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

http://ift.tt/2fPt0to

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

http://ift.tt/2gw3GXF

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.

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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.

This article is protected by copyright. All rights reserved.

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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

A case of leucocytoclastic vasculitis as a complication of IgG4-related skin disease

http://ift.tt/2gDlAqL

Paraneoplastic pityriasis rubra pilaris: case report and literature review

Summary

Pityriasis rubra pilaris (PRP; MIM 173200) is an uncommon papulosquamous inflammatory dermatosis. Only a few cases of PRP associated with an underlying malignancy have been documented. We investigated a 59-year-old patient presenting with a fulminant form of PRP recalcitrant to systemic retinoid therapy, in whom the skin disease heralded a diagnosis of cholangiocarcinoma. We searched the MEDLINE database to find articles reporting on similar associations of PRP with malignancies. We identified 10 studies linking PRP and malignancies, but an association between PRP and cholangiocarcinoma has not yet been reported.

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Neural Correlates of the Binaural Masking Level Difference in Human Frequency-Following Responses

Abstract

The binaural masking level difference (BMLD) is an auditory phenomenon where binaural tone-in-noise detection is improved when the phase of either signal or noise is inverted in one of the ears (S_πN_o or S_oN_π, respectively), relative to detection when signal and noise are in identical phase at each ear (S_oN_o). Processing related to BMLDs and interaural time differences has been confirmed in the auditory brainstem of non-human mammals; in the human auditory brainstem, phase-locked neural responses elicited by BMLD stimuli have not been systematically examined across signal-to-noise ratio. Behavioral and physiological testing was performed in three binaural stimulus conditions: S_oN_o, S_πN_o, and S_oN_π. BMLDs at 500 Hz were obtained from 14 young, normal-hearing adults (ages 21–26). Physiological BMLDs used the frequency-following response (FFR), a scalp-recorded auditory evoked potential dependent on sustained phase-locked neural activity; FFR tone-in-noise detection thresholds were used to calculate physiological BMLDs. FFR BMLDs were significantly smaller (poorer) than behavioral BMLDs, and FFR BMLDs did not reflect a physiological release from masking, on average. Raw FFR amplitude showed substantial reductions in the S_πN_o condition relative to S_oN_o and S_oN_π conditions, consistent with negative effects of phase summation from left and right ear FFRs. FFR amplitude differences between stimulus conditions (e.g., S_oN_o amplitude–S_πN_o amplitude) were significantly predictive of behavioral S_πN_o BMLDs; individuals with larger amplitude differences had larger (better) behavioral B MLDs and individuals with smaller amplitude differences had smaller (poorer) behavioral B MLDs. These data indicate a role for sustained phase-locked neural activity in BMLDs of humans and are the first to show predictive relationships between behavioral BMLDs and human brainstem responses.

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Natural Compounds as Occult Ototoxins? Ginkgo biloba Flavonoids Moderately Damage Lateral Line Hair Cells

Abstract

Several drugs, including aminoglycosides and platinum-based chemotherapy agents, are well known for their ototoxic properties. However, FDA-approved drugs are not routinely tested for ototoxicity, so their potential to affect hearing often goes unrecognized. This issue is further compounded for natural products, where there is a lack of FDA oversight and the manufacturer is solely responsible for ensuring the safety of their products. Natural products such as herbal supplements are easily accessible and commonly used in the practice of traditional eastern and alternative medicine. Using the zebrafish lateral line, we screened a natural products library to identify potential ototoxins. We found that the flavonoids quercetin and kaempferol, both from the Gingko biloba plant, demonstrated significant ototoxicity, killing up to 30 % of lateral line hair cells. We then examined a third Ginkgo flavonoid, isorhamnetin, and found similar levels of ototoxicity. After flavonoid treatment, surviving hair cells demonstrated reduced uptake of the vital dye FM 1-43FX, suggesting that the health of the remaining hair cells was compromised. We then asked if these flavonoids enter hair cells through the mechanotransduction channel, which is the site of entry for many known ototoxins. High extracellular calcium or the quinoline derivative E6 berbamine significantly protected hair cells from flavonoid damage, implicating the transduction channel as a site of flavonoid uptake. Since known ototoxins activate cellular stress responses, we asked if reactive oxygen species were necessary for flavonoid ototoxicity. Co-treatment with the antioxidant D-methionine significantly protected hair cells from each flavonoid, suggesting that antioxidant therapy could prevent hair cell loss. How these products affect mammalian hair cells is still an open question and will be the target of future experiments. However, this research demonstrates the potential for ototoxic damage caused by unregulated herbal supplements and suggests that further supplement characterization is warranted.

