Παρασκευή 27 Ιανουαρίου 2017
Free Dermal Fat Graft Reconstruction of the Head and Neck: An Alternate Reconstructive Option
Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy.
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Autopsy after transcatheter aortic valve implantation
Abstract
Autopsy after transcatheter aortic valve implantation (TAVI) is a new field of interest in cardiovascular pathology. To identify the cause of death, it is important to be familiar with specific findings related to the time interval between the procedure and death. We aimed to provide an overview of the autopsy findings in patients with TAVI in their medical history divided by the timing of death with specific interest in the added value of autopsy over a solely clinically determined cause of death. In 8 European centres, 72 cases with autopsy reports were available. Autopsies were divided according to the time interval of death and reports were analysed. In 32 patients who died ≤72 h postprocedure, mortality resulted from cardiogenic or haemorrhagic shock in 62.5 and 34.4%, respectively. In 31 patients with mortality >72 h to ≤30 days, cardiogenic shock was the cause of death in 51.6% followed by sepsis (22.6%) and respiratory failure (9.7%). Of the nine patients with death >30 days, 88.9% died of sepsis, caused by infective endocarditis in half of them. At total of 12 patients revealed cerebrovascular complications. Autopsy revealed unexpected findings in 61.1% and resulted in a partly or completely different cause of death as was clinically determined. Autopsy on patients who underwent TAVI reveals specific patterns of cardiovascular pathology that clearly relate to the time interval between TAVI and death and significantly adds to the clinical diagnosis. Our data support the role of autopsy including investigation of the cerebrum in the quickly evolving era of cardiac device technology.
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Reply
Source:Journal of Allergy and Clinical Immunology
Author(s): Jennifer Koplin, Katrina J. Allen
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Ruxolitinib reverses dysregulated T helper cell responses and controls autoimmunity caused by a novel signal transducer and activator of transcription 1 (STAT1) gain-of-function mutation
Publication date: Available online 27 January 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Katja G. Weinacht, Louis-Marie Charbonnier, Fayhan Alroqi, Ashley Plant, Qi Qiao, Hao Wu, Clement Ma, Troy R. Torgerson, Sergio D. Rosenzweig, Thomas A. Fleisher, Luigi D. Notarangelo, Imelda C. Hanson, Lisa R. Forbes, Talal A. Chatila
BackgroundGain-of-function (GOF) mutations in the human signal transducer and activator of transcription 1 (STAT1) manifest in immunodeficiency and autoimmunity with impaired TH17 cell differentiation and exaggerated responsiveness to type I and II interferons. Allogeneic bone marrow transplantation has been attempted in severely affected patients, but outcomes have been poor.ObjectiveWe sought to define the effect of increased STAT1 activity on T helper cell polarization and to investigate the therapeutic potential of ruxolitinib in treating autoimmunity secondary to STAT1 GOF mutations.MethodsWe used in vitro polarization assays, as well as phenotypic and functional analysis of STAT1-mutated patient cells.ResultsWe report a child with a novel mutation in the linker domain of STAT1 who had life-threatening autoimmune cytopenias and chronic mucocutaneous candidiasis. Naive lymphocytes from the affected patient displayed increased TH1 and follicular T helper cell and suppressed TH17 cell responses. The mutation augmented cytokine-induced STAT1 phosphorylation without affecting dephosphorylation kinetics. Treatment with the Janus kinase 1/2 inhibitor ruxolitinib reduced hyperresponsiveness to type I and II interferons, normalized TH1 and follicular T helper cell responses, improved TH17 differentiation, cured mucocutaneous candidiasis, and maintained remission of immune-mediated cytopenias.ConclusionsAutoimmunity and infection caused by STAT1 GOF mutations are the result of dysregulated T helper cell responses. Janus kinase inhibitor therapy could represent an effective targeted treatment for long-term disease control in severely affected patients for whom hematopoietic stem cell transplantation is not available.
Graphical abstract
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Reply
Source:Journal of Allergy and Clinical Immunology
Author(s): Mary Feeney, George Du Toit, Gideon Lack
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Role of TGF-β in anti-rhinovirus immune responses in asthmatic patients
Source:Journal of Allergy and Clinical Immunology
Author(s): Carina Bielor, Nina Sopel, Anja Maier, Ashley Blau, Himanshu Sharma, Tytti Vuorinen, Bettina Kroß, Susanne Mittler, Anna Graser, Stephanie Mousset, Volker O. Melichar, Alexander Kiefer, Theodor Zimmermann, Rebekka Springel, Corinna Holzinger, Sonja Trump, Stella Taka, Nikolaos G. Papadopoulos, Scott T. Weiss, Susetta Finotto
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Early or delayed introduction of food? Misunderstanding is in the air
Source:Journal of Allergy and Clinical Immunology
Author(s): Simona Di Mario, Vittorio Basevi, Costantino Panza, Sergio Conti Nibali, Adriano Cattaneo
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Oral Contraceptive Okay for Acne as Last Resort, Says EMA
EU regulators said the available evidence for drugs combining dienogest and ethinylestradiol does not raise new safety concerns.
Medscape Medical News
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Lymphoepithelial carcinoma in parotid gland related to EBV infection: A case report
Lymphoepithelial carcinoma commonly occurs at the nasopharynx and rarely occurs at other sites in the head and neck region. It is well known to occur at limited patients of local area as Asia or Arctic Circle. Related to this point, it is pointed out that this tumor has strong relation with Epstein–Barr Virus (EBV) infection.In this time, we experienced to treat lymphoepithelial carcinoma with metastatic cervical lymph nodes occurring at parotid gland. The morbidity ratio of this tumor is less than one percent of all parotid gland tumors.
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Evaluation of maternal history of miscarriage, infertility, and in-vitro fertilization use as associated factors in PHACE
Abstract
The etiology of PHACE (Posterior fossa anomalies, Hemangioma, Arterial anomalies, Coarctation of the aorta, and Eye anomalies) is unknown. A genetic etiology has been proposed but there are no published reports of heritability in families of children with PHACE. PHACE has a female predominance although preliminary X-inactivation studies have not demonstrated significant skewing in affected female patients or their mothers.1 Copy number variation studies have yet to identify a common pathogenic variant.
