

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Manuel Moser, Raphael Schmid, Ralf Schindel, Gerhard Hildebrandt
PurposeThe aim of this study was to review a new template-based technique for intraoperative patient-specific cranioplasty manufacturing (PSCM) with polymethylmethacrylate (PMMA) to cover large calvarial defects.Material and MethodsA polypropylene foil thermoformed on a three-dimensional reprint of the calvarial defect was used as an intraoperative moulding device for PMMA between August 2012 and December 2015. Surgical and radiological data were retrospectively reviewed, and a patient questionnaire was used to assess functional and cosmetic outcome (numeric rating scale, Odom´s criteria).ResultsSeventeen patients (mean age 42.2±14.5 years) received PSCM. Operating time averaged 130±34 min, and the approximate blood loss was 293±185ml. Volumetric analysis revealed a lower implant volume compared to index bone (mean 66.5 vs. 72 cm³, p=0.513), the mean difference in thickness being the lowest in the posterior parietal and pterional (0.4-0.7 mm) and the highest in the anterior-superior frontal area (1.8 mm). Cosmetic satisfaction averaged 9±1.5, with 70.6% of patients judging the overall result as excellent or good and 29.4% as satisfactory. Mean follow-up was 19.5±13.3 months, with an overall complication rate of 17.6%, including 11.8% surgical site infections (SSIs) and one implant removal.ConclusionsIntraoperative PSCM using PMMA moulded on a thermoformed polypropylene foil leads to satisfactory outcomes. It is a safe technique with complication rates comparable but not superior to those of other alloplastic techniques, but the device has considerable production costs.



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Influence of Bone Invasion on Outcomes after Marginal Mandibulectomy in Squamous Cell Carcinoma of the Oral Cavity

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Ivana Petrovic, Pablo H. Montero, Jocelyn C. Migliacci, Frank L. Palmer, Ian Ganly, Snehal G. Patel, Jatin P. Shah
IntroductionMarginal mandibulectomy (MM) is indicated for oral cavity squamous cell carcinomas (OCSCC) that abut or minimally erode the mandible without gross invasion. Successful implementation of MM is predicated on accurate patient selection and appropriate adjuvant treatment based on well-known host and tumor characteristics. The incidence of microscopically diagnosed bone involvement in MM specimens and its implications on outcomes have however not been reported in large contemporary series.PurposeTo report the incidence of bone involvement and analyze its influence on oncologic outcomes in selected patients who underwent MM in treatment of OCSCC.MethodA retrospective cohort study was performed on a consecutive series of previously untreated patients requiring MM, at a tertiary care cancer center between 1985 and 2012 (n=326). The median age was 64 years and 59% were male. The majority of patients (67%) had a primary tumor of the floor of the mouth or lower alveolus, 80% were clinically staged T1-2, and 31% were clinically N+. Postoperative radiation (PORT) was used in 27% and chemoradiation (POCTRT) in 8% of patients who had microscopic bone invasion. The median follow up period was 55 months and endpoints of interest were local and regional recurrence free (LRFS and RRFS) and disease specific (DSS) survival.ResultsMicroscopic bone invasion was present in 15% of patients. (n=49). . Among these cortical invasion was present in 32, medullary in 13 and it was not specified in 4. Eight patients had microscopic positive bone margins. Positive bone margins were associated with medullary bone involvement (p<0.001), floor of mouth and buccal mucosa primary site (p=0.0), and positive soft tissue margins (p=0.05). LRFS and DSS were similar in patients without versus with bone invasion (62.8% vs 79.7% and 76.2% vs 66% respectively, p=NS). LRFS were similar in patients with microscopic positive versus negative bone margins, as long as postoperative adjuvant treatment was administered.ConclusionMicroscopic bone involvement does not adversely influence outcomes but medullary bone involvement does confer a higher risk of positive bone margins. MM and appropriate adjuvant treatment is an effective strategy for treatment of OCSCC in selected patients with primary tumors adherent to or in proximity to the mandible.



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Improving outcome of trauma patients by implementing patient blood management.

Purpose of review: Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. Recent findings: Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients. Summary: In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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An update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine.

