Clinical Trials for Immunosuppression in Transplantation; The Case for Reform and Change in Direction.

Currently trials of immunosuppression in transplantation are in decline because their objectives remain focused on improving acute rejection rates and graft survival in the first 12 months. With 1 year renal graft survival rates of greater than 90% the best that can be hoped for is noninferiority trial outcomes compared to current standard of care. Current trial design is not leading to novel therapies improving long term outcomes and safety, and hence important unmet clinical needs in transplantation remain unanswered. Issues that need to be addressed include but are not limited to: prevention of subclinical rejection in the first year, better 5 and 10 year graft outcomes, more effective treatment for high immunological risk and sensitized (including DSA) patients, immunosuppressive combinations that are better tolerated by patients with fewer side effects and less morbidity and mortality. In September 2015 the Transplantation Society convened a group of transplant clinical trial experts to address these problems. The aims were to substantially realign the priorities of clinical trials for renal transplant immunosuppression with the current unmet needs and to propose new designs for clinical trials for transplant immunosuppression. Moving forward, the transplant community needs to provide trial data that will identify superior treatment options for patient subgroups and allow new agents to be evaluated for efficacy and safety and achieve timely regulatory approval. Trial designs for new transplant immunosuppression must be intelligently restructured in order to ensure that short- and long-term clinical outcomes continue to improve. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Laparoscopic Donor Hepatectomy: The Long and Winding Road.

No abstract available

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Are We Ready for Epitope-Based HLA Matching in Clinical Organ Transplantation?.

This overview describes recent developments demonstrating the significance of epitopes in HLA antibody responses and matching for organ transplantation. HLA epitopes are defined by molecular modeling and amino acid comparisons between HLA alleles and the HLAMatchmaker algorithm considers eplets as essential components. Each allele represents a distinct string of eplets and matching is done by aligning donor and recipient strings. Evidence is summarized how mismatched eplet loads affect antibody responses and transplant outcomes. Epitope-based matching has been applied not only to identify acceptable mismatches for sensitized transplant candidates but also to identify more suitably mismatched donors for nonsensitized patients. Three recently proposed theories will further our understanding of the immunogenicity of individual HLA eplets. It has become apparent that epitope-based matching is superior to antigen matching; we should be ready soon to apply this principle in the clinical transplant setting very soon. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Acute Liver Failure/Injury Related to Drug Reaction With Eosinophilia and Systemic Symptoms: Outcomes and Prognostic Factors.

Background: Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) is a rare severe adverse drug induced reaction with multiorgan involvement. The outcome and prediction of those patients who develop severe acute liver injury (sALI) or acute liver failure (ALF) remain little known. Methods: A multicenter retrospective study of patients admitted with a diagnosis of DRESS-related sALI or ALF. Histological review was performed on liver core biopsies from native livers. Results: Sixteen patients (11F, 5M; mean age: 39+/-17.2 years) were classified as having definite (n=13) or probable (n=3) DRESS. At admission, 3 patients had hepatic encephalopathy; median levels of prothrombin time, INR and total bilirubin were respectively 33% (Q1-Q3: 21-41); 2.74 (1.98- 4.50) and 94 [mu]mol/L (Q1-Q3: 39.5-243.5). Nine patients received corticosteroid therapy. Overall, 9 patients improved spontaneously and 7 worsened (liver transplantation (n=5), deceased (n=2)). Transplantation-free and postliver transplantation (LT) survival was 56% and 60% respectively. After LT, DRESS recurrence was observed in 3/5 patients. Systemic corticosteroid therapy was not significantly associated with a clinical improvement. In the multivariate analysis, factor V level =40% at admission but decreasing at day 2 were associated with worse outcome. Pathological findings (n=7) revealed atypical lymphoid infiltrates, kupffer cell hyperplasia with erythrophagocytosis and an inconstant presence of eosinophils. Conclusion: The spontaneous prognosis of patients with sALI/ALF due to DRESS is poor and was not improved by corticosteroid therapy. Histology is helpful to establish diagnosis. Dynamic variables regarding factor V values are predictive of a poor outcome. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Ethnic Background is a Potential Barrier to Living Donor Kidney Transplantation in Canada: A Single Center Retrospective Cohort Study.

Background: We examined if African or Asian ethnicity was associated with lower access to kidney transplantation (KT) in a Canadian setting. Methods: Patients referred for KT to the Toronto General Hospital from January 1, 2003 to December 31, 2012, who completed social work assessment, were included (n=1769). The association between ethnicity and the time from referral to completion of KT evaluation or receipt of a KT were examined using Cox proportional hazards models. Results: About 54% of the sample was Caucasian, 13% African, 11% East Asian, and 11% South Asian; 7% had "other" (n = 121) ethnic background. African Canadians (HR 0.75 [95% CI: 0.62, 0.92]) and patients with "other" ethnicity (HR 0.71 [95% CI: 0.55, 0.92]) were less likely to complete the KT evaluation compared to Caucasian Canadians, and this association remained statistically significant in multivariable adjusted models. Access to KT was significantly reduced for all ethnic groups assessed compared to Caucasian Canadians, and this was primarily driven by differences in access to living donor KT. The adjusted hazard ratios for living donor KT were 0.35 (95% CI: 0.24, 0.51), 0.27 (95% CI: 0.17, 0.41), 0.43 (95% CI: 0.30, 0.61) and 0.34 (95% CI: 0.20, 0.56) for African, East or South Asian Canadians and for patients with "other" ethnic background, respectively. Conclusion: Similarly to other jurisdictions, non-Caucasian patients face barriers to accessing KT in Canada. This inequity is very substantial for living donor KT. Further research is needed to identify if these inequities are due to potentially modifiable barriers. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Kidney Transplantation Rates Across Glomerulonephritis Subtypes in the United States.

Background: Whether kidney transplantation rates differ by glomerulonephritis (GN) subtype remains largely unknown. Methods: Using the US Renal Data System, we identified all adult patients with ESRD attributed to 1 of 6 GN subtypes who initiated dialysis in the US (1996-2013). Patients with diabetic nephropathy (DN) and autosomal-dominant polycystic kidney disease (ADPKD) served as "external" non-GN comparators. Using Cox proportional hazards regression, with death considered a competing risk, we estimated hazard ratios [HRs (95% confidence intervals)] for first kidney transplantation, controlling for year, demographics, comorbidities, socioeconomic factors, and Organ Procurement Organization (OPO). Results: Among 718,480 patients studied, unadjusted and multivariable-adjusted transplant rates differed considerably across GN subtypes. Adjusted transplant rates were highest for patients with IgA nephropathy (IgAN, referent) and lower for all other groups: focal segmental glomerulosclerosis, HR=0.80 (0.77-0.82); membranous nephropathy, HR=0.88 (0.83-0.93); membranoproliferative GN, HR=0.84 (0.76-0.92); lupus nephritis, HR=0.69 (0.66-0.71); vasculitis, HR=0.66 (0.61-0.70); DN, HR=0.50 (0.47-0.52); ADPKD, HR=0.85 (0.82-0.88). Reduced kidney transplantation rates among comparator groups were driven more so by lower rates of waitlisting [HRs, vs. IgAN, ranged from 0.49 for DN to 0.92 for membranous nephropathy or ADPKD] than by lower rates of deceased donor kidney transplantation after waitlisting [rates were only significantly lower, vs. IgAN, for those with secondary GN subtypes: lupus nephritis, HR=0.91 (0.86-0.97), vasculitis, HR=0.85 (0.76-0.94); DN, HR=0.73 (0.69-0.77)]. Conclusions: Identifying underlying reasons for apparent disease-specific barriers to kidney transplantation might inform center-specific transplant candidate selection procedures, along with national organ allocation policies, leading to more equitable patient care and improved patient outcomes. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Association Between Pretransplant Cancer and Survival in Kidney Transplant Recipients.