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The objective Psoriasis Area Severity Index: A randomised controlled pilot study comparing the effectiveness of cyclosporine and methotrexate using an objective PASI (oPASI)
Abstract
A randomised controlled pilot study was performed to compare the clinical effectiveness of cyclosporine and methotrexate, using a new objective severity assessment method, which we then compared with the Psoriasis Area Severity Index (PASI) for usefulness and reliability.
Psoriatic patients with psoriatic lesions over 5% of body surface area were enrolled and underwent 16 weeks of treatment with either cyclosporine or methotrexate. In the cyclosporine group, the initial dose was 150 mg/day for females and 200 mg/day for males.
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Possible inducible skin-associated lymphoid tissues (iSALT)-like structures with CXCL13+ fibroblast-like cells in secondary syphilis
Abstract
Non-lymphoid organs, are not merely the sites for effector T-cell-function.Ectopic accumulations of lymphoid cells arise in non-lymphoid organs under long-lived self-perpetuating chronic inflammation.1 These accumulations are called tertiary lymphoid organs (TLOs), and they function as antigen-presenting sites.1 TLOs are characterized by their cellular, organizational, chemokine, and vascular similarity to lymph nodes (LNs).1
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Chronic Urticaria and Atopic Disorders: a Cross-sectional Study of 11,271 Patients
Abstract
Chronic urticaria (CU) and atopic disorders such as atopic dermatitis (AD), allergic rhinoconjunctivitis (AR), and asthma are related to aberrant immune function. The relationship between atopic disorders and CU is controversial, mostly since epidemiological data are lacking.
The aim of our study was to investigate the association between CU and asthma, AD, and AR using a database of Clalit Health Services (CHS) - the largest healthcare provider organization in Israel.
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BRAF inhibitor-associated cutaneous squamous cell carcinoma: new mechanistic insight, emerging evidence for a viral involvement, and perspectives on clinical management
Abstract
Mutations in the BRAF proto-oncogene occur in the majority of cutaneous melanomas. The commonly detected valine (V) to glutamate (E) mutation (V600E) is known to drive melanomagenesis and has thus been the target of two highly selective chemotherapeutic agents: vemurafenib and dabrafenib. While BRAF inhibitor therapy has revolutionized the treatment of metastatic melanoma, unanticipated cutaneous toxicities including the development of cutaneous squamous cell carcinomas (cSCCs) are frequently reported and hinder therapeutic durability. However, the mechanisms by which BRAF inhibitors induce cutaneous neoplasms are poorly understood, thus posing a challenge for specific therapies. In this review, we summarize the clinical and molecular profile of BRAF inhibitor-associated cSCCs, with a focus on factors that may contribute to disease pathogenesis. In particular, we discuss the emerging evidence pointing toward viral involvement in BRAF inhibitor-induced cutaneous neoplasms and offer new perspectives on future therapeutic interventions. Continued clinical and mechanistic studies along this line will not only allow for better understanding of the pathogenic progression of BRAF inhibitor-induced cSCCs, but also lead to development of new therapeutic and preventative options for patients receiving targeted cancer therapy.
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BRAFV600 inhibitor discontinuation after complete response in advanced melanoma. A retrospective analysis of 16 patients
Abstract
BRAF inhibitors (BRAFi) improve progression-free survival and overall survival in patients with advanced melanoma (1,2), with 3 to 6% of patients experiencing complete remission (CR)(1,3). Nevertheless, this efficacy comes at a cost with 90% of patients experiencing at least one adverse event and 45% grade 3 or 4 adverse events (4).
Management of long-term responders is not yet well delineated: safety argues for treatment continuation, because evolution after discontinuation is unknown.
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Non-invasive proteome analysis of psoriatic stratum corneum reflects pathophysiological pathways and is useful for drug profiling
Summary
Background
Protein expression is disturbed in psoriatic stratum corneum. Non-invasive methods for the description of pathophysiological changes and drug profiling in psoriasis are desirable.
Objectives
Undertake large scale non-invasive protein expression studies in psoriatic stratum corneum to identify biomarkers of pathophysiological processes and use them for drug profiling.
Methods
Psoriatic stratum corneum was harvested through repetitive tape-stripping. Non-lesional and lesional stratum corneum, as well as vehicle- and drug-treated lesional stratum corneum samples were collected. Protein extracts from non-lesional and lesional skin biopsies were used for comparison. Calcipotriol-Betamethasone (CB) was used as a reference medication. Proteins extracted from pooled tape strips were quantified using mass spectrometry (MS), western blotting, ELISA and Luminex technologies.
Results
MS-based methods identified 140 proteins differentially expressed in psoriatic stratum corneum. Epidermis development, glycolysis, regulation of apoptosis, cytoskeleton organization and peptide cross-linking were modulated, all reflecting perturbed epidermal differentiation.
Using antibody-based techniques, increased levels of sICAM1, of CXCL1 and CXCL8 attracting neutrophils, of CXCL10 and CCL4 attracting Th1 cells, and of CCL2 and CCL4 attracting monocytes and dendritic cells were observed. Quantification of the Th1 and Th17 markers TNF, IL12B, IL17A and IL17F in lesional stratum corneum was successful, while the Th2 cytokines IL4, IL5 and IL13, not involved in the disease process, were not detected. The pruritic cytokine IL31 was detected in lesional stratum corneum.
CXCL1, CXCL8, CXCL10 and sICAM, were used to investigate disease remission, ranking three topical treatments according to their known clinical efficacy.
Conclusions
Protein biomarker quantification in psoriatic stratum corneum detects key pathophysiological mechanisms and enables non-invasive drug profiling in translational medicine settings.
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Oral squamous cell carcinoma in the background of oral submucous fibrosis is a distinct clinico-pathological entity with better prognosis
Abstract
Background
The aim of this study was to compare the clinicopathological features of oral squamous cell carcinoma in the background of oral submucous fibrosis (OSCC-OSMF) and oral squamous cell carcinoma (OSCC).
Methods
217 cases of OSCC were retrieved from achieves for the analysis.OSCC-OSMF cases were segregated on the basis of history and clinico-pathological parameters.