Purpose of review: The present review aims to provide an update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine. Recent findings: The STOP-Bang questionnaire was originally validated as a screening tool to identify surgical patients who are at high-risk of obstructive sleep apnea (OSA). A recent meta-analysis confirmed that STOP-Bang is validated for use in the sleep clinic, surgical, and general population. Patients with a STOP-Bang score of 0--2 can be classified as low-risk for moderate-to-severe OSA. Those with a score of 5--8 can be classified as high-risk for moderate-to-severe OSA. In patients with a score of 3 or 4, a specific combination of a STOP score at least 2 + BMI more than 35 kg/m2 or STOP score at least 2 + male or STOP score at least 2 + neck circumference more than 40 cm indicates higher risk for moderate-to-severe OSA. Further, patients with a STOP-Bang score at least 3 can be classified as high risk for moderate-to-severe OSA if the serum HCO3- at least 28 mmol/l. STOP-Bang can be used as a novel tool for perioperative risk stratification because it easily identifies patients who are at increased risk of perioperative complications. Summary: STOP-Bang at least 3 was recommended previously to identify the suspected or undiagnosed OSA. To reduce the false positive cases and to improve its specificity, a stepwise stratification is recommended to identify the patients at high risk of moderate-to-severe OSA. Because of its practical application, STOP-Bang is a useful screening tool for patients with suspected or undiagnosed OSA. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2fBUUKS

Abnormal cell-clearance and accumulation of autophagic vesicles in lymphocytes from patients affected with Ataxia-Teleangiectasia

Publication date: Available online 30 November 2016
Source:Clinical Immunology
Author(s): Roberta D'Assante, Anna Fusco, Loredana Palamaro, Elena Polishchuk, Roman Polishchuk, Gabriella Bianchino, Vitina Grieco, Maria Rosaria Prencipe, Andrea Ballabio, Claudio Pignata




http://ift.tt/2fBVpoh

Regional Variation across Canadian Centers in Radioiodine Administration for Thyroid Remnant Ablation in Well-Differentiated Thyroid Cancer Diagnosed in 2000–2010

Background. Use of radioactive iodine (RAI) ablation has been reported to vary significantly between studies. We explored variation in RAI ablation care patterns between seven thyroid cancer treatment centers in Canada. Methods. The Canadian Collaborative Network for Cancer of the Thyroid (CANNECT) is a collaborative registry to describe and analyze patterns of care for thyroid cancer. We analyzed data from seven participating centers on RAI ablation in patients diagnosed with well-differentiated (papillary and follicular) thyroid cancer between 2000 and 2010. We compared RAI ablation protocols including indications (based on TNM staging), preparation protocols, and administered dose. We excluded patients with known distant metastases at time of RAI ablation. Results. We included 3072 patients. There were no significant differences in TNM stage over time. RAI use increased in earlier years and then declined. The fraction of patients receiving RAI varied significantly between centers, ranging between 20–85% for T1, 44–100% for T2, 58–100% for T3, and 59–100% for T4. There were significant differences in the RAI doses between centers. Finally, there was major variation in the use of thyroid hormone withdrawal or rhTSH for preparation of RAI ablation. Conclusion. Our study identified significant variation in use of RAI for ablation in patients with well-differentiated thyroid cancer both between Canadian centers and over time.

http://ift.tt/2fHF1Ow

The role of the otolaryngologist in the evaluation and diagnosis of eosinophilic esophagitis

Objective

To describe the clinical presentation and role of the otolaryngologist in the evaluation of eosinophilic esophagitis (EoE) at a tertiary pediatric hospital.

Study Design

Retrospective review.

Methods

Records from pediatric patients with a diagnosis of EoE from 2003 to 2015 were reviewed. Study variables were analyzed to compare patients presenting to different specialties.

Results

Two hundred and fifty-one patients with EoE were evaluated. The median age at diagnosis was 9.0 years (range 0.8–19.0); 73% were male. Sixty-seven percent of patients initially presented to gastroenterology and 18% to otolaryngology. Time from initial presentation to diagnosis did not differ between the patients presenting to the two specialties (median 2.3 vs. 2.0 months, P = 0.510). Overall, 26% presented with airway symptoms (stridor, chronic cough, croup, or dysphonia). Patients diagnosed by the otolaryngology service were younger (3.4 vs. 10.4 years, P < 0.0001), had a higher incidence of airway symptoms (68% vs. 15%, P < 0.001), and demonstrated fewer gastrointestinal symptoms (86% vs. 100%, P < 0.001).

Conclusion

Patients with EoE frequently present to otolaryngology undiagnosed in the first 5 years of life, making esophagoscopy with biopsy an important adjunct to airway endoscopy in children with refractory aerodigestive symptoms. Otolaryngologists are uniquely poised to facilitate early diagnosis and initiation of therapy for these children, potentially reducing long-term sequelae.