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How Deleterious Is Facial Nerve Dissection for the Facial Nerve in Parotid Surgery: An Electrophysiological Evaluation.

Objective: This study was conducted to investigate subclinical electrophysiological deleterious effect due to microtrauma to the nerve in response to the dissection of a tumor and parotid tissue from the facial nerve and its branches and surgical traction experienced during the operation. Methods: The study included 34 adult patients who underwent parotidectomy operations under intraoperative facial nerve monitoring. Three measurements were taken from each patient to evaluate facial nerve functions, with 3 stimuli of different intensities applied with different timing. An initial stimulus of 1 mA was applied to confirm the identification of the main trunk of the facial nerve (Group 1: Initial-Normal). Then, a threshold value was found by stimulating the main trunk until muscle fasciculations were observed on facial muscles (Group 2: Basal-Minimal). The same procedure was repeated after the tumor was resected (Group 3: Final-Minimal). Results: There was no significant difference between the stimulus thresholds of Group 2 (0.31 mA) and Group 3 (0.30 mA). The highest amplitude in all 3 groups was observed at the mental branch, and the lowest at the frontal. The highest latency value was measured at the frontal branch and the lowest at the mental branch. Five (14.7%) of the patients developed postoperative pareses that was completely resolved by the seventh postoperative day visit in these patients. Conclusion: This study demonstrated that the surgical trauma of a meticulously conducted dissection and surgical traction did not cause any deleterious electrophysiological alteration on the facial nerve. (C) 2016 by Mutaz B. Habal, MD.

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Application of Dexamethasone in the Masseter Muscle During the Surgical Removal of Lower Third Molars.

Purpose: The aim of the present study was to analyze the effect of the application of dexamethasone in the masseter muscle during third molar surgery. Methods: This randomized, clinical trial used dependent samples and the split-mouth method. A sample of 30 patients, with impacted or semi-impacted third molars, as well as vertical and mesioangular positions of a similar surgical difficulty (on both sides), was subjected to 2 operations: an experimental operation and a control procedure, with a 30-day wash-out. The choice of which group would be experimental or control was random. The experimental group received 8 mg of dexamethasone, which was applied directly to the masseter muscle immediately after surgery. The control group did not receive corticosteroids. Seven and 15 days after the surgery, the patients were assessed in relation to their levels of pain, trismus, and edema. Results: Concerning edema and trismus, there was a significant difference (P

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Mid-Face Degloving: An Alternate Approach to Extended Osteotomies of the Midface.

Extended osteotomies for mid-face advancement require generous exposure of the anterior maxilla, nasal bones, infraorbital rims, orbital floor, zygoma, and the anterior third of the zygomatic arches. This cannot be obtained with an exclusive transoral approach. Hence, the surgeon is usually compelled to utilize supplemental cutaneous incisions that are a compromise on the purpose behind a cosmetic surgery. In order to alleviate the need for such compromise, the authors advocate the mid face degloving approach for extended osteotomies at Lefort II and Lefort III levels. Mid face degloving involves a combination of circumvestibular incision, with inter cartilaginous and transfixation components from a nasal incision. The authors have utilized this technique for 9 patients and documented favorable results. The purpose of this paper is to focus the utility of this approach in orthognathic surgery and promote this as a viable alternative to traditional approaches in surgery of the mid face because of the absence of external scars. (C) 2016 by Mutaz B. Habal, MD.

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Surgically Clipping a Posterolaterally Projecting Posterior Communicating Artery Aneurysm With Anterior Petroclinoid Fold Fenestration.