Results
The study included 217 patients of which 112 had OSCC and 105 OSCC-OSMF. OSCC-OSMFs were younger compared with OSCC. Overall oral cancer was noted predominantly in males compared to females. The number of OSCC-OSMF were more in TNM Stage I and Stage II as compared to OSCC, where as the number of OSCC were more in Stage III and Stage IV compared to OSCC-OSMF.Histological presentation of well differentiated Squamous cell carcinoma (WDSCC) was significantly more in OSCC-OSMF compared to OSCC, where as histological presentation of moderately differentiated squamous cell carcinoma was significantly more in OSCC compared to OSCC-OSMF. Regional lymph node metastasis was significantly higher in OSCC compared to OSCC-OSMF. Three year disease free survival rate was significantly higher in OSCC-OSMF compared to OSCC.
Conclusion
The OSCC-OSMF was found to be a clinicpathologically distinct entity compared to OSCCwith a better grade of tumor differentiation, less incidence of nodal metastases and early detection (early clinical TNM stage).All these factors probably contribute to a better prognosis and increased three yeardisease free survival.
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Nailing the Shared Etiology in the Formation of Curved Hair and Nail Growth
Abstract
A 55 year old African American woman presented for evaluation of alopecia and was noted to have very long fingernails that she had not cut for 10 years. Physical examination revealed long and curly fingernails with nail plate lengths of approximately 5-30 cm (Figure 1). The dominant right hand nail plates were shorter, as the patient reported occasional breakage from every day maneuvers.
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Fatal infection of Pneumocystis jiroveci pneumonia in a pemphigus patient treated with rituximab
Abstract
Rituximab is an effective treatment for pemphigus and can be considered as a first-line treatment for severe cases.1-4 Rituximab increases the risk of infection with Pneumocystis jiroveci pneumonia (PJP), an opportunistic pathogen, especially in hematopoietic stem cell transplant and Wegener's granulomatosis, with a high associated mortality rate up to 30%.5 The risk of PJP infection in pemphigus patients treated with rituximab has been underreported to date.
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Bullous Pemphigoid Associated with Nivolumab, a Programmed Cell Death 1 Protein Inhibitor
Abstract
Checkpoint inhibitors, such as nivolumab, are revolutionary new drugs in cancer therapy. Mild dermatologic toxicities are commonly reported adverse events. Herein, we highlight the development of the autoimmune blistering condition, bullous pemphigoid (BP) in a patient undergoing treatment with nivolumab.
A 60-year-old man, who was being treated with nivolumab (3mg/kg intravenously every 2 weeks) after failing chemotherapy for metastatic renal cell carcinoma, presented acutely with a blistering rash.
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Pseudo-pitting of the nail in psoriasis
Abstract
Psoriasis is a chronic and recurrent inflammatory skin disease with a worldwide prevalence of approximately 1 to 3% causing significant distress and morbidity in the affected patients.1,2,3
Skin manifestations are the most characteristic findings of psoriasis, however, nail psoriasis is often overlooked despite its common occurrence.1,2 Nail involvement occurs in 61% of cases of cutaneous psoriasis and with a lifetime incidence among patients with psoriatic arthritis between 80% and 90%. About 1–5% of patients manifest with nail changes only.4,5
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Phace syndrome: is timolol gel a chance for treatment?
Abstract
a 3-months-old baby presented to our Pediatric Dermatology Unit with a large facial hemangioma involving also the left arm and the left side of the trunk (Figure 1a).
The clinical examination revealed a prominent and extensive vascular network on the face, trunk and upper limb of the left side, a voluminous hemangioma of the upper left eyelid and multiple small and confluent hemangiomas of the left trunk.
The ophthalmological examination excluded any anomalies of the posterior or anterior segments, but the patient had a left palpebral closure due to the large hemangioma of the face (Figure 1a).
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Predictors of Tanning Dependence in White Non-Hispanic Females and Males
Abstract
Background
Growing evidence suggests that some individuals may exhibit symptoms of dependence on ultraviolet (UV) light, a known carcinogen, in the context of tanning; however, few studies have investigated predictors of tanning dependence (TD).
Objective
To identify predictors of tanning dependence (TD).
Methods
Non-Hispanics of European-ancestry who had previously participated in a case-control study of early-onset basal cell carcinoma completed an online survey to ascertain TD and other behaviors (alcohol dependence, nicotine dependence, seasonal affective disorder (SAD), exercise 'addiction', and depression). Information on host factors, such as skin and eye color and history of sunbathing and indoor tanning, was obtained from a study in which the participants were previously enrolled. Lifetime TD was assessed using the modified Cut down, Annoyed, Guilty, Eye-opener (mCAGE) and the modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (mDSM-IV-TR) questionnaires. Participants were classified as 'TD' if positive on both questionnaires and not TD if negative on both questionnaires.
Results
In total, 499 individuals completed the online survey (81.9% participation rate), 24.4% were classified as 'TD'. In the multivariate model, women were more likely to be TD (odds ratio (OR) 6.93; 95% Confidence Intervals (95% CI) (3.36-14.27)) than men. Alcohol dependence (OR 6.55: 95% CI 3.19-13.42), SAD (OR 2.77; 95% CI 1.26-6.09) and exercise 'addiction' (OR 5.47; 95% CI 1.15-26.06) were all significant predictors for TD.
Conclusion
Increased knowledge of those at risk for TD will allow appropriate interventions to be designed.
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No Evidence for Increased Anxiety in Acne Patients Treated with Isotretinoin
Abstract
Acne is associated with social and psychological problems such as depression and anxiety.1,2 Isotretinoin is the most effective treatment for recalcitrant nodulocystic acne. However, the possible induction of depressive symptoms by isotretinoin as an acne treatment was first reported in 1983.3 The relationship between isotretinoin treatment for acne and depression is still controversial.
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Adjuvanzien
Zusammenfassung
Geschätzt wird, dass etwa 5 % aller Patienten, die prinzipiell von einer spezifischen Immuntherapie (SIT) profitieren können, tatsächlich einer SIT unterzogen werden. Dabei ist die SIT derzeit die einzige kurative Therapie mit der Toleranz bei individueller Allergie, insbesondere gegen Aeroallergene und Insektengifte, erzeugt werden kann. Therapeutika, mit denen in möglichst kurzen Therapieprotokollen Allergien hochwirksam und sicher behandelt werden können, sind das Ziel neuer Entwicklungen. Adjuvanzien sind pharmakologische und/oder immunologische wirksame Moleküle, die die spezifische immunologische Antwort gegen Antigene modifizieren können. In der Impftechnologie werden Adjuvanzien bereits breit eingesetzt, um die Immunogenität hochgereinigter, wenig immunstimulierender Antigene zu erhöhen. Dabei können Adjuvanzien auf eine verlängerte Antigenexposition oder eine Modulation der Immunantwort abzielen oder auch als Vektorsysteme dienen, mit denen Allergene und Adjuvanzien gezielt an Zielzellen transportiert werden können.