Level of Evidence

4. Laryngoscope, 2016

http://ift.tt/2fPs48E

Paclitaxel inhibits post-traumatic recurrent laryngeal nerve regeneration into the posterior cricoarytenoid muscle in a canine model

Objectives/Hypothesis

To investigate the efficacy of paclitaxel, a potent microtubule inhibitor with a more favorable therapeutic index as compared with vincristine, in preventing post-traumatic nerve regeneration of the recurrent laryngeal nerve into the posterior cricoarytenoid muscle in a canine laryngeal model.

Study Design

Experimental animal study.

Methods

Forty-nine canine hemilaryngeal specimens were divided into five experimental groups. Under general anesthesia, a tracheostomy, recurrent laryngeal nerve (RLN) transection and repair, and laryngeal adductory pressures (LAP) were measured pre–RLN injury. The approach to the posterior cricoarytenoid (PCA) muscle for neurotoxin injection was transoral or open transcervical, at 0 or 3 months. At 6 months, postinjury LAPs were measured and the animals were sacrificed at 6 months to allow for laryngeal harvesting and analysis.

Results

Paclitaxel demonstrated increased mean laryngeal adductory pressures (70.6%) as compared with saline control (55.5%). The effect of paclitaxel was the same as observed with vincristine at 0 months and with a delayed injection at 3 months. There was no difference between transoral or open injection groups.

Conclusions

PCA muscle injection with paclitaxel resulted in improved strength of laryngeal adduction. This effect was similar to that of vincristine at both 0 and 3 months following nerve injury. A single intramuscular injection of paclitaxel was well tolerated. Additional human studies are needed to determine the degree of clinical benefit of this intervention.

Level of Evidence

NA Laryngoscope, 2016

http://ift.tt/2gw0aN5

Pilot testing of a novel surgical simulator for endoscopic zenker's diverticulotomy

Objectives/Hypothesis

Restrictions on resident work hours and the increasing purview of otolaryngology reduce the efficacy of the traditional surgical training model. With limited case volumes at many institutions and the unique instrumentation of endoscopic Zenker's diverticulotomy (EZD), simulation may be useful to improve training. In this study, a novel surgical simulator for EZD is developed and validated.

Study Design

Simulation model development.

Methods

An EZD model was designed using an intubation trainer and disposable diverticulum inserts. A novel objective structured assessment of technical skill (OSATS) for EZD was developed. Performance of otolaryngology residents on simulations using the OSATS and time to completion were evaluated during an instructional course. Pre- and postencounter surveys were completed. Inter-rater and intrarater reliability were evaluated via blinded video review of resident performance.

Results

Seventeen residents participated (n = 17). Surveys showed confidence improved two points on a five-point scale (P < .001), and 94% agreed that the model would improve resident performance with in vivo EZD. More experienced trainees (postgraduate year [PGY] 3–5, n = 11 vs. PGY 1–2, n = 6) had shorter times to completion (P < .001) and higher assessment scores on initial attempts (P = .006). Both groups showed significant improvements from initial to final attempts on 30-point scales for global rating by 6.2 ± 4.2 (mean ± standard deviation, P < .001). The novel OSATS demonstrated fair live/video reliability (к = 0.40) and inter-rater reliability (к = 0.44), and moderate intrarater reliability (к = 0.60).

Conclusions

Pilot testing of an EZD simulator demonstrated acceptability, content validity, and construct validity. A novel OSATS was developed and evaluated. Further investigation of the impact on operative performance and validation of the OSATS in vivo is needed.

Level of Evidence

NA Laryngoscope, 2016

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Contemporary management of carotid blowout syndrome utilizing endovascular techniques

Objectives/Hypothesis

To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS).

Study Designs

Retrospective chart review.

Methods

Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied.

Results

Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable.

Conclusions

The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist.

Level of Evidence

4. Laryngoscope, 2016

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Is nonabsorbable nasal packing after septoplasty essential? A meta-analysis

Objectives

Septoplasty is one of the most frequently performed rhinologic surgeries. Complications include nasal bleeding, pain, headache, septal hematoma, synechia, infection, residual septal deviation, and septal perforation. In this study, we aimed to compare complication rates among patients according to packing method.