Background: Kidney transplantation in recipients with a previous malignancy is often deferred 2-5 years after cancer treatment due to fear of cancer recurrence. In Norway, the required waiting period has been 1 year. Methods: We compared patient and graft survival of recipients with pretransplant cancer to the outcomes of matched recipients without such cancer (comparators) using Cox regression. Results: From 1963 to 2010, 377 of 5867 recipients (6.4%) had a pretransplant cancer. During a median follow-up of 6.8 years, 256 recipients died, 35 (13.7%) from recurrent cancer and 27 (10.5%) from de novo cancer. Uncensored and death-censored graft loss occurred in 263 and 46 recipients, respectively. All-cause mortality was similar as in comparators (HR 1.06 [0.93-1.20], P=0.40), death-censored graft loss was lower (HR 0.63 [0.47-0.84], P=0.002), and uncensored graft loss was similar (HR 0.99 [0.87-1.12], P=0.87). Cancer mortality was higher than in comparators (hazard ratio [HR] 1.97 [95% confidence interval 1.51-2.56], P0.45). Results were similar within cancer subgroups, with most data in patients with a history of kidney cancer, prostate cancer, urothelial cancer and skin squamous cell carcinoma. Conclusion: Kidney transplant recipients with a pretransplant cancer had a similar overall patient and graft survival as recipients without such cancer. Cancer mortality was increased, particularly during the first 5 years after transplantation. A short waiting period was not associated with mortality. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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The Efficacy of a Prevascularized, Retrievable Poly(D,L,-lactide-co-[epsilon]-caprolactone) Subcutaneous Scaffold as Transplantation Site for Pancreatic Islets.

Background: The liver as transplantation site for human pancreatic islets is a harsh microenvironment for islets and it lacks the ability to retrieve the graft. A retrievable, extrahepatic transplantation site that mimics the pancreatic environment is desired. Ideally this transplantation site should be located subdermal for easy surgical-access but this never resulted in normoglycemia. Here we describe the design and efficacy of a novel prevascularized, subcutaneously implanted, retrievable poly (D,L-lactide-co-[epsilon]-caprolactone) (PDLLCL) scaffold. Method: Three dosages of rat islets, ie, 400, 800, and 1200, were implanted in immune compromised mice to test the efficacy (n=5). Islet transplantation under the kidney capsule served as control (n=5). The efficacy was determined by nonfasting blood glucose measurements and glucose tolerance tests. Results: Transplantation of 800 (n=5) and 1200 islets (n=5) into the scaffold reversed diabetes in respectively 80 and 100% of the mice within 6.8 - 18.5 days posttransplant. The marginal dose of 400 islets (n=5) induced normoglycemia in 20%. The glucose tolerance test showed major improvement of the glucose clearance in the scaffold groups compared to diabetic controls. However, the kidney capsule was slightly more efficacious as all 800 (n=5) and 1200 islets (n=5) recipients and 40% of the 400 islets (n=5) recipients became normoglycemic within 8 days. Removal of the scaffolds or kidney grafts resulted in immediate return to hyperglycemia. Normoglycemia was not achieved with 1200 islets in the unmodified skin group. Conclusion: Our findings demonstrate that the prevascularized PDLLCL scaffold maintains viability and function of islets in the subcutaneous site. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Association of Local Intrapulmonary Production of Antibodies Specific to Donor Major Histocompatibility Complex Class I with the Progression of Chronic Rejection of Lung Allografts.

Background: Antibody-mediated rejection may lead to chronic lung allograft dysfunction, but antibody-mediated rejection may develop in the absence of detectable donor-specific antibody (DSA) in recipient serum. This study investigated whether humoral immune responses develop not only systemically but locally within rejected lung allografts, resulting in local production of DSA. Methods: Lewis rats received orthotopic left lung transplantation from Lewis (syngeneic control) or Brown-Norway (major histocompatibility complex-mismatched allogeneic) donor rats. Rats that underwent allogeneic lung transplantation were subsequently administered cyclosporine until day 14 (short immunosuppression) or day 35 (long immunosuppression). The lung grafts and spleens of recipient animals were tissue cultured for 4 days, and the titer of antibody against donor major histocompatibility complex molecules was assayed by flow cytometry. Explanted lung grafts were also evaluated pathologically. Results: By day 98, DSA titers in supernatants of lung graft (p=0.0074) and spleen (p=0.0167) cultures, but not serum, from the short immunosuppression group were significantly higher than titers in syngeneic controls. Cultures and sera from the long immunosuppression group showed no production of DSA. Microscopically, the lung grafts from the short immunosuppression group showed severe bronchiole obliteration and parenchymal fibrosis, along with lymphoid aggregates containing T and B cells, accompanying plasma cells. These findings suggestive of local humoral immune response were not observed by days 28 and 63. Conclusions: DSA can be locally produced in chronically rejected lung allografts, along with intra-graft immunocompetent cells. Clinical testing of DSA in serum samples alone may underestimate lung allograft dysfunction. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Predictors of Waitlist Mortality in Portopulmonary Hypertension.

Background: The current Organ Procurement Transplantation Network (OPTN) policy grants Model for End Stage Liver Disease (MELD) exception points to patients with portopulmonary hypertension (POPH), but potentially important factors, such as severity of liver disease and pulmonary hypertension, are not included in the exception score, and may affect survival. The purpose of this study was to identify significant predictors of waitlist mortality in patients with POPH. Methods: We performed a retrospective cohort study of patients in the OPTN database with hemodynamics consistent with POPH [defined as mean pulmonary arterial pressure (mPAP) >25mmHg and pulmonary vascular resistance (PVR) >=240 dynes-s-cm-5] who were approved for a POPH MELD exception between 2006 and 2014. Using a Cox proportional hazards model, we identified predictors of waitlist mortality (or removal for clinical deterioration). Results: One hundred ninety adults were included. Age (HR 1.04, 95% CI 1.00-1.08, P=0.0499), initial native MELD score (HR 1.11, 95% CI 1.05-1.17, P

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Reasons for rarity of anal melanocytic naevi

Abstract

In the last 16 years only seven definite cases of anal melanocytic naevi have been reported in the literature. We describe three new cases, none of which were suspected clinically and were incidentally diagnosed on histological examination of haemorrhoidectomy specimens. The infrequency of these special site flexural melanocytic lesions may be related to changes in the involutionary mechanisms of the anal melanocyte proliferation. However, other factors related to the low detection rates by clinicians and pathologists need also to be considered.