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Arthritis Drugs Get Nod From EMA's CHMP
Tofacitinib citrate (Xeljanz), two adalimumab (Humira) biosimilars, and one methotrexate hybrid get thumbs up from EMA committee.
International Approvals
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HLA-G variability and haplotypes detected by massively parallel sequencing procedures in the geographicaly distinct population samples of Brazil and Cyprus
Source:Molecular Immunology, Volume 83
Author(s): Erick C. Castelli, Petroula Gerasimou, Michelle A. Paz, Jaqueline Ramalho, Iane O.P. Porto, Thálitta H.A. Lima, Andréia S. Souza, Luciana C. Veiga-Castelli, Cristhianna V.A. Collares, Eduardo A. Donadi, Celso T. Mendes-Junior, Paul Costeas
The HLA-G molecule presents immunomodulatory properties that might inhibit immune responses when interacting with specific Natural Killer and T cell receptors, such as KIR2DL4, ILT2 and ILT4. Thus, HLA-G might influence the outcome of situations in which fine immune system modulation is required, such as autoimmune diseases, transplants, cancer and pregnancy. The majority of the studies regarding the HLA-G gene variability so far was restricted to a specific gene segment (i.e., promoter, coding or 3′ untranslated region), and was performed by using Sanger sequencing and probabilistic models to infer haplotypes. Here we propose a massively parallel sequencing (NGS) with a bioinformatics strategy to evaluate the entire HLA-G regulatory and coding segments, with haplotypes inferred relying more on the straightforward haplotyping capabilities of NGS, and less on probabilistic models. Then, HLA-G variability was surveyed in two admixed population samples of distinct geographical regions and demographic backgrounds, Cyprus and Brazil. Most haplotypes (promoters, coding, 3′UTR and extended ones) were detected both in Brazil and Cyprus and were identical to the ones already described by probabilistic models, indicating that these haplotypes are quite old and may be present worldwide.
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Is fruit and vegetable intake associated with asthma or chronic rhino-sinusitis in European adults? Results from the Global Allergy and Asthma Network of Excellence (GA2LEN) Survey
Fruits and vegetables are rich in compounds with proposed antioxidant, anti-allergic and anti-inflammatory properties, which could contribute to reduce the prevalence of asthma and allergic diseases.
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COPD exacerbation: 5 things EMS providers need to know
By Bob Sullivan
Chronic obstructive pulmonary disease affects approximately 32 million Americans, and it is the fourth leading cause of death in the United States. COPD includes a group of degenerative conditions that impair airflow through the lungs. Cigarette smoking is the most common cause of COPD, and chronic bronchitis and emphysema are the two main types [1].
COPD exacerbations are frequently encountered by EMS providers, and proper assessment and treatment can significantly improve the patient's respiratory status. Here are five things EMS providers need to know about respiratory compromise from COPD:
1. Baseline respiratory status is compromised and declines further during COPD exacerbations.
Lung damage from COPD is irreversible, and people living with COPD have a prescribed treatment plan to manage their symptoms. The plan may include oral and inhaled medications to reduce bronchoconstriction and inflammation, as well as home oxygen to treat chronic hypoxia. In addition to the respiratory compromise caused by COPD, patients with COPD are at higher risk of pneumonia and right-sided heart failure.
Chronic bronchitis causes excess mucus to be secreted in the terminal bronchi, and impairs the cilia lining the terminal bronchi from clearing the secretions. The bronchi are also hypersensitive to inflammation, which increases the frequency of sudden bronchoconstriction. Patient with chronic bronchitis are often overweight, have cyanotic skin and have a frequent productive cough.
Emphysema causes the alveoli to lose elasticity. This reduces the surface area available for oxygen diffusion on inhalation and prevents CO2-filled air from leaving the alveoli on exhalation. Trapped air causes the weakened alveoli to dilate, which eventually destroys the alveolar walls. Once destroyed, several tiny alveolar sacs consolidate into one large sac, or bleb, which further decreases the surface area available for gas exchange. Patients with emphysema are often thin and have a barrel- shaped chest, pink and dry skin, and a dry cough.
EMS is often called for exacerbations of COPD, which occurs when a patient's baseline symptoms worsen. COPD exacerbations may be triggered by noncompliance with a treatment plan, exposure to an allergen such as cigarette smoke or a respiratory infection. The onset of a COPD exacerbation may be sudden or gradual and patients may try to manage symptoms on their own for a long period before calling 911.
2. Understand how exam findings and point-of-care monitoring tools can be used.
Observe the patient's level of consciousness and position to assess their work of breathing. Patients in severe respiratory distress may be upright in a tripod position, and patients in respiratory failure may appear drowsy or unconscious. Supraclavicular and intercostal retractions indicate that the patient is using accessory muscles to breathe. Patients with COPD may also exhale through pursed lips, which helps keep weakened alveoli open.
Auscultation of the lungs may reveal high pitched wheezes from air movement through constricted lower airways and low pitched, sonorous wheezes may be heard from air movement across mucus secretions. Diminished or absent breath sounds indicates poor air movement through the lungs, and is an ominous sign.
Attempt to determine how the patient's current respiratory status compares to their baseline. Patients in severe respiratory distress may only be able speak in short phrases or nod their head yes or no to questions. Ask about what treatment they have used before you arrived, if their respiratory distress today is worse than it has ever has been before, and if they have ever been intubated for respiratory distress. This helps determine initial treatment steps and anticipate the patient's clinical course.
Measure pulse-oximetry and observe skin color to assess oxygenation. Both may be abnormal at baseline for COPD patients and many COPD patients know what their pulse-oximetry reading normally is. For patients on home oxygen, ask how many liters per minute they normally use, and if they have had to increase it recently.
Compromised exhalation from COPD may cause CO2 retention or hypercarbia. This is a sign that respiratory effort is failing and that they are at risk of respiratory failure from fatigue. Waveform capnography provides continuous feedback on the amount of CO2 exhaled with each breath (end-tidal CO2, or ETCO2), which is normally between 35 and 45 mm Hg. Hypercarbic patients may be in respiratory failure, even if patients are adquetely oxygenated and have normal pulse oximetry.