Methods

We performed a literature search using PubMed, Embase, and the Cochrane Library through August 2016. Our systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effect models were used to calculate risk differences and risk ratio with 95% confidence intervals (CIs). Cases referred to the nonpacking group included patients treated with transseptal sutures or septal splints. Cases referred to as the packing group included patients treated with nonabsorbable packing such as Merocel or gauze.

Results

Our search included 20 randomized controlled trials (RCTs) with a total of 1,321 subjects in the nonpacking group and 1,247 subjects in the packing group. There were no significant differences between packing methods regarding bleeding, hematoma, perforation, infection, and residual septal deviation. The risk differences of postoperative pain, headache, and postoperative synechia were −0.50 [95% CI: −0.93 to −0.07, P = .02], −0.42 [95% CI: −0.66 to −0.19, P = .0004], and −0.03 [95% CI: −0.06 to −0.01, P = .01], respectively.

Conclusions

Nonabsorbable nasal packing is no more effective than treatments without packing after septoplasty. Septal splints and transseptal sutures reduce postoperative pain, headache, and synechia.

Level of Evidence

NA Laryngoscope, 2016

http://ift.tt/2fPsUCl

A novel thyroid cancer nodal map classification system to facilitate nodal localization and surgical management: The A to D map

Objectives/Hypothesis

To evaluate the effectiveness, reproducibility, and usability of our proposed nodal nomenclature and classification system employed for several years in our high-volume thyroid cancer unit, for the adequate localization and mapping of lymph nodes in thyroid cancer patients with extensive nodal disease.

Study Design

Retrospective review.

Methods

Thirty-three thyroid cancer patients with extensive nodal disease treated from January 2004 to May 2013 were included in our study. Preoperative ultrasound and computed tomography scans of these patients were reanalyzed by blinded radiologists to investigate the feasibility for the assignment of abnormal lymph nodes to compartments defined in our proposed nodal classification system and to identify areas of difficulty in the assignment.

Results

Analysis of nodal localization revealed a discrepancy in compartment agreement between the two radiologists in the assignment of abnormal nodes in nine patients (9/33, 27%). In six patients (6/33, 18%), discrepancy existed in labeling paratracheal and pretracheal nodes. In three patients (3/33, 9%), disagreement arose in the classification of retrocarotid nodes into lateral versus central compartment. A further refinement of the definition of key borderline regions of the pretracheal versus paratracheal and retrocarotid regions of our classification improved the agreement and demonstrated a complete concordance (100%) amongst the reviewing radiologists.

Conclusions

The proposed nodal classification system, derived specifically for differentiated thyroid carcinoma, with readily identifiable anatomic boundaries on imaging and at surgery, facilitates communication among multidisciplinary physicians and aids in creating a uniform and reproducible radiographic nodal map to guide surgical therapy.

Level of Evidence

4 Laryngoscope, 2016

http://ift.tt/2gIhTQT

Otolaryngologist-Beware of Zika.

Otolaryngologist-Beware of Zika.

JAMA Otolaryngol Head Neck Surg. 2016 Nov 17;:

Authors: Brook I

PMID: 27892997 [PubMed - as supplied by publisher]

http://ift.tt/2gDNNxy

Laryngeal Mass in an Infant.

Laryngeal Mass in an Infant.

JAMA Otolaryngol Head Neck Surg. 2016 Nov 17;:

Authors: Scott WC, Vanleer JA, Rose AS

PMID: 27892995 [PubMed - as supplied by publisher]

http://ift.tt/2fHnZ2Z

Zika Virus-What the Otolaryngologist Should Know: A Review.

Zika Virus-What the Otolaryngologist Should Know: A Review.

JAMA Otolaryngol Head Neck Surg. 2016 Nov 17;:

Authors: Arnaoutakis D, Padhya T

Abstract
Importance: Initially discovered in 1947, Zika virus infection received little notoriety as a tropical disease until 2015 when an outbreak of microcephaly cases was reported in Brazil. Zika is a single-stranded RNA arbovirus of the Flaviviridae family. The primary source of infection in humans stems from Aedes aegypti mosquito bites but can also occur through sexual, blood, and perinatal transmission. With expectations that 3 to 4 million people across the Americas will be infected over the next year, the World Health Organization has declared this event a Public Health Emergency of International Concern.
Observations: Although acute Zika virus infection is typically mild and self-limited, researchers have demonstrated serious neurologic complications associated with it such as microcephaly and Guillain-Barre syndrome. Otolaryngologists should be aware of head and neck manifestations which include conjunctivitis, retro-orbital pain, cephalgia, and odynophagia. The Centers for Disease Control and Prevention have developed specific molecular and serologic testing protocols and algorithms for follow-up care of suspected cases. Currently, the mainstay of management is conservative care while researchers attempt to develop a vaccine. Strategies to contain the Zika virus include vector control, travel restriction for women who are pregnant or trying to become pregnant, and avoidance of mosquito bites in endemic regions of the world.
Conclusions and Revelance: The future outlook regarding the current Zika virus outbreak in the Americas remains uncertain. What is certain is our need to promptly and efficiently address research gaps in our understanding of clinical outcomes from infection and environmental factors that influence emergence meanwhile improving diagnostic, therapeutic, and preventive measures against the disease.

PMID: 27892990 [PubMed - as supplied by publisher]

http://ift.tt/2g0Sjqf

The old reliables outperform new media in social marketing of Euromelanoma in Ireland

Abstract

Euromelanoma is a pan-European prevention campaign against skin cancer and promotes a walk-in screening day in May of each year. The screening day serves to highlight awareness of skin cancer amongst the general public and to encourage self-checks for new or changing lesions. The South Infirmary Victoria University Hospital (SIVUH) provides regional dermatology and skin cancer services for the Cork/Kerry region in Ireland and held a Euromelanoma Screening day in May 2014 and 2015.

This article is protected by copyright. All rights reserved.

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Sunbed use among Portuguese beach goers – A crave group while wainting sunbeds to be abolished

Abstract

Although sunbed use is considered a complete carcinogen for skin cancer, over the past decades exposure to indoor tanning is becoming more popular.(1, 2)

The risk appears to be stronger for young women, initial use at an early age (less than 35 years) and higher number of sunbed sessions. (3, 4)

With this study we aim to better understand the features of sunbed users in Portuguese beach goers, a group at high risk for skin cancer.

This article is protected by copyright. All rights reserved.

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Nympho-hymenal tear: a distinctive entity?

Abstract

Vulvar fissures are linear tears extending into the dermis. When in the posterior fourchette, it is known as granuloma fissuratum plicae labioalveolaris, or vulvar granuloma fissuratum, a term first described by Sutton et al. in 1932. ¹ The other pattern are small fissures occurring at other vulvar locations, and sexually active patients report entry dyspareunia. ^2-8 In majority of cases, vulvar fissures are secondary findings in a plethora of inflammatory dermatoses or infections, rarely, can occur as primary findings without any apparent causes. ⁹ There is very little published data on vulvar fissures occurring in otherwise healthy women, especially at the introitus reaching

This article is protected by copyright. All rights reserved.

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Sites of recurrence in patients following clearance of psoriasis with biologic therapy

Abstract

Management of psoriasis has vastly improved since the emergence of biologic medications, however such drugs tend to lose effectiveness with extended use.¹ We assessed the distribution of psoriatic lesions that reoccur in patients who experienced a loss of efficacy from their biologic medication.

This retrospective chart review focused on patients with psoriasis who presented to Kaiser Permanente Los Angeles Medical Center from January 2008 to September 2016.

This article is protected by copyright. All rights reserved.

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Tetracyclines and/ or Nicotinamide in blistering dermatoses

Abstract

I read with interest a report by von Köckritz et al¹. Tetracycline therapy, particularly in autoimmune blistering conditions, has become an acceptable treatment modality among elderly individuals, particularly those with osteoporosis, DM, and hypertension. This drug has also been given in combination with immunosuppressive treatment for more rapid tapering of the latter² .Minocycline besides having antimicrobial activity, it possesses anti-inflammatory and anti-apoptotic properties and causes inhibition of proteolysis, angiogenesis, and collagenase, and ability to induce read-through of premature stop mutations³. Nicotinamide is a potent modulator of several pro-inflammatory cytokines.

This article is protected by copyright. All rights reserved.

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Disseminated Cobblestone-like Skin Lumps In a Newborn

Abstract

An newborn boy showed multiple skin lumps at birth. On examination, there were disseminated red cobblestone-like skin neoplasms, 5-30mm in diameter with hard serosanguineous crust, some were with scabs, over the scalp, face, trunk and extremities (Fig. 1A,B). The liver was 3 cm palpable below the costal margin. He was active and stable. The mother' prenatal investigation on antibodies of rubella, herpes simplex virus (HSV) and hepatitis B surface antigen were positive. The baby's antibodies for HAV, HBV, HCV, rubella, HSV, HIV and syphilis were negative. Blood cultures were negative. However, his condition deteriorated on the 10th day, presented as poor circulation and respiratory distress.