The anterior petroclinoid fold (APF) is a ligamentous structure consisting of collagen fiber and extends from the petrous apex to the anterior clinoid process. During the surgical clipping of some posterolaterally projecting posterior communicating artery aneurysms, it may pose a technical challenge due to obscuration of the aneurismal neck by the APF. Herein, the authors describe a simple and effective technique utilizing fenestration of the APF to facilitate visualization and surgical clipping of these aneurysms. To the best knowledge of us, this technique of the APF fenestration has been reported in only a few patients. (C) 2016 by Mutaz B. Habal, MD.

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Healing Effects of Platelet-Rich Plasma on Peripheral Nerve Injuries.

Regeneration of peripheral nerve injuries (PNIs) has been a major challenging issue in regenerative medicine and tissue engineering. Inferior alveolar nerve and lingual nerve injuries are the major difficulties and complications of oral surgeries following dental implant placement, etc. The aim of this study was to systematically review the effects of platelet-rich plasma (PRP) on the regeneration of PNIs. Medline NCBI databases were searched for related articles up to and including May 2016. Being published in English papers, use of PRP in peripheral nerve regeneration, in vivo studies, and having histological evaluations was the inclusion criteria. Seventeen papers were selected according to the inclusion and exclusion criteria, and categorized regarding PNIs types including cut or crushed injuries. The effects of using PRP only or in combination with cells on the functional recovery and histological assessments are discussed and compared with the other treatments such as autologous nerve graft, acellular nerve allograft, and synthetic nerve conduits. The authors also clarified the perspectives in the current field. Consequently, PRP demonstrated positive effects on healing of the nerve function as well histological improvements in cut nerve PNIs model; however, more studies in the field of crushed nerves are needed to arrive at an evidence-based conclusion. (C) 2016 by Mutaz B. Habal, MD.

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Stapler Esophageal Closure During Total Laryngectomy.

Mechanical esophageal closure with stapler during total laryngectomy has been used by various authors to decrease the surgical time and pharyngocutaneous fistula (PCF) rates. In a few of the studies, surgical site infection (SSI) rates are mentioned and none of the studies emphasize the effect of decreased surgical time on postoperative cardiovascular and cerebrovascular complications. In this study, the authors compared the PCF rates, SSI rates, operation times between 30 mechanical stapler and 40 manual esophageal closure during total laryngectomy for laryngeal cancer patients. National Nasocomial Infections Surveillance system (NNISS) scores were recorded and compared between groups. Total laryngectomy and total operation times were lower in the stapler group patients (P

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Changes at Mean Platelet Volume and Platelet Distribution Width Levels After Septoplasty and Its Correlation With Epworth Sleepness Scale.

Objective: Nasal septum deviation may affect cardiopulmonary system. Those effects can be determined via blood tests and Epworth sleepness scale (ESS). In this study, it was aimed to measure mean platelet volume (MPV) and platelet distribution width (PDW) in patients with nasal septum deviation and to assess changes at their levels after septoplasty. Furthermore, it was purposed to document the correlation between ESS score and MPV, PDW levels. Methods: Eighty-one patients who underwent septoplasty and 50 healthy controls composed the study group. Epworth sleepness scale was performed to all patients preoperatively and patients were divided into 2 groups in terms of ESS scores. Mean platelet volume and PDW levels were measured preoperatively and it was repeated postoperatively. Results: In Group A (ESS 0.05), PDW reduced from 14.56 +/- 1.27% to 14.43 +/- 1.03% after surgery (P >0.05). On the other hand, in Group B (ESS >=10), MPV reduced from 9.54 +/- 0.68 fl to 8.87 +/- 0.44 fl (P

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Ferromagnetic Artifacts Seen Incidentally on Magnetic Resonance Imaging After Temporomandibular Joint Surgery.

No abstract available

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Changes in Upper Airway Volume Following Orthognathic Surgery.