The shape of the capnography waveform also identifies bronchospasm, which can help differentiate a COPD exacerbation from other causes of respiratory distress, such as heart failure. During bronchospasm, the normally rectangular capnography waveform will have a slurred upstroke, or "shark fin" appearance. The more pronounced the slurring, the more severe the bronchospasm. In emphysema, the plateau of the waveform may slope downward if air remains trapped in the alveoli.
3. Administer oxygen, bronchodilators, corticosteroids and CPAP.
The treatment approach for exacerbations of chronic bronchitis and emphysema is the same. Supplemental oxygen administration is vital for hypoxic COPD patients, but too much oxygen may worsen CO2 retention and be harmful [2]. An Australian study found that COPD patients who received high flow oxygen had a higher mortality rate than patients who received only enough oxygen to maintain SpO2 of 88 to 92 percent. Consider using a nasal cannula or Venturi mask to administer oxygen initially, and use pulse-oximetry as a guide for titration [2].
Administer nebulized bronchodilators, connected to oxygen at 6-8 LPM, to open lower airways and improve ventilation. Albuterol stimulates beta-2 receptor sites to causes rapid bronchodilation. Ipratropium bromide (Atrovent) inhibits the vagal response, which causes bronchodilation and reduces mucus secretion, and has a twenty minute onset of action. Albuterol and ipratropium bromide can be mixed together in a nebulizer and administered until the patient's respiratory status improves [1].
Corticosteroids decrease inflammation from a COPD exacerbation, which also improves air flow through the lungs. Methylprednisolone (Solu-Medrol) can be administered intravenously or intramuscularly, and prednisone can be administered orally. The onset for both medications is four to six hours, so time on scene should not be delayed to administer corticosteroids [1]. While the benefit may not be seed during EMS contact, corticosteroid administration during transport can significantly help the patient's hospital course.
For patients in moderate to severe shortness of breath, who are alert and have a patent airway, CPAP helps improve oxygenation reduces work of breathing. CPAP works by forcing terminal bronchioles and alveoli open, which increases the surface area available for gas exchange and allows trapped air to escape [3]. CPAP also delivers nebulized medications deeper into the lower airways. Consider applying CPAP early for patients with elevated ETCO2, or had no relief from home breathing treatments before calling EMS.
4. Assist ventilation with caution for patients in respiratory failure.
Respiratory failure occurs when a patient's respiratory effort can no longer compensate for compromised oxygenation and ventilation. Fatigue, altered mental status and worsening hypercapnea along with decreasing respiratory rate are signs of respiratory failure. Patients in respiratory failure require assisted ventilation with a bag valve mask and possibly placement of an advanced airway.
Positive pressure ventilation may be life saving during a COPD exacerbation, but it has a number of risks and side effects. Patients with COPD are at high risk of barotrauma from excessive ventilation rate and tidal volume. The goal of assisted ventilation is to deliver as little tidal volume as needed to achieve an oxygen saturation of 90 percent. Squeeze the BVM gently over one second and stop squeezing as soon as chest rise is visible. Use waveform capnography as a guide to maintain a ventilation rate of 10-12 breaths per minute and to ensure that the patient has exhaled completely before delivering the next breath.
5. Waveform capnography provides objective data about response to treatment.
Trends in ETCO2 and capnography waveform shape are a reliable indicator of whether the patient is improving or deteriorating. A decrease in respiratory rate, decrease in ETCO2 and shark-fin waveform shift towards a rectangular shape indicates that the patient's ventilation is improving. However, a rise in ETCO2 with a decrease in respiratory rate indicates that the patient is declining and in respiratory failure. For patients receiving assisted ventilation, a sudden drop in ETCO2 may indicate a pneumothorax or cardiovascular collapse. Use this information to titrate nebulized bronchodilator administration, and to identify patients in need of CPAP or assisted ventilation.
Timely assessment and care can significantly improve the respiratory status of patients with COPD exacerbations. Use information from a physical exam, pulse oximetry and capnography to identify the severity of a COPD exacerbation, to choose the most appropriate treatment options and to assess the patient's response to treatment.
References
1. Kleinschmidt P. (2016, January 27) Chronic obstructive pulmonary disease and emphysema in emergency medicine treatment & management. Medscape. Retrieved from: http://ift.tt/2jmRrgk
2. Austin M, Wills K, Blizzard L., Walters H. & Wood-Baker W. (2010). Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. British Medical Journal, 341, c5462. doi:10.1136/bmj.c5462
3. Hsieh A. (2016 October 24). EMS use of CPAP for respiratory emergencies EMS 1. Retrieved from: http://ift.tt/2jxGtYI
4. McEvoy M. Manual ventilation in EMS: a primer. (2013 July 21) EMS 1. Retrieved from: http://ift.tt/2jmRt7W
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Effects of exposure to 2100MHz GSM-like radiofrequency electromagnetic field on auditory system of rats
Publication date: Available online 27 January 2017
Source:Brazilian Journal of Otorhinolaryngology
Author(s): S.M.J. Mortazavi, S.A.R. Mortazavi, Maryam Paknahad
http://ift.tt/2kBKzAK
Free Dermal Fat Graft Reconstruction of the Head and Neck: An Alternate Reconstructive Option
Source:American Journal of Otolaryngology
Author(s): Adam Honeybrook, Sanjay M. Athavale, Sarah L. Rohde, James L. Netterville
ObjectivesAblative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects.Study DesignNon-randomized retrospective analysis.MethodsThe medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction.ResultsSixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site.ConclusionsFrom our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.
http://ift.tt/2jcXEAl
Peril of missing a double gall bladder: report of a patient who needed cholecystectomy two times over
Gall bladder (GB) duplication is a rare anomaly, not often seen in regular clinical practice. Though a vestigial organ, the presence of calculi within the GB can cause the patient to be acutely symptomatic with right hypochondriac pain, which can even be life threatening if not treated. The presence of two GBs means this pathology can be seen in both the GBs, highlighting the importance of diagnosing this condition, lest the patient returns years after a cholecystectomy with cholecystitis yet again!