This article is protected by copyright. All rights reserved.

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Cyclosporine a for severe atopic dermatitis in children. efficacy and safety in a retrospective study of 63 patients

Abstract

Background

Cyclosporin A (CSA) is an immunosuppressant agent widely used in severe atopic dermatitis (AD). However, experience in children is limited.

Objectives

To assess the efficacy and adverse events of CSA therapy in children.

Methods

Retrospective study of children with severe AD treated with CSA between January 2009 and December 2015.

Results

Data from 63 patients were collected. Mean age at the beginning of treatment was 8.4 years (±3.6). The median starting dose was 4.27 (±0.61) mg/kg/day. After four weeks of treatment, the outcome was excellent in 35% of cases, good in 29%, and poor in 36% of the patients. The response was better in patients without eosinophilia (p<0.05). The median duration of treatment was 4.6 months (range 1.5-21.6). Side effects were frequent but mild, being more common in patients after longer treatment periods (p<0.05). Mean time of follow-up was 19.4 months (±12.7). Prolonged remission (> 6 months) was observed in 13 patients (20%).

Limits

This is a retrospective review. The follow-up period is limited.

Conclusions

Our data confirm that CSA is efficacious and acts rapidly in the majority of children with severe AD. CSA therapy can provide sustained remission in some patients. CSA seems to be well tolerated in children, but strict monitoring is mandatory.

This article is protected by copyright. All rights reserved.

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Melanomas versus nevi in high risk patients under long term monitoring with digital dermatoscopy: Do melanomas and nevi already differ at baseline?

Abstract

Background

What lesions to select for a most efficient dermatoscopic monitoring of patients with multiple nevi remains an unresolved issue.

Objective

To compare the grade of atypia of melanomas and nevi of the same patient at baseline.

Methods

Prospective observational study using 236 dermatoscopic baseline images (59 quartets from 59 patients, each including 1 melanoma detected during follow-up and 3 nevi). Dermatologists (n=26) were asked to assess the "grade of dermatoscopic atypia" on a numerical scale and to identify the melanomas.

Results

On average each dermatologist identified 24 of 59 melanomas (40%, range: 11-37). The number of correct picks was greater for dermatologists with moderate (mean: 28) or high (mean: 28) experience compared to beginners (mean 17; p<0.001). In 3 of the 59 sets none of the 26 dermatologists identified the melanoma. The mean grade of dermatoscopic atypia was 2.5 for nevi (95% CI: 2.4-2.6) and 3.0 for melanomas (95% CI: 2.9-3.1, p<0.001).

Limitations

Rating dermatologists were informed that each quartet of images included one melanoma creating substantial deviation from a real-life situation.

Conclusion

A significant proportion of melanomas detected during follow-up cannot be differentiated from nevi at baseline. This necessitates the additional inclusion of less atypical lesions for monitoring.

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Contact allergy to preservatives: ESSCA* results with the baseline series, 2009-2012

Abstract

Background

Allergic contact dermatitis caused by biocides is common, and causes significant patient morbidity.

Objective

To describe the current frequency and pattern of patch test reactivity to biocide allergens included in the baselines series of most European countries.

Methods

Data collected by the European Surveillance System on Contact Allergies (ESSCA) network between 2009 and 2012 from 12 European countries were analysed.

Results

Methylisothiazolinone 0.2% aq. produced the highest prevalence of sensitization during the study period, with an overall prevalence of 4.5%. The mixture methylchloroisothiazolinone/methylisothiazolinone tested at 0.02% aq. followed closely, with 4.1% of positive reactions. Other preservatives with lower rates of sensitisation, but still over 1%, include methyldibromo glutaronitrile (MDBGN) 0.5% pet. and iodopropynyl butylcarbamate (IPBC) 0.2% pet. Formaldehyde releasers and parabens yielded less than 1% positive reactions during the study period. Some regional differences in the prevalence of contact allergy to biocides among European countries were observed.

Conclusions

Contact allergy to biocides is common throughout Europe, and regional differences could be explained by differences in exposure or characteristics of the population tested. Timely regulatory action for isothiazolinones is required. Although MDBGN is banned from cosmetics products since 2005, sensitization prevalence has not appeared to plateau. IPBC is an emerging allergen with an increasing prevalence over the last few years, and its inclusion in the European baseline series may be appropriate.