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Pemphigus, a pathomechanism of acantholysis

Abstract

Autoantibodies to the desmosomal proteins desmoglein 1 and 3 cause pemphigus foliaceus and pemphigus vulgaris, which are characterised by keratinocyte dissociation (acantholysis) and intraepidermal blister formation. The passive transfer of pathogenic anti-desmoglein antibodies induces blisters in mice in vivo and the loss of keratinocyte adhesion in vitro. The pathogenetic mechanisms of acantholysis due to anti-desmoglein autoantibodies are not fully understood. However, recent studies have revealed that signalling-dependent and signalling-independent pathways are operative in the loss of cell adhesion. In this review, we focus on the pathomechanism of acantholysis due to autoantibodies to desmogleins and recent therapeutic approaches.

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Editorial Board

Publication date: January 2017
Source:Clinical Immunology, Volume 174





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A granulomatous conundrum: Concurrent necrobiosis lipoidica, cutaneous sarcoidosis and erythema nodosum in a nondiabetic patient

Abstract

Necrobiosis lipoidica (NL) and cutaneous sarcoidosis are granulomatous disorders with a largely unknown aetiopathogenesis. Evidence of co-existing NL and sarcoidosis in the same patient may suggest a degree of overlap between these entities through shared granulomatous inflammatory pathways. Occasionally, one condition can mimic the other, making their distinction difficult. We report a novel case of a non-diabetic woman who presented with concurrent NL, cutaneous sarcoidosis and erythema nodosum. We discuss some of the complexities distinguishing these entities and propose that they may represent different stages of the same granulomatous process linked through yet unknown pathomechanisms.

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Correlation of Leptin, Adiponectin, and Resistin Levels in Different Types of Lipodystrophy in HIV/AIDS Patients

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.


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Change in Body Weight from Age 20 Years Is a Powerful Determinant of the Metabolic Syndrome

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.


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Alterations in Multiple Lifestyle Factors in Subjects with the Metabolic Syndrome Independently of Obesity

Metabolic Syndrome and Related Disorders , Vol. 0, No. 0.


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Modified Mallampati Score Improves Specificity of STOP-BANG Questionnaire for Obstructive Sleep Apnea.

Background: An accurate, clinical screening tool for obstructive sleep apnea (OSA) that identifies patients for further diagnostic testing would assist in the diagnosis of this comorbidity. One example, the STOP-BANG questionnaire (SBQ), has been validated as a screening tool with high sensitivity. However, its specificity may result in a high false-positive rate. The aim of this study to determine if addition of the Modified Mallampati score to the SBQ improves its specificity. Methods: The authors studied 162 patients referred to the Sleep Disorders Clinic at Yedikule Chest Disease Education and Research Hospital. All patients were prospectively screened for risk of OSA using the SBQ, their oral anatomy was assessed by Modified Mallampati scoring, and sleep quality characterized by polysomnography. Polysomnography results were reviewed when available and the predictive performance of the SBQ and the modified SBQ scoring models were compared. Results: In the authors' study an SBQ score >=3 yielded sensitivities of 0.85, 0.86, and 0.91 for Apnea-Hypopnea Index (AHI) >=5/h, AHI >=15/h, and AHI >=30/h, respectively, and specificities of 0.09, 0.10, and 0.18. The modified SBQ with a cutoff of >=4 (>3) points for AHI levels of >5, >15, and >30 yielded respective sensitivities of 0.84, 0.86, and 0.91 and specificities of 0.25, 0.26, and 0.27. Conclusions: The author's results from indicated the modified SBQ with a cutoff of >3 points in this study was more specific than the standard SBQ but no less sensitive, and may be used in identifying OSA patients for further diagnostic evaluation or avoiding unnecessary testing. (C) 2017 by Mutaz B. Habal, MD.

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Using Dental Implants Concomitant With Onlay Bone Grafting for Auricular Reconstruction.

Conventional dental implants have been reported for nasal and orbital regions but due to limited thickness of calvarium they are not used in mastoid region. Onlay bone grafting in skull concomitant with implants is a predictable method and experimental animal studies confirm it. Parietal bone and lateral mandibular ramus are suggested source of bone grafts and dental implants with 7 mm length can be used safely. Increased fixture length may lead to increase survival in long term. (C) 2017 by Mutaz B. Habal, MD.

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What Are the Contributing Factors for Postsurgical Relapse After Two-Jaw Surgery in Patients With Cleft Lip and Palate.

The purpose of this study was to investigate the amount and pattern of postsurgical relapse after 2-jaw surgery in cleft lip and palate patients in terms of the sagittal and vertical aspects. The samples consisted of 21 adult patients who had the similar initial skeletodental pattern before surgery and underwent 2-jaw surgery. They were divided into high relapse (n = 11) and low relapse groups (n = 10) (criteria, 30% forward relapse of the B point). After the cephalometric variables of cephalograms taken at 1 month before surgery (T0), immediately after surgery (T1), and at least 1 year after surgery (T2) were measured, the Wilcoxon test, Mann-Whitney U test, and Pearson correlation test were performed for statistical analysis. When compared with the low relapse group, the high relapse group exhibited significant counterclockwise rotation of the distal segment of the mandible resulting in more forward movement of the mandible and significant labioversion of the maxillary incisors during T1-T2. The amount of postsurgical relapse of the mandible had a positive relationship with the amounts of setback and clockwise rotation of the mandible with surgery. In addition, the more decrease in overbite through surgery occurred, the more relapse (forward movement of the mandible) produced. Therefore, for the prevention of significant postsurgical relapse of the mandible in cleft patients, it is necessary to reduce unnecessary clockwise rotation of the mandible and to increase the vertical stability of maxilla during orthognathic surgery. (C) 2017 by Mutaz B. Habal, MD.

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Implantation of Thickened Artificial Bone for Reduction of Dead Space and Prevention of Infection Between Implant and Dura in Secondary Reconstruction of the Skull.

For the treatment of skull defect compensation after neurosurgery, a customized artificial bone is often employed owing to its toughness and the relative ease of producing cosmetically good result. However, implants are vulnerable to infection and removal of implant is sometimes necessary. Several other treatment options such as autologous bone graft or free flap are likely to be considered for the secondary reconstruction to avoid reinfection; however, reimplantation of artificial bone is beneficial for the patients, being not concerned with donor site morbidity. The authors consider one of risk factors of infection of artificial bone as dead space between the implant and dura. To attain reduction of the dead space, we have employed thickened artificial bone. Between 2010 and 2014, 6 patients underwent implantation of thickened artificial bone for the secondary reconstruction. First, the infected artificial material was removed with proper debridement. More than 3 months after the closure of the infected wound, tissue expander was inserted beneath the surrounding scalp to ensure the coverage of subsequently implanted artificial bone without skin tension. The thickened artificial bone was designed from the computed tomography findings so as not to leave any dead space between the implant and dura. After optimal expansion of the scalp, the artificial bone was implanted. Postoperative courses were uneventful and the appearance of the cranial vault was satisfactory in all patients. The authors consider the use of the thickened artificial bone is easier and more suitable for patients having a skull defect, particularly in secondary reconstruction. (C) 2017 by Mutaz B. Habal, MD.