http://ift.tt/2kB8lc8
Metastatic endometrial endometrioid carcinoma mimicking pilomatrixoma of the distal vagina
Endometrioid carcinoma with a prominent squamous component has the ability to mimic pilomatrixoma. One previous case is documented of cutaneous metastasis in the upper limb derived from ovarian endometrioid carcinoma mimicking pilomatrixoma. Here, we describe a case of metastasis of endometrial endometrioid carcinoma in the distal vagina, treated with radiotherapy and later resected. The histology of the lesion was thought initially to represent pilomatrixoma; this has not previously been described in the vagina, where no hair matrix cells are normally present. We hypothesise that radiotherapy may have effectively 'sterilised' the glandular component, blinding the malignant features. Further management was significantly altered by the reinterpretation of this result as metastatic disease. We emphasise that in the context of known endometrioid carcinoma, the diagnosis of pilomatrixoma should be made with caution, particularly where radiotherapy has been used.
http://ift.tt/2kBiKIO
Lumbo-costo-vertebral syndrome with inguinal hernia and other anomalies
Description
A 20 day-old full-term vaginally delivered baby boy, weighing 3.25 kg, presented to the surgical department with deformity of spine and lower limbs, swelling in left groin and left lumbar region since birth. Antenatal ultrasound was not available. On examination, the child was active, crying well, lips were cyanosed and there was no pedal oedema. Cardiovascular examination revealed the presence of systolic murmur. Abdominal examination showed the presence of left lumbar and inguinal hernia (figure 1). Telipus equinovarus deformity was present bilaterally in lower limbs. Scoliosis of spine with concavity towards left side was present. Echocardiography showed tetralogy of Fallot. Ultrasound scan of the abdomen revealed the absence of left kidney, left lumbar and inguinal hernia. X-ray showed scoliosis, hemivertebrae of thoracic region, left rib anomalies, herniation of bowel loops in left lumbar region and left scrotum (figure 2).
Figure 1
Left lumbar and...
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Topical timolol for the treatment of pyoderma gangrenosum
Treatment of pyoderma gangrenosum (PG) remains a challenge, and there are currently no specific or uniformly effective therapies. Although widespread or rapidly progressive disease often requires systemic treatment, localised and mild lesions may be effectively controlled with topical agents. The most frequently applied topical drugs are corticosteroids and calcineurin inhibitors. Recently, a patient with idiopathic PG of the lower limb was successfully treated with topical timolol and collagenase. Here, we report a case of a patient with collagenous colitis, ankylosing spondylitis and periumbilical PG. Persistent ulcerated skin lesions were successfully treated with topical timolol, although a flare of the underlying bowel disease temporarily interrupted the improvement. The case presented enhances the previously reported therapeutic potential of topical timolol in the treatment of PG. Control of chronic underlying disorders is critical to prevent rebound flares and maintain the benefit.
http://ift.tt/2kB2WWC
Rumpel-Leede phenomenon in a patient with adult-onset Still's disease
Rumpel-Leede phenomenon (RLP), also known as acute capillary rupture syndrome (ACRS), is a rare occurrence where distal dermal capillaries rupture in response to a proximal compressive force, such as a blood pressure cuff or tourniquet. This phenomenon has been reported to occur in states of vascular fragility such as long-term steroid use, hypertension or diabetes mellitus. Here, we provide a report of RLP occurring secondary to tourniquet application in a 26-year-old woman with adult-onset Still's disease (AOSD) and a recent drug rash. In this case, the cause of the phenomenon is most likely multifactorial. Likely contributing factors include long-term steroid use for the treatment of AOSD, and increased vascular permeability secondary to the drug rash. Patients and clinicians should be aware that the treatment of AOSD may induce a state of capillary fragility and they should work together to minimise the risk of complications.
http://ift.tt/2kBf45T
Migrating coil
We describe a rare case of a 60-year-old man with known history of peptic ulcer disease who presented with melena and epigastric pain secondary to coil migration into duodenal mucosa 4 years after the initial therapeutic embolisation of the gastroduodenal artery. Upper endoscopy revealed oozing duodenal ulcer at the same site of the previously located duodenal ulcer 4 years ago and metal coil impacted at the duodenal mucosa. It is unclear if the coil migration is the effect or the cause of the bleeding duodenal ulcer. Our patient was treated by surgical intervention due to failed endoscopic haemostasis and medical management.
http://ift.tt/2kBpwyz
Indian erythrodermic postkala-azar dermal leishmaniasis
Postkala-azar dermal leishmaniasis (PKDL) is a complication of kala-azar or visceral leishmaniasis and is caused by Leishmania donovani. We describe an Indian male patient with the rarer erythrodermic form of PKDL and multiple unusual skin lesions viz. verrucous, annular and mucosal ulceration.
http://ift.tt/2kAWRp0
Very late rupture of a post-traumatic abdominal aortic pseudoaneurysm
Post-traumatic abdominal aortic pseudoaneurysms remain a rare yet severe complication of aortic injuries and may present many years later. Clinical presentations vary, from the traditional aneurysmal symptoms of abdominal and/or back pain with or without a pulsatile mass, to a fatal rupture. We present the case of a man aged 42 years, with a history of blunt abdominal trauma 14 years ago, presenting with symptoms of non-specific lower abdominal pain and a recent history of straining due to constipation. Clinical examination revealed umbilical bruising, in keeping with Cullen's sign, and extensive postsacral bruising. This case highlights some of the atypical manifestations of aneurysmal rupture and the importance of early recognition and management.
http://ift.tt/2kBcLnB
Limited cutaneous systemic sclerosis arising in a patient with Graves disease
Although Graves' disease and systemic sclerosis are both autoimmune disorders, their relationship is rarely reported. We present the case of a Filipino woman with goitre and thyrotoxic signs and symptoms. Diagnosed with Graves' disease at the outpatient clinic, she took antithyroid medications and underwent radioactive iodine ablation with resultant hypothyroidism after 6 months, during which she began to experience skin tightness over the face, neck and fingers. Workup revealed limited cutaneous systemic sclerosis, and the patient improved with methotrexate. This case highlights the increased prevalence of coincident autoimmune disorders in Graves' disease.
http://ift.tt/2kAWRW2
Giant renal oncocytoma with classic stellate scar
Description
A middle-aged man with poor access to medical care presented with shortness of breath and 3 years of abdominal distention. On physical examination, he was found to have a palpable mass in the left upper quadrant. He was found to have undiagnosed congestive heart failure with dilated cardiomyopathy, and a CT scan of the abdomen and pelvis revealed a left renal mass.