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Sleep-related disorders in Latin-American children with atopic dermatitis: A case control study

Publication date: Available online 29 November 2016
Source:Allergologia et Immunopathologia
Author(s): M. Urrutia-Pereira, D. Solé, N.A. Rosario, H.J.C. Neto, V. Acosta, C.F. Almendarez, M.M. Avalos, H. Badellino, F. Berroa, M. Álvarez-Castelló, A.J. Castillo, R.L. Castro-Almarales, M.M. De la Cruz, A.M. Cepeda, C. Fernandez, M. González-León, J. Lozano-Saenz, C. Sanchez-Silot, J.C. Sisul-Alvariza, M. Valentin-Rostan, R.O.S. Sarni
BackgroundAtopic dermatitis (AD) has been associated with impairment of sleep. The aim of this study was to evaluate sleep disorders in AD Latin-American children (4–10 years) from nine countries, and in normal controls (C).MethodsParents from 454 C and 340 AD children from referral clinics answered the Children Sleep Habits Questionnaire (CSHQ), a one-week retrospective 33 questions survey under seven items (bedtime resistance, sleep duration, sleep anxiety, night awakening, parasomnias, sleep-disordered breathing and daytime sleepiness). Total CSHQ score and items were analysed in both C and AD groups. Spearman's correlation coefficient between SCORAD (Scoring atopic dermatitis), all subscales and total CSHQ were also obtained.ResultsC and AD groups were similar regarding age, however, significantly higher values for total CSHQ (62.2±16.1 vs 53.3±12.7, respectively) and items were observed among AD children in comparison to C, and they were higher among those with moderate (54.8%) or severe (4.3%) AD. Except for sleep duration (r=−0.02, p=0.698), there was a significant Spearman's correlation index for bedtime resistance (0.24, p<0.0001), sleep anxiety (0.29, p<0.0001), night awakening (0.36, p<0.0001), parasomnias (0.54, p<0.0001), sleep-disordered breathing (0.42, p<0.0001), daytime sleepiness (0.26, p<0.0001) and total CSHQ (0.46, p<0.0001). AD patients had significantly higher elevated body mass index.ConclusionLatin-American children with AD have sleep disorders despite treatment, and those with moderate to severe forms had marked changes in CSHQ.



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Effectiveness of immunotherapy in children depends on place of living – A pilot study

Publication date: Available online 29 November 2016
Source:Allergologia et Immunopathologia
Author(s): M. Pawlowski, J. Jerzynska, D. Podlecka, W. Stelmach, P. Majak, I. Stelmach
BackgroundIt is considered that farm areas protect young patients from allergy and asthma due to high exposure to endotoxins. Allergen immunotherapy (AIT) is the only treatment of allergy modifying the immune response with the potential to change the natural history of allergic diseases. It seems that studies evaluating the efficacy of immunotherapy in large cohorts of allergic patients living in farm areas are needed to understand the influence of environment on immune response during AIT.Aim. To compare the clinical effectiveness of immunotherapy between children living in farm versus urban areas.Materials and methodsThis was a retrospective analysis of 87 children living in farm area (n=42) and city area (n=45), aged 8–16, who completed three years of subcutaneous immunotherapy due to allergic rhinitis/asthma. An AIT efficacy questionnaire has been designed to be filled in by the allergy specialist during a regular immunotherapy visit before and after AIT.ResultsWe observed significantly higher improvement in total score among children from farm area compared to children from city area (p<0.001). Between-group differences in symptoms and drug scores did not reached the level of significance. Multivariate logistic regression analysis (adjustment for the effect of gender and type of allergy) showed that living in farm areas was independently associated with significant improvement in total score after immunotherapy (OR: 10.9; 95%CI: 3.7–32.2).ConclusionThe current analysis of the better AIT effectiveness in the farm population has shown the protective influence of environmental exposures on asthma and allergic rhinitis in our children.