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Two Rare Variants of Left Vertebral Artery.

Though the variations of vertebral artery are clinically asymptomatic yet abnormalities are of diagnostic importance either prior to vascular surgery in the neck region or in patients of intravascular diseases such as arteriovenous malformations or cerebral aneurysms. Therefore, the aim of the study is to bring out 2 variations in the configuration of vertebral artery and their clinical implication. During dissection of thorax of 2 female cadavers, 2 different variants of configurations of left vertebral arteries were observed. In 1 patient, the left vertebral artery arose aberrantly from arch of aorta between left common carotid artery and left subclavian artery. This artery then, following oblique course, abnormally entered into foramen transversarium of C4 vertebra. In the second patient, the left common stump emerged from arch of aorta in the left side of left common carotid artery and then instantly bifurcated into vertebral artery and subclavian artery. Then following the usual oblique course, the left vertebral artery anomalously entered into foramen transversarium of C3 vertebra at the level of upper border of thyroid cartilage. The knowledge of these rare variations in the origin of vertebral artery is of paramount importance to surgeons performing surgery in neck region, radiologist performing angiography to avoid misinterpretation of radiographs and to anatomists for rare variations in academics and research. (C) 2017 by Mutaz B. Habal, MD.

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The Subunit Principle in Scar Face Revision.

Facial scaring is considered one of the most difficult cosmetic problems for any plastic surgeon to solve. The condition is more difficult if the direction of the scar is not parallel to relaxed skin tension lines. Attempts to manage this difficult situation included revisions using geometric designs, Z plasties or W plasties to camouflage the straight line visible scaring. The use of long-lasting resorbable sutures was tried too. Recently, the use of botulinum toxin during revision improved the results. Fractional CO2 lasers, microfat grafts, and platelet-rich plasma were added to the armamentarium. The scar is least visible if placed in the junction between the facial subunits. The aim of this study is to investigate the use of the subunit principle to improve the results of scar revision. Four patients were included in this study. Tissue expansion of the intact part of the subunit allowed shifting the scar to the junction between the affected subunit and the adjacent one. Tissue expansion, delivery of the expanders, and advancement of the flaps were successful in all patients. The fact that this is a 2-stage procedure and sacrifices some of the intact skin from the affected facial subunit, makes this technique reserved to patients with ugly facial scars who are ambitious to improve their appearance. (C) 2017 by Mutaz B. Habal, MD.

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A Periodical Article Reviewer as Gottfried: The Uncle of Jean-Christophe.

No abstract available

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Significant Differences in the Bone of an Isogenic Inbred Versus Nonisogenic Outbred Murine Mandible: A Study in Rigor and Reproducibility.

Inattention to differences between animal strains is a potential cause of irreproducibility of basic science investigations. Accordingly, the authors' laboratory sought to ensure that cross-comparisons of results generated from studies of mandibular physiology utilizing the Sprague Dawley and Lewis rat strains are valid. The authors specifically investigated baseline histomorphometrics, bone mineral density, and biomechanical strength of the unaltered endogenous mandibles of the inbred, isogenic Lewis rat, and the outbred, nonisogenic Sprague Dawley rat to determine if they are indeed equal. The authors hypothesized that little difference would be found within these metrics. The authors' study utilized 20 male Lewis and Sprague Dawley rats, which underwent no manipulation other than final dissection and analysis. Ten rats from each strain underwent bone mineral density and biomechanical strength analysis. The remaining rats underwent histological analysis. Descriptive and bivariate statistics were computed and the P value was set at 0.05. Lewis rats had a significantly greater number of empty lacunae. Sprague Dawley rats exhibited a significantly greater ratio of bone volume-to-total volume, bone mineral density, tissue mineral density, bone volume fraction, and total mineral content. No differences were found during biomechanical testing. This study demonstrates that differences exist between the Lewis and Sprague Dawley rat within unaltered baseline mandibular tissue. However, these differences appear to have limited functional impact, as demonstrated by similar biomechanical strength metrics. Other specific differences not addressed in this manuscript may exist. However, the authors believe that researchers may confidently cross-compare results between the 2 strains, while taking into account the differences found within this study. (C) 2017 by Mutaz B. Habal, MD.

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Anthropometric Outcome Measures in Patients With Metopic Craniosynostosis.

Purpose: Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft-ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided. Methods: Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA. Results: Mean frontal width at preoperative scan for endoscopic and open patients was 55 +/- 0.6 and 64 +/- 0.7 mm, respectively (Z-score 1.6 and -3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 +/- 0.4 and 81 +/- 0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P

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Sequence of Surgical Reconstruction in a Child With Cleft Lip and Palate Associated With Congenital Facial Teratomas.

We describe a case of left homolateral complete cleft lip/palate associated with a congenital left maxillary teratoma and left orbital teratoma. The patient required step-by-step reconstruction that first included resection of the 2 teratomas in consideration of cleft lip repair, cleft palate repair, and correction of the left periorbital anomalies, which were performed later. After performing all the necessary procedures, complete resection of the tumors and correction of the anomalies associated with the lip, palate, and left orbit were achieved. The rare occurrence of this type of association and its devastating effect on a patient's growth, aesthetics, and function of craniofacial elements require careful surgical planning to enable restoration of the anatomy and proper functional development. At follow-up, the patient showed significant improvement in the functional and aesthetic aspects. (C) 2017 by Mutaz B. Habal, MD.

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Improving Functional and Aesthetic Outcomes in Syndromic Patients With Webbed Neck Deformity: Utilizing a Staged Endoscopic-Assisted Approach to Improve the Posterior Hairline and Decrease Scar Burden.

Introduction: Webbed neck deformity (WND) can have significant functional and psychosocial impact on the developing child. Surgical correction can be challenging depending on the extent of the deformity, and patients often also have low posterior hairlines requiring simultaneous correction. Current surgical techniques include various methods of single-stage radical excision that often result in visible scar burden and residual deformity. There is currently no general consensus of which technique provides the best outcomes. Methods: A modified approach to WND was designed by the senior author aimed to decrease scar burden. Endoscopic-assisted fasciectomy was performed with simultaneous posterior hairline reconstruction with local tissue rearrangement camouflaged within the hair-bearing scalp. Staged surgical correction was planned rather than correction in a single operation. A retrospective review was performed to evaluate all patients who underwent this approach over a 2-year period. Results: Two patients underwent the modified approach, a 17-year-old female with Noonan syndrome and a 2-year-old female with Turner syndrome. Both patients showed postoperative improvement in range of motion, contour of the jaw and neckline, and posterior hairline definition. Patients were found to have decreased scar burden compared with traditional techniques. Discussion: A staged, combination approach of endoscopic-assisted fasciectomy and strategic local tissue reconstruction of the posterior hairline to correct WND achieves good functional and aesthetic results and good patient satisfaction. This modification should be considered when managing WND. (C) 2017 by Mutaz B. Habal, MD.

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Improving the Aesthetic Outcome in Scaphocephaly Correction: Hairline Lowering During Vault Remodeling Procedures.