Reduced volume of the internal skeletal dimensions of the face is 1 of the main causes of obstructive sleep apnea, and attention to patients' airways is necessary when planning orthognathic treatment. This study aims to describe changes in upper airway volume following virtually planned orthognathic surgery. A retrospective pilot study was designed with 30 randomly selected patients (10 men and 20 women, aged 23.1 +/- 6.8 years, molar-relations: 15 neutral, 8 distal, and 7 mesial). Cone-beam computed tomography scans were performed before surgery and 1 week following surgery. The authors did total upper airway volume measurements and obtained 1-mm slices at vertical levels in the velo-, oro-, and hypopharynx and at the smallest visible cross-section. Measurements before and after surgery were compared using Student t test. After orthognathic surgery, the minimum cross-sectional area at the vertical level increased from 83 mm3 +/- 33 before surgery to 102 mm3 +/- 36 after surgery (P = 0.019). In patients with neutral and distal occlusions, the minimum cross-sectional slice volume increased in 87% but in only 57% with mesial occlusion. The present findings suggest that orthognathic surgery increases upper airway volume parameters, but a few patients have continued impairment of the airways following orthognathic surgery. Further studies are needed to confirm an individual surgical planning approach that potentially could bring the minimum cross sectional area out of the risk zone. (C) 2016 by Mutaz B. Habal, MD.

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Medial Femoral Condyle Free Flap for Premaxillary Reconstruction in Median Facial Dysplasia.

Objective: Median facial dysplasia is a distinct development anomaly of the craniofacial region that is characterized by deficient mid facial structures. Medial femoral condyle free flap could be used as a bony flap, and the unique characteristics of this flap provide the surgeons with the periosteal component as well. In this work, the authors present our experience with a patient of median facial dysplasia with unilateral cleft lip, cleft palate, and premaxillary deficiency. Methods: The patient was diagnosed with median facial dysplasia accompanied by unilateral cleft lip, cleft palate, and premaxillary. She had presented with severe midface hypoplasia with missing premaxillary bone. Premaxillary reconstruction was performed with the use of medial femoral condyle free flap. Results: Medial femoral condyle free flap was successfully used for premaxillary reconstruction. The flap fitted well to the alveolar bony gap. Since the flap is a periosteal bone flap, the gingival mucosa was reconstructed very well. The lip harmony was considerably restored compared with the preoperative status. Conclusions: Although several other options are available, the medial femoral condyle free flap is particularly suited for the reconstruction of median facial dysplasia. (C) 2016 by Mutaz B. Habal, MD.

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Personalized Reconstruction of Traumatic Orbital Defects Based on Precise Three-Dimensional Orientation and Measurements of the Globe.

Objective: The aim of the study was to precisely assess the severity of traumatic orbital defects and techniques for personalized orbital reconstruction. Methods: A retrospective study was conducted in 97 patients with traumatic orbital defects who were treated in our hospital between July 2003 and June 2012. Pre- and postoperative spiral computed tomography scans were performed in all patients. A spatial orientation technique was used to measure the three-dimensional position of the globe and calculate the changes in the orbital volume. Subsequently, a computer-assisted technique and a rapid prototyping technique were used to create a personalized orbital model to aid in the planning of surgery as well as the preforming of implants and bone plates. During surgery, the herniated orbital contents were returned; the preformed titanium mesh, Medpor, or other implants were placed; the orbital shape in the defect site was precisely restored; and normal proportions between the orbital walls and orbital contents were regained. The treatment outcomes were evaluated with respect to postoperative appearance, patients' satisfaction, ophthalmologic examination, and computed tomography scan. The complications were analyzed accordingly. Results: Satisfactory results were achieved in all patients with the following exceptions: 1 patient with an unsatisfactory facial appearance; 2 patients with old trauma and an unfavorable correction of enophthalmos who experienced diplopia with no significant improvement within 6 months after surgery; and 2 patients of mild postoperative lower eyelid ectropion. All other patients achieved satisfactory treatment effects, that is, the orbital shape in the defect site was precisely restored, and normal proportions between the orbital walls and orbital contents were regained. There were no other severe complications reported. Conclusions: In patients with traumatic orbital defects, accurate digital evaluations of the three-dimensional position of the globe and changes in the orbital volume aid in surgical planning with a personalized model and promote early surgery with minimal trauma. When the orbital volume was restored and the position of the globe was maintained or corrected, the precise reconstruction of the anatomic shape of the orbit was concurrently completed. Personalized orbital reconstruction can improve the efficacy of plastic surgery in patients with orbital deformities. (C) 2016 by Mutaz B. Habal, MD.