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Childhood Hypopigmented Mycosis Fungoides: A Rare Diagnosis

Primary cutaneous lymphomas (PCL) are rare in pediatrics. Mycosis fungoides (MF) is the most frequent PCL diagnosed in childhood. There are various clinical variants of MF, including the hypopigmented MF (HMF). We present a 5-year-old boy with an 18-month history of progressive, generalized, nonpruritic hypopigmented lesions with central lacy erythema. He had no improvement with emollients. Skin biopsy showed typical features of HMF. He was treated with topical corticosteroids and tacrolimus and narrow-band ultraviolet B (NBUVB) phototherapy, with good response. HMF may mimic multiple skin disorders. Unusual hypopigmented skin lesions should be biopsied. Though phototherapy is effective, recurrence is common.

http://ift.tt/2g0sqH7

On the pathogenesis of mTOR-associated stomatitis (mIAS) – studies using an organotypic model of the oral mucosa

Abstract

Objective

mTOR inhibitor treatment of solid cancers is associated with mTOR inhibitor-associated stomatitis (mIAS) a common, significant, dose-limiting toxicity, with aphthous-like lesions. Our objective was to assess the utility of a new organotypic model in defining mIAS' pathogenesis.

Materials And Methods

The effect of everolimus on organotypic human oral mucosa was studied. Sterile specimens were assessed 24 hr and 48 hr after exposure to varying concentrations of everolimus. Morphologic changes and measures of apoptosis, proliferation, and levels of six Th1 and Th2 cytokines were studied.

Results

Following a 24 hr incubation, concentrations of 500 ng/mL of everolimus resulted in histological changes consistent with epithelial injury, disorganization and pre- or early apoptosis, increased TUNEL-positive staining (p<0.05) and reduced PCNA-positive staining cells (p<0.001) and increased levels of IL-6 (p<0.0001), IL-8 (p<0.01) and IFN-γ (p<0.09).

Conclusions

Everolimus elicited epithelial damage manifest by morphologic changes, increased apoptosis, and decreased proliferation with concurrent release of keratinocyte-derived pro-inflammatory cytokines in the absence of bacteria. The extent of the effect was concentration- and time-dependent. These results suggest that mIAS is likely initiated by direct epithelial injury, independent of the microbiome. Keratinocyte cytokine release could likely play a role in accelerating an inflammatory infiltrate.

This article is protected by copyright. All rights reserved.

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LEAPing Through the Looking Glass: Secondary Analysis of the Effect of Skin Test Size and Age of Introduction on Peanut Tolerance after Early Peanut Introduction

Abstract

Background

In the Learning Early About Peanut Allergy (LEAP) study, early peanut introduction in high-risk 4-11 month olds was associated with a significantly decreased risk of developing peanut allergy. However, the influences of key baseline high-risk factors on peanut tolerance are poorly understood.

Methods

Secondary analysis was conducted on the publically available LEAP dataset, exploring relationships between peanut tolerance, baseline peanut/egg sensitization, eczema severity/duration, age of introduction, gender, and race.

Results

A multiple logistic regression model predicting odds of successful oral food challenge (OFC) at 60 months noted higher odds with early introduction (OR 9.2, P<0.001, 95%CI 4.2-20.3), white race (OR 2.1, p=0.04, 95%CI 1.1-3.9), and advancing age (OR 4.8, P=0.04, 95%CI 1.1-20.8). Odds of peanut tolerance were lower with increasing peanut wheal size (OR 0.58, P<0.001, 95%CI 0.46-0.74), increased baseline SCORAD score (OR 0.98, p=0.04, 95%CI 0.97-1), and increased kU_A/L of egg serum IgE (sIgE) (OR 0.99, p=0.04, 95%CI 0.98-1). The probability of peanut tolerance in the early introduction group was 83% vs. 43% in the avoidance group with SPT wheal of less than 4mm. The probability of a successful OFC was significantly higher with peanut introduction between 6-11 months than at 4-6 months. Increasing eczema severity had limited impact on the probability of peanut tolerance in the early introduction arm.

Conclusion

Increasing peanut wheal size predicted peanut tolerance only in the avoidance arm. Peanut introduction between 6-11 months of age was associated with the highest rates of peanut tolerance, questioning the "urgency" of introduction before 6 months.

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Recurrent Massive Epistaxis from an Anomalous Posterior Ethmoid Artery

A 50-year-old man, with no previous history of epistaxis, was hospitalized at our facility for left recurrent posterior epistaxis. The patient underwent surgical treatment three times and only the operator's experience and radiological support (cranial angiography) allowed us to control the epistaxis and stop the bleeding. The difficult bleeding management and control was attributed to an abnormal course of the left posterior ethmoidal artery. When bleeding seems to come from the roof of the nasal cavity, it is important to identify the ethmoid arteries always bearing in mind the possible existence of anomalous courses.

http://ift.tt/2grmojq