An MRI performed to further characterise the lesion demonstrated a large exophytic mass with a central scar and segmental enhancement originating from the lateral aspect of the left kidney with no evidence of renal vein or caval thrombus (figure 1). Owing to the possibility of renal malignancy, the patient underwent an open left radical nephrectomy through a hemi-chevron incision. The patient recovered well with no complications and was discharged home in good condition. Gross pathology demonstrated a 26 cm well-circumscribed mahogany brown tumour with intervening...
http://ift.tt/2kBdkO2
Pulmonary actinomycosis: a clinical surprise!
Description
A 65 year-old man with diabetes presented with a brief febrile illness, extreme debility and respiratory distress. X-ray chest showed a right lower lobe consolidation. A clinical diagnosis of severe community-acquired pneumonia was made for which he required antibiotics, non-invasive ventilatory support and admission to intensive care for a week. Nasopharyngeal swab was positive for influenza A by real-time PCR. The patient made apparent clinical recovery but a persisting right lower zone infiltrate. At follow-up as an outpatient 2 weeks later, he was stable haemodynamically but continued to have low-grade fever, mild hypoxia and a weight loss of 14 kg since illness onset. He was edentulous but had good oral hygiene. Chest X-ray (figure 1) and CT showed dense consolidation in the right lower lobe. Bronchoalveolar lavage showed non-acid fast, Gram positive, branching, filamentous bacteria, identified as actinomycetes in culture on blood agar (figure 2), while...
http://ift.tt/2kB2qEb
Basilar stroke from a persistent hypoglossal artery
Occlusion of the basilar artery can be treated with endovascular thrombectomy, although the results have not been well studied. Persistent fetal cerebrovascular anatomy can lead to unusual presentation of carotid atherosclerotic disease and can be a barrier to successful mechanical thrombectomy if not recognized. This case presents a rare persistent carotico–basilar anastomosis which resulted in basilar occlusion via the persistent hypoglossal artery and coincident absence of contralateral vertebral arterial access due to a left vertebral artery terminating in the left posterior inferior cerebellar artery. Preoperative recognition of this anatomy afforded by review of cross-sectional imaging was critical to success during this emergent procedure.
http://ift.tt/2kBo7YH
Swallowing outcomes for patients with oropharyngeal squamous cell carcinoma treated with primary (chemo)radiation therapy receiving either prophylactic gastrostomy or reactive nasogastric tube: A prospective cohort study
Abstract
Objectives
There is currently no consensus on the optimal feeding route for an oropharyngeal squamous cell cancer (OPSCC) patient without pre-existing dysphagia undergoing chemoradiotherapy (CRT). This study aims to compare the swallowing outcomes for OPSCC patients fed via either prophylactic RIG (pRIG) or reactive naso-gastric tube (rNGT).
Design
A prospective cohort study.
Setting
Four head and neck cancer centres in the North of England Cancer Network.
Participants
Fifty-three participants with OPSCC, on a normal diet pre-(chemo) radiotherapy.
Main outcome measure
Swallowing outcomes for patients with rNGT and pRIG were compared using the following outcome measures administered prospectively at pre-treatment, three and twelve months post-treatment: MD Anderson Dysphagia Inventory (MDADI), Performance Status Scales (Normalcy of Diet), timed water swallow test.
Results
Twenty-three patients received pRIG while 30 were planned for a rNGT. No differences in demographics were found between the groups. The rNGT group had a clinically significant higher score on MDADI at 12 months post-treatment. No significant difference was found on a timed water swallow test or diet texture scale.
Conclusions
There is no statistical difference for swallowing outcomes in either group. However, patients' in the rNGT group reported a clinically meaningful difference at one year, with a trend for them to do better across all measures. Neither group returned to their baseline swallowing function. Further research with a larger sample size is indicated.
This article is protected by copyright. All rights reserved.
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Clinicopathological relevance of antithyroglobulin antibodies in low-risk papillary thyroid cancer
Abstract
Objective
The extent of initial surgical management in papillary thyroid cancer (PTC) is controversial. We examined whether the presence of perioperative antithyroglobulin antibodies (TGA) could predict long-term recurrence and occurrence of adverse features among a homogenous group of PTC patients.
Methods
The clinical features of PTC patients treated at a single institution (Jewish General Hospital, McGill University, Montreal, Canada) were obtained from the medical records and all clinicopathologic information were reviewed. Only low-risk PTC without clinical evidence of nodal disease before surgery and treated with 30mCi of radioactive iodine (RAI) were included in the study.
Results
The chart review retrieved 361 patients with a median follow-up of 85.0 months (Q25-Q75 73-98). Forty-two (11.6%) patients had presence of perioperative TGA. Perioperative TGAs were associated with present extrathyroidal extension (P=0.005), unsuspected nodal disease (P=0.001) and autoimmune thyroiditis (P<0.0001). Overall, 17 (4.7%) patients experienced locoregional recurrence. Perioperative TGAs were a significant predictor of recurrence in univariable (P=0.021) but not in multivariable analysis (P=0.13).
Conclusion
Presence of perioperative TGAs is associated with aggressive histological features and the presence of thyroiditis. Detection of TGA perioperatively may encourage surgeons to consider more extensive initial surgery.
This article is protected by copyright. All rights reserved.