The bossed forehead in patients with scaphocephaly often leads to a high hairline. A new technique to improve the aesthetic outcome of patients undergoing scaphocephaly correction is described. Sixteen patients with scaphocephaly and having a high hairline due to frontal bossing who underwent scaphocephaly correction by subtotal or total vault remodeling were analyzed. The median age at surgery was 18 months. The mean distance between the nasofrontal suture and the hairline was preoperatively 70 mm (range 58-91). An obvious lowering of the hairline could be achieved in all 16 patients. The mean postoperative distance nasofrontal suture to hairline was 59 mm (range 50-73). There were no complications associated with the technique. The hairline lowering technique is a useful addition to vault remodeling techniques and can improve the postoperative aesthetic appearance considerably. The authors recommend this technique in scaphocephaly patients, who present with a high hairline. (C) 2017 by Mutaz B. Habal, MD.

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Intradiploic Epithelial Inclusion Cyst of the Cranium Mimicking Fibrous Dysplasia.

Intradiploic inclusion cysts are exceedingly rare in the pediatric population. The authors present a 16-year-old male patient who presented with a large growing calvarial mass with a preoperative diagnosis of fibrous dysplasia based on radiologic imaging. Craniectomy followed by autogenous reconstruction was performed. Histopathological examination revealed a relatively small inclusion cyst of the intradiploic space, surrounded by reactive bone. This patient demonstrates a highly unusual presentation of a rare entity, and the authors discuss the diagnosis and management of intradiploic inclusion cysts. (C) 2017 by Mutaz B. Habal, MD.

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Application of Computer-Aided Design and Customized Implants in the Reconstruction of Pyriform Aperture Defects Secondary to Unilateral Cleft Lip and Palate.

Purpose: To design and develop customized implants with the rapid prototyping (RP) technique in order to reconstruct the defected pyriform aperture. Methods: A 3-dimensional digital model was reconstructed with the software proplan CMF based on the computed tomography data of the patient's skeleton. Then an individualized implant was designed by computer-aided design (CAD) and prepared with the RP technique. A total of 5 patients (3 males and 2 females) with unilateral secondary nasal deformities received the customized implants in this study. Results: All the implants closely matched the surface of the defects. During the 12- to 24-month follow-up period, all the patients reported satisfactory outcomes except for 1 patient where exposure of the implant was observed and had to be removed 3 months after the surgery. Conclusion: With high precision and matching degree, individualized implants designed by CAD and prepared with the RP technique can be used to overcome the limitations of ready-made materials and improve the accuracy of the surgical procedure in reconstructing the defected pyriform aperture. (C) 2017 by Mutaz B. Habal, MD.

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Relative Location of Fundus Meatus Acustici Interni Via Porus Acusticus Internus in Facial Nerve Decompression.

Facial neural edema is the pathophysiological base of Bell's palsy. The middle cranial fossa approach is used to relieve the oppression of facial nerve at its most narrow course in the facial canal. In this research, the authors mainly discussed the internal auditory canal segment of facial nerve, completely in the shadow of the bony structure, which is inconvenient for transmastoid decompression. Therefore, the objective was to explore the definite position of the fundus meatus acustici interni from internal acoustic pore. Two hundred persons (age 22-60, 100 men and 100 women), presenting with healthy facial nerve, ear, and internal auditory canal, were investigated by computed tomography 3-dimensional reconstruction. Using statistical method to analyze, the authors obtained the definite position of the fundus meatus acustici interni, regarding the internal acoustic pore as the origin of coordinates. Our data provided more significant information for medical workers to improve the efficiency of operation and to prevent complications of surgery. (C) 2017 by Mutaz B. Habal, MD.

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Ex utero intrapartum treatment (EXIT) for upper airway obstruction.

Purpose of review: Improvements in the antenatal diagnosis of congenital malformations have led to increased detection of fetal airway obstructing lesions, and pediatric ear, nose, and throat surgeons are increasingly involved in these cases. Recent findings: This article outlines the typical range of pathology seen, the logistics in providing support for anticipated deliveries and the multidisciplinary management of complex airway cases. Summary: Traditionally, difficulty in obtaining a patent airway at delivery was a major factor in the dismal prognosis of these pregnancies. The ex utero intrapartum treatment procedure, which involves controlled partial delivery of the fetus whilst maintaining placental circulation, allows various airway maneuvers to be performed to secure the airway in a controlled fashion. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2loKq3y

Hypoparathyroidism after thyroidectomy: prevention, assessment and management.

Purpose of review: Permanent hypoparathyroidism is the most common long-term complication after total thyroidectomy and it can cause significant morbidity and increased costs. Its incidence varies from 30% to 60%. Recent findings: The surgical technique and the extent of thyroidectomy are related to parathyroid injury and hypoparathyroidism. The glands should be identified in situ, carefully manipulated and preserved, as well as their vascularization. In case of incidental removal, routine autotransplantation is advocated. Low calcium levels, identification of fewer than two parathyroid glands at surgery, reoperation for bleeding, Graves disease and heavier thyroid specimens were considered independent predictors of permanent hypocalcemia. Intraoperative parathyroid hormone (PTH) measurements allows the early detection of hypocalcemia. Treatment is recommended for patients with symptoms of hypocalcemia or corrected serum calcium

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Open partial laryngectomy after failure of (chemo) radiation: indications, oncologic and functional outcomes.

Purpose of review: Early-stage squamous cell carcinoma of the larynx can be successfully treated with radiotherapy or surgery (transoral or open approaches). Oncologic results are comparable while functional results may be different according to the volume of resection. In some countries radiotherapy is often preferred as primary treatment. In case of recurrence, surgical salvage is the only option. Careful examination, endoscopic assessment, computed tomography or magnetic resonance imaging are necessary to assess superficial and deep extensions into the larynx, including cartilage framework and to restage the tumor. Recent findings: The choice between endoscopic and open partial laryngectomy is based on the extension and characteristics of the tumor. Oncologic results of open approaches are encouraging as local control, survival, and laryngeal preservation rates reported in the literature are close to those obtained in nonpreviously treated patients. Functional results are not significantly worse and major complications in the previously irradiated patients undergoing open neck surgery not increased. Supracricoid partial surgery seems to be more and more performed. Summary: With regards to the results, open partial surgery, like in nonpreviously treated patients, is still indicated for the surgical treatment of postradiotherapic recurrent/persistent disease. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2kZ52yJ

Relationship Between Central Obesity and Spread of Spinal Anesthesia in Female Patients.

Central obesity may be related to the spread of spinal anesthesia in female patients. Fifty-seven female patients undergoing spinal anesthesia were allocated to either the central obesity or noncentral obesity group. After induction of spinal anesthesia, maximal sensory blockade (primary outcome), time for maximal sensory block, maximum motor block, time to maximum motor block, time to L2 regression, and time to Bromage scale 0 were evaluated. Multiple linear regression analyses showed that maximal sensory blockade was related to central obesity (P = .004). Central obesity is related to a more extensive spread of spinal anesthesia in female patients. (C) 2017 International Anesthesia Research Society

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In Response.

No abstract available

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Smart Phones Application for Intraoperative Patient Care.

No abstract available

http://ift.tt/2m0FKxG

The Need for Mandatory Random Drug Testing in Anesthesia Providers.