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Cranial Bone Graft Donor Site Reconstruction.

My most important concern, in my entire experience with cranial bone grafting procedures, is managing the bone graft donor site such as donor site cavity from harvesting and weakness of the cranium. The most common patient complaint, following cranial bone grafting for aesthetic indications, is the presence of a cavity at the donor site. The authors have managed more than 200 patients since 2001, wherein the cranial bone graft-donor sites were reconstructed with tiny bone chip lamellae harvested from the area adjacent to the donor site. This procedure was associated with a low incidence of patient complaints, thereby suggesting higher patient satisfaction. This approach for cranial bone grafting appears to have a high patient acceptance. (C) 2016 by Mutaz B. Habal, MD.

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Finite Element Evaluation of Different Osteosynthesis Variations That Used After Segmental Mandibular Resection.

Purpose: The purpose of this study was to evaluate the effect of different reconstruction plates and screw combinations on stress distribution of segmental resected mandibles using finite element analysis. Methods: Lateral (L) and lateral-central (LC) defects were simulated by a computer aided design modeling. The straight (s) and angular (a) titanium locking reconstruction plates of 2.5 mm (12 holes for L defects and 16 holes for LC defects) were modeled. Each screw was 2.5 mm in diameter and 10 mm in length. A total of 20 different screw placement combinations were created. The bite force used in the present model was a unilateral molar clench. The data obtained from finite element analysis were recorded as von Mises, maximum principle and minimum principle stress values. Results: It was observed that stress values on neck of screw were higher for screws close to the resection area. When the first screw was loosened, the stress on the plate body and the remaining screws increased. Principle stress values were within the tolerance limits of the bone. Conclusion: The highest stress is observed in the screws nearest to the resection edge. Therefore, it is very important to place a screw adjacent to the resection edge. (C) 2016 by Mutaz B. Habal, MD.

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Clinical Evaluation of Zygomatic Implant-Supported Fixed and Removable Prosthesis.

The aim of our study was to present success and complication rates of 32 zygomatic implants (ZI) and compare satisfaction of patients rehabilitated with ZI supported hybrid prosthesis in atrophic jaws and removable prosthesis in maxillary defects. Sixteen patients who have been diagnosed as atrophic maxilla or maxillary defect were treated with ZI supported hybrid or removable prosthesis between 2008 and 2016 years, respectively. Thirty-two of 70 implants were placed in the zygomatic bone. Two prosthetic groups were compared 1 month after prosthesis delivery in terms of general satisfaction, stability, performance, esthetics, phonetics, hygiene level based on visual analog scale. Zygomatic implants success rate was found 93.7% after a mean follow-up of 28 +/- 22 months (range 6-96 months). Thirty of 32 ZIs have been functioning with their prosthesis. The rate of biologic complications related to ZIs was found 9.3% and prosthetic complication's rate related to ZI was 3%. Two early failures of ZIs were recorded. Chewing performance (P: 0.003), stability (P: 0.0001), and phonetics (P: 0.003) were found higher in hybrid prosthetic group. On the other hand, there was a statistically significant difference between groups in favor of removable prosthetic group regarding ease of cleaning (P: 0.007). Our study shows high success rate and minimal complications for 32 ZIs. This procedure seems to be an alternative to the bone grafts or sinus lifting techniques in patient of severely resorbed maxilla or to the obturator prosthesis for maxillectomy patients. (C) 2016 by Mutaz B. Habal, MD.

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Pressureless Orbital Decompression for Myopic Proptosis.

Orbital decompression surgery increases the orbital volume. It has rarely been used for proptosis of the large highly myopic globe. However, external decompression surgery carries significant risks because of the large thin-walled globe. The authors report the first use of endoscopic medial wall orbital decompression surgery in this setting to obviate the risk of globe pressure. Endoscopic medial wall decompression brought about a 4 mm reduction of proptosis, correction of exotropia and elimination of retrobulbar ache providing good symmetry with the fellow eye. Endoscopic medial wall orbital decompression can be very effective for correcting the proptosis of high myopia and minimizes the risk of damage to the very large, thin-walled globe. (C) 2016 by Mutaz B. Habal, MD.

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