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First-line treatment of hymenoptera venom anaphylaxis: a 23-year real-life experience
Source:Annals of Allergy, Asthma & Immunology
Author(s): Radoslaw Gawlik, Magdalena Marcak, Izabela Kołodziej, Anna Dzienniak, Andrzej Bozek
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Management of children with anaphylaxis in an urban emergency department
Source:Annals of Allergy, Asthma & Immunology
Author(s): Jonathan A. Hemler, Hemant P. Sharma
http://ift.tt/2ksFcAK
The TH2-polarizing function of atopic interleukin 17 receptor B–positive dendritic cells up-regulated by lipopolysaccharide
Source:Annals of Allergy, Asthma & Immunology
Author(s): Rui Zheng, Feng-Hong Chen, Wen-Xiang Gao, Dan Wang, Qin-Tai Yang, Kai Wang, Yin-Yan Lai, Jie Deng, Li-Jie Jiang, Yue-Qi Sun, Jian-Bo Shi
BackgroundRecent studies suggest that epithelial cell (EC)-derived cytokines contribute to allergic airway disease exacerbation.ObjectiveTo confirm our hypothesis that atopic dendritic cells (DCs) are activated to up-regulate the receptors of cytokines that mainly derived from ECs and enhance TH2 responses.MethodsThe expressions of interleukin 17 receptor B (IL-17RB) (IL-25 receptor), membrane-bound ST2 (IL-33 receptor), thymic stromal lymphopoietin receptor (TSLPR), granulocyte-macrophage colony-stimulating factor receptor (GM-CSFR), and several functional markers on CD1c+ monocyte-derived DCs (mo-DCs) were detected by flow cytometry. Lipopolysaccharide (LPS)-activated mo-DCs were cocultured with autologous CD4+ T cells, and cytokine production by these T cells was determined by intracellular flow cytometry.ResultsLPS activated both nonatopic and atopic mo-DCs to express a higher level of GM-CSFR but only activated atopic mo-DCs to express increased IL-17RB, which was subsequently activated by IL-25 involved with signal transducer and activator of transcription 5 phosphorylation. In addition, LPS increased the expression of the OX40 ligand (OX40L) but decreased inducible costimulator ligand on atopic CD86+ mo-DCs. More importantly, IL-25 further up-regulated OX40L on atopic CD86+ mo-DCs. After coculturing with LPS-activated mo-DCs from atopic individuals, CD4+ T cells had enhanced inflammatory responses by increased production of IL-4, IL-5, IL-13, and interferon γ (IFN-γ). In contrast, further addition of IL-25 led CD4+ T cells to produce higher level of IL-4 but lower level of IFN-γ.ConclusionAtopic IL-17RB+ DCs can be up-regulated by LPS and promote a TH2-type response, implying that the IL-25/IL-17RB pathway may represent a potential molecular mechanism underlying the regulation of ECs on DCs in allergic airway disease.
http://ift.tt/2jby0vM
Erratum
Source:Annals of Allergy, Asthma & Immunology
http://ift.tt/2ksD2ko
Prognostic Performance of a New Staging Category to Improve Discrimination of Disease-Specific Survival in Nonmetastatic Oral Cancer.
Prognostic Performance of a New Staging Category to Improve Discrimination of Disease-Specific Survival in Nonmetastatic Oral Cancer.
JAMA Otolaryngol Head Neck Surg. 2017 Jan 26;:
Authors: Lee CC, Huang CY, Lin YS, Chang KP, Chi CC, Lin MY, Su HH, Chang TS, Chen HC, Yang CC
Abstract
Importance: Inflammatory status is associated with outcome in oral squamous cell carcinoma (OSCC). Combining the preoperative neutrophil to lymphocyte ratio (NLR) and histopathologic features may provide clinicians with more exact information regarding the prognosis of OSCC.
Objective: To compare the prognostic performance of the routinely used pathologic TNM staging with a new staging category that incorporates the NLR and histopathologic features.
Design, Setting, and Participants: This retrospective cohort study included 396 patients with newly diagnosed OSCC who underwent major surgery at a medical center from January 1, 2006, through December 31, 2013. Follow-up was completed on October 31, 2015, and data analysis was performed from January 1, 2016, through April 30, 2016.
Main Outcomes and Measures: The multivariate Cox proportional hazards regression model was used to determine the clinical or pathologic factors associated with 5-year disease-specific survival (DSS), and these factors were assigned integer points to create a new staging category. The monotonicity and discriminatory ability of the pathologic TNM staging and new staging category were evaluated with the linear trend χ2 test, Akaike information criterion, and Harrell C statistic.
Results: In total, 396 patients who underwent major surgery with curative intent for OSCC with or without adjuvant therapy were included in this study (mean [SD] age, 53 [11] years; 367 men [92.7%] and 29 women [7.3%]). Perineural invasion (adjusted hazard ratio [aHR], 1.74; 95% CI, 1.23-2.46), high NLR (aHR, 1.60; 95% CI, 1.11-2.30), advanced pT (T3 + T4) classification (aHR, 1.59; 95% CI, 1.13-2.25), and advanced pN (N2) classification (aHR, 3.96; 95% CI, 2.78-5.63) were independent prognostic survival factors. The β coefficients from the Cox proportional hazards regression model were used to develop an integer-based weighted point system (perineural invasion, score of 1; NLR, score of 1; advanced pT, score of 1; and advanced pN, score of 3). The summations of these risk scores were stratified for the new staging category as follows: new stage I, score of 0; new stage II, score of 1; new stage III, score of 2 or 3; and new stage IV, score of 4 to 6. Compared with the American Joint Committee on Cancer staging category, this new staging category provided better monotonicity with a higher linear trend χ2 value (106 vs 49), better discriminatory ability with smaller Akaike information criterion (1497 vs 1533), and greater Harrell C statistic (0.73 vs 0.69) for 5-year DSS. The results remained robust after adjusting other risk factors.
Conclusions and Relevance: In this study, new staging category had better DSS discriminatory ability and could help to identify high-risk patients for intense adjuvant therapy.
PMID: 28125757 [PubMed - as supplied by publisher]
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The Case for a Definitive Multisite, Randomized Clinical Trial of Repetitive Transcranial Magnetic Stimulation for Tinnitus.
The Case for a Definitive Multisite, Randomized Clinical Trial of Repetitive Transcranial Magnetic Stimulation for Tinnitus.
JAMA Otolaryngol Head Neck Surg. 2017 Jan 26;:
Authors: Mennemeier M, George M
PMID: 28125755 [PubMed - as supplied by publisher]
http://ift.tt/2jlCWJN
Treatment of Severe Acquired Tracheomalacia With a Patient-Specific, 3D-Printed, Permanent Tracheal Splint.
Treatment of Severe Acquired Tracheomalacia With a Patient-Specific, 3D-Printed, Permanent Tracheal Splint.
JAMA Otolaryngol Head Neck Surg. 2017 Jan 26;:
Authors: Morrison RJ, Sengupta S, Flanangan CL, Ohye RG, Hollister SJ, Green GE
PMID: 28125750 [PubMed - as supplied by publisher]
http://ift.tt/2k97nqs
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