No abstract available

http://ift.tt/2kZ1DzG

A Reply to Epidural Local Anesthetics versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

No abstract available

http://ift.tt/2m0q5hJ

Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series.

This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%-64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%) (C) 2017 International Anesthesia Research Society

http://ift.tt/2kYSAyC

Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.

Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements. (C) 2017 International Anesthesia Research Society

http://ift.tt/2m0oFEe

Association Between Anesthesiology Volumes and Early and Late Outcomes After Cystectomy for Bladder Cancer: A Population-Based Study.

BACKGROUND: Hospital and surgeon volume are related to postoperative complications and long-term survival after radical cystectomy. Here, we describe the relationships between these provider characteristics and anesthesiologist volumes on early and late outcomes after radical cystectomy for bladder cancer. METHODS: Records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with radical cystectomy in Ontario during 1994 to 2008. Volume was divided into quartiles and determined on the basis of mean annual number of hospital/surgeon/anesthesiologist radical cystectomy cases during a 5-year study period. A composite anesthesiologist volume also was used and defined as major colorectal procedures in addition to radical cystectomy given the similar complexity of these cases. Logistic and Cox proportional hazards regression models were used to explore the associations between volume and outcomes while adjusting for potential patient-, disease-, and system-related confounders. The primary outcomes were postoperative readmission rates, postoperative mortality, and 5-year survival. RESULTS: The study included 3585 patients with radical cystectomy between 1994 and 2008. Median annual anesthesiologist radical cystectomy volume was 1 (maximum 8.8 cases/year); lowest volume quartile (Q1) 1.4 cases/year. The median annual composite anesthesiologist volume was 9 radical cystectomy and colorectal cases (Q1 [range 0.2-6.4 cases/year], Q4 [range 11.8-29.2 cases/year]); subsequent analyses used this composite volume. Anesthesiologist volume was associated with readmission rates at 30 days (P = .02, Q1 mean = 27% versus Q4 mean = 21%) and at 90 days (P = .01, Q1 mean = 39% versus Q4 mean = 31%). In multivariable analysis, including the adjustment for surgeon and hospital volume, the cohort of anesthesiologists who performed the lowest volume of cases annually (Q1) was associated with greater rates of readmission at 30 days (OR 1.36, 95% CI 1.09-1.71, P = .04) and at 90 days (OR 1.36, 95% CI 1.11-1.66, P = .03). Anesthesiologist volumes were not associated with postoperative mortality or long-term survival. CONCLUSIONS: Anesthesiologist case volume for radical cystectomy was low, reflecting the lack of subspecialization in urologic procedures in routine clinical practice. Lower volume anesthesia providers were associated with higher readmission rates after radical cystectomy. Further studies are needed to validate this finding and to identify the processes that may explain an association between provider volume and patient outcome. (C) 2017 International Anesthesia Research Society

http://ift.tt/2kZ6C3v

A Role for Adrenergic Receptors in the Uterotonic Effects of Ergometrine in Isolated Human Term Nonlaboring Myometrium.

BACKGROUND: Ergometrine is a uterotonic agent that is recommended in the prevention and management of postpartum hemorrhage. Despite its long-standing use, the mechanism by which it acts in humans has never been elucidated fully. The objective of this study was to investigate the role of adrenoreceptors in ergometrine's mechanism of action in human myometrium. The study examined the hypothesis that [alpha]-adrenoreceptor antagonism would result in the reversal of the uterotonic effects of ergometrine. METHODS: Myometrial samples were obtained from women undergoing elective cesarean delivery. The samples were then dissected into strips and mounted in organ bath chambers. After the generation of an ergometrine concentration-response curve (10-15 to 10-5 M), strips were treated with increasing concentrations of ergometrine (10-15 to 10-7 M) alone and ergometrine (10-7 to 10-5 M) in the presence of phentolamine (10-7 M), prazosin (10-7 M), propranolol (10-6 M), or yohimbine (10-6 M). The effects of adding ergometrine and the effect of drug combinations were analyzed using linear mixed effects models with measures of amplitude (g), frequency (contractions/10 min), and motility index (gxcontractions/10 min). RESULTS: A total of 157 experiments were completed on samples obtained from 33 women. There was a significant increase in the motility index (adding 0.342 g x counts/10 min/[mu]M; 95% confidence interval [CI] 0.253-0.431, P

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Is It Quality Improvement or Is It Research?: Ethical and Regulatory Considerations.

No abstract available

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The CARE approach to reducing diagnostic errors

Abstract

Background

Diagnostic errors appear to be the most common, costly, and dangerous of all medical mistakes. There has been a notable increase on the focus of error prevention as part of a growing patient safety movement. However, diagnostic errors have received less attention than other types of error. Our goal is to present a short mnemonic that can act as a checklist or posted reminder to help practitioners in dermatology or any field of medicine to avoid diagnostic errors.

Methods

To meet this goal, the authors reviewed the literature and discussed errors and potential errors they have experienced over 55 years of combined practice, to create a short mnemonic.

Results

The CARE method has helped the authors prepare and review their differential diagnoses in the relatively fast-paced practice of dermatology, but it has yet to be tested on a large scale.

Conclusion

The CARE (communicate, assess for biased reasoning, reconsider differential diagnoses, enact a plan) method is an efficient, recallable checklist that uses an educational approach to reduce diagnostic error while reminding us to simply "care" from a humanistic perspective. This method may help reduce preventable diagnostic errors and improve patient care.

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Concerns about “The spectrum of skin diseases in a black population in Durban, KwaZulu-Natal, South Africa”

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Bronchial allergen challenge – An old, but still useful tool in research and diagnostics

Publication date: Available online 16 February 2017
Source:Alergologia Polska - Polish Journal of Allergology
Author(s): Zenon Siergiejko, Grzegorz Siergiejko, Mark Klukowski, Ewa Maria Swiebocka
A bronchial allergen challenge may serve both as a diagnostic as well as investigative procedure. Its usage in the diagnosis of asthma is infrequent due to its time-consuming nature as well as (in our opinion) an unfounded fear for a patient's safety. It is quite useful in the diagnostics of workplace related illnesses. Due to its ability to produce a controlled, long-lasting allergic-inflammatory reaction in the bronchi, this procedure is commonly used in research settings as well as in the assessment of new substances which may potentially have a place in the treatment of asthma, for ex. through the blocking of late asthmatic reactions. Changes stimulated by a bronchial allergen challenge may be evaluated by many methods using different materials, i.e. samples obtained from direct biopsies, bronchoalveolar lavages, exhaled breath condensates, or measured fractional exhaled nitric oxide. This procedure is a seemingly ideal research and diagnostic tool, however, a common protocol for its execution has not yet been accepted. Recent legal regulations have resulted in difficulties obtaining various allergens for challenge tests. Hopefully this is a temporary and minor setback for this very useful and constantly developing procedure.



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Evaluation of augmented pulse pressure variation using the Valsalva manoeuvre as a predictor of fluid responsiveness under open-chest conditions: A prospective observational study.

BACKGROUND: Pulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial. OBJECTIVE: We evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy. DESIGN: A prospective, observational study. SETTING: Single-centre trial, study period from October 2014 to June 2015. PATIENTS: Forty-nine adult patients who underwent off-pump coronary arterial bypass grafting. INTERVENTION: After midline sternotomy, haemodynamic parameters were measured before and after volume expansion (6 ml kg-1 of crystalloids). PPV was calculated both automatically (PPVauto) and manually (PPVmanual). For PPV augmentation, we performed Valsalva manoeuvres with manual holding of the rebreathing bag and constant airway pressure of 30 cmH2O for 10 s before fluid loading and calculated PPV during the Valsalva manoeuvre (PPVVM). MAIN OUTCOME MEASURES: The predictive ability of PPVVM for fluid responsiveness using receiver-operating characteristic curve analysis. Responders were identified when an increase in cardiac index of at least 12% occurred after fluid loading. RESULTS: Twenty-one patients were responders and 28 were nonresponders. PPVVM successfully predicted fluid responsiveness with an area under the curve (AUC) of 0.88 [95% confidence interval (95% CI) 0.75 to 0.95; sensitivity 91%, specificity 79%, P

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Patterns of Treatment Failure in Anaplastic Thyroid Carcinoma

Thyroid , Vol. 0, No. 0.


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Previous External Beam Radiation Treatment Exposure Does Not Confer Worse Outcome for Patients with Differentiated Thyroid Cancer

Thyroid , Vol. 0, No. 0.


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Psoriasis and Psoriasiform Eruptions in Pediatric Patients with Inflammatory Bowel Disease Treated with Anti–Tumor Necrosis Factor Alpha Agents

Abstract

Background

Anti–tumor necrosis factor alpha (TNF-α) agents are used to treat a variety of autoimmune and inflammatory conditions, including psoriasis. Paradoxically, numerous reports have documented new-onset or exacerbation of psoriasis or psoriasiform skin lesions (PSO) in patients treated with these agents for conditions other than PSO—particularly in adults with inflammatory bowel disease (IBD). Not much is known regarding similar cases in children.

Methods

A retrospective chart review was performed on children younger than 19 years of age with IBD seen at the Mayo Clinic between 2003 and 2015 who developed new-onset or recurrent PSO while undergoing anti-TNF-α therapy.

Results

Fourteen children developed PSO while undergoing anti-TNF-α therapy for IBD. All three anti-TNF-α agents (infliximab, adalimumab, certolizumab) used to treat IBD in this series led to induction or recurrence of PSO lesions. The median time to development of PSO was 11 months (range 0–48 mos), the median age was 15 years (range 12.5–17.5 yrs), and 57% of patients were male. IBD activity was quiescent in 93% of cases at PSO onset. Seven patients (50%) discontinued their initial anti-TNF-α therapy because of their skin disease. Ultimately, four patients (29%) had to discontinue all anti-TNF-α therapy to induce PSO resolution.

Conclusion

TNF-α antagonist–induced PSO in children with IBD is a rarely reported adverse reaction. PSO onset has a variable latency, but usually occurs during IBD remission, with a slight male bias. Nearly half of patients required a change in their initial anti-TNF-α agent despite conventional skin-directed therapies, and one-third of patients discontinued all anti-TNF-α therapy because of PSO.

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In Silico Analysis of L1/L2 Sequences of Human Papillomaviruses: Implication for Universal Vaccine Design

Viral Immunology , Vol. 0, No. 0.


http://ift.tt/2kYL2w9

Myeloid-Derived Suppressor Cells

Viral Immunology , Vol. 0, No. 0.


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Surgical Site Infections in Patients receiving Osteomyocutaneous Free Flaps to the Head and Neck. Does Choice of Antibiotic Prophylaxis Matter?

Publication date: Available online 16 February 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): James Murphy, Amal Isaiah, Donita Dyalram, Joshua E. Lubek
PurposeThe most appropriate prophylactic antibiotic for clean contaminated head and neck osteomyocutameous free tissue transfer procedures is unclear. The purpose of this study is to determine whether choice of perioperative antibiotic was related to recipient surgical site infection (SSI) in subjects receiving an osteomyocutaneous free tissue transfer (OFF) to the head and neck.MethodRetrospective cohort study between July 2010 and October 2013 at a tertiary care medical center to evaluate SSI in relation to perioperative antibiotic received. Minimum follow-up of 6 months. SSI was defined by the Centers for Disease Control and Prevention wound infection criteria. Perioperative antibiotic selected, duration of use, OFF performed, medical comorbidities,and SSI were recorded and analyzed.ResultsOne hundred and two subjects(64M,38F) met the inclusion criteria. Forty subjects developed a SSI. Analysis of variance revealed that age[P=0.64], gender[P=0.97], use of alcohol[P=0.87], final pathology[P=0.3], cardiovascular disease[P=0.33], diabetes/immune dysfunction[P=0.95] did not have a significant association with the development of a postoperative wound infection. On univariate analysis, non-head and neck primary malignancies demonstrated a significant risk factor for SSI [P=0.03] with previous head and neck surgery [P=0.05] and oral tobacco use [P=0.06] having trends for increased risk of SSI. Clindamycin antibiotic was strongly associated with the development of a SSI with 50% of that cohort developing a recipient SSI [OR 7.0, P<0.002], regardless of the duration of use. The rate of development of a recipient SSI with cefazolin was 25% and for Unasyn it was 19%.ConclusionA statistically significant number of subjects who developed a recipient surgical site infection received clindamycin as perioperative antibiotic prophylaxis. An alternative antibiotic regime other than clindamycin should be considered in patients with an allergy to penicillin/cephalosporin who are undergoing an OFF to the head and neck.



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Genetic Characterization of Adenoid Cystic Carcinoma of the Minor Salivary Glands: A Potential Familial Occurrence in First-Degree Relatives

Abstract

Adenoid cystic carcinoma (AdCC) is a malignant salivary gland tumor. To date, no cases of AdCC in first-degree relatives have been reported in the literature. We present a 50-year-old female (Case 1) and this patients' father (Case 2), both of whom were diagnosed with AdCC of the minor salivary glands. Histology of Case 1 demonstrated a tubulocribriform AdCC whereas Case 2 primarily was an AdCC of solid type. Both cases harbored the MYB–NFIB gene fusion as demonstrated by FISH and RNA-sequencing. After filtering and selection of putative deleterious variants, whole exome sequencing identified 18 germline variants in common between Case 1 and Case 2. However, none of the variants were associated with AdCC or other head and neck cancers. To our knowledge, we present the first potential case of familial AdCC. The presented genetic data may contribute to further investigations of the underlying genetic mechanisms for AdCC susceptibility.

http://ift.tt/2lntZnR

A Novel Monoclonal Antibody Against Alpha-Methylacyl-CoA Racemase Applicable for Paraffin-Embedded Tissues and Diagnostics of Prostate Cancer

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy , Vol. 0, No. 0.


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Preparation and Characterization of a Novel Monoclonal Antibody Against the Extracellular Domain of Human Transferrin Receptor1

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy , Vol. 0, No. 0.


http://ift.tt/2kPBQaH

U.S. Obstetricians and Midwives Only Infrequently Recommend Iodine Supplementation during Preconception, Pregnancy, and Lactation

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 68-70.


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Sequential TSH Determinations May Help in Assessing the Adequacy of Treatment for Overt Hypothyroidism in Older Patients

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 48-51.


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Age Cutoff of 45 Years May Not Be Appropriate for Papillary Thyroid Cancer Staging

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 52-54.


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Schwannoma Presenting as Right Neck Mass with Asymmetric Goiter

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 75-77.


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Recurrence Rates in Patients with Intermediate-Risk Differentiated Thyroid Cancer Are Similar after Low-Dose and High-Dose Radioiodine Ablation in a Korean Series

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 55-57.


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Radioactive Iodine Has the Most Favorable Efficacy and Safety Profile for the Treatment of Graves' Disease at the Mayo Clinic

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 65-67.


http://ift.tt/2lZTxEM

Quality of Life Is Relatively Favorable in Persons with a History of Pediatric Differentiated Thyroid Cancer

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 58-61.


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Abnormal Gestational Thyroid-Function Trajectories Are Associated with Premature Delivery

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 71-74.


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Diffuse Sclerosing Variant of PTC Is Aggressive and May Have a Poor Outcome

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 62-64.


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Metastatic Choriocarcinoma Is a Rare Cause of Hyperthyroidism

Clinical Thyroidology Feb 2017, Vol. 29, No. 2: 78-79.


http://ift.tt/2m0erU9

Panorama Dermatologische Praxis

http://ift.tt/2m085Ej

The Skin as a Route of Allergen Exposure: Part II. Allergens and Role of the Microbiome and Environmental Exposures

Abstract

Purpose of Review

This second part of the article aims to highlight recent contributions in the literature that enhance our understanding of the cutaneous immune response to allergen.

Recent Findings

Several properties of allergens facilitate barrier disruption and cutaneous sensitization. There is a strong epidemiologic relationship between the microbiome, both the gut and skin, and atopic dermatitis (AD). The mechanisms connecting these two entities remain enigmatic; however, recent murine models show that commensal skin bacteria play an active role in supporting skin barrier homeostasis and defense against microbial penetration. Likewise, the association between the lack of colonization with Staph species and AD development suggests a potentially functional role for these organisms in regulating the skin barrier and response to environmental allergens. In undisrupted skin, evidence suggests that the cutaneous route may promote allergen tolerance.

Summary

Properties of environmental allergens and commensal bacteria add to the complex landscape of skin immunity. Further investigation is needed to elucidate how these properties regulate the cutaneous immune response to allergen.

http://ift.tt/2ln1GGd

Icariin promotes mouse hair follicle growth by increasing insulin-like growth factor 1 expression in dermal papillary cells

Summary

Background

Icariin is a major flavonoid isolated from Epimedium spp. leaves (Epimedium Herba), and has multiple pharmacological functions, including anti-angiogenesis, anti-oxidant, anti-inflammatory and immunoprotective effects.

Aim

To investigate whether icariin can stimulate growth of hair follicles in mice and the underlying mechanism.

Methods

In vitro, the effect of icariin on hair growth was assessed by using a vibrissae hair follicle (VHF) organ-culture model. The proliferation of hair matrix keratinocytes and the expression of insulin-like growth factor (IGF)-1 in follicles were examined by double immunostaining for 5-bromo-2′-deoxyuridine and IGF-1, in the presence or absence of icariin. Dermal papilla cells (DPCs) were cultured and IGF-1 level was measured by reverse transcription-PCR and ELISA after icariin treatment. In vivo, the effect of icariin on hair growth was examined by gavage feeding of icariin to mice whose backs had been depilated, and the conversion of telogen to anagen hair was observed.

Results

Treatment with icariin promoted hair shaft elongation, prolonged the hair cycle growth phase (anagen) in cultured VHFs, and accelerated transition of hair cycle from telogen to anagen phase in the dorsal skin of mice. There was significant proliferation of matrix keratinocytes and an increased level of IGF-1 in cultured VHFs. Moreover, icariin treatment upregulated IGF-1 mRNA expression in DPCs and increased IGF-1 protein content in the conditioned medium of DPCs.

Conclusions

These results suggest that icariin can promote mouse hair follicle growth via stimulation of IGF-1 expression in DPCs.

http://ift.tt/2ldjUYz

Severe bullous pemphigoid associated with pembrolizumab therapy for metastatic melanoma with complete regression

Summary

Bullous pemphigoid (BP) is considered to be a humorally mediated autoimmune disease, but autoreactive T-cells and T-regulatory cells (Tregs) have also been implicated in this disease. Tregs and the programmed death-1 (PD-1) : programmed death ligand (PD-L) pathway are both critical in terminating immune response, and elimination of either can result in breakdown of tolerance and development of autoimmunity. We report a patient with metastatic malignant melanoma (MM), who underwent pembrolizumab (anti-PD-1) therapy following unsuccessful treatment with ipilimumab [anti-cytotoxic T-lymphocyte-associated protein (CTLA)-4]. The patient developed BP with increasing serum titres of anti-BP180 IgG autoantibodies and increasing disease severity during pembrolizumab therapy. High doses of corticosteroids and methotrexate were needed to control the BP. Following the termination of pembrolizumab therapy, imaging showed complete regression of all metastatic sites. This result may indicate a crucial role for T-cell suppressive activity in controlling and preventing BP.

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Alitretinoin treatment in mycosis fungoides with CD30-positive large cell transformation

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Detection of SERPINB7 mutation can distinguish Nagashima-type palmoplantar keratoderma from other keratodermas with palmoplantar lesions

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Toddlers in transition: Linear enamel hypoplasias in the Hadza of Tanzania.

Abstract

Bioarchaeologists often use linear enamel hypoplasias (LEH) as a proxy for systemic physiological stress in prehistoric populations. Increased incidences of LEH have been observed in many cases associated with rapid social or environmental changes, such as with the Neolithic transition and agricultural intensification. Still, there have yet to be studies published of LEH incidence among living peoples in the process of transitioning from a foraging to a farming economy. It is important to document LEH occurrence in living groups with known subsistence strategies to better contextualize interpretations of bioarchaeological populations. Here we present LEH data for a sample of the Hadza of Tanzania. We compare LEH incidence and frequency on the permanent anterior teeth of individuals who spent their infancy and early childhood 1) in the bush consuming wild foods, 2) in the village with a weaning diet dominated by domestic cereals, and 3) transitory, dividing their time between the bush and village. Our results demonstrate that Hadza living in the bush during the period of tooth formation less frequently have LEH on these teeth, and have fewer of them on average, than do villagers. This is particularly so for the comparison of males. The transient group is intermediate in LEH incidence, though not significantly different from the bush and village samples. A lower LEH frequency in the bush Hadza is consistent with a diet that meets nutrient requirements of tooth formation, but higher incidence in the village sample suggests interruption of enamel secretion, most likely due to malnutrition. Such studies provide valuable context with which to interpret and understand bioarchaeological evidence, and to track effects of sedentization on the biology of modern foragers.

http://ift.tt/2lnWToh

Clinical Thyroidology for the Public – Highlighted Article

From Clinical Thyroidology for the Public: Hypothyroidism is most often caused by an autoimmune process where the body makes antibodies that attack and destroy the thyroid. Read More….

The post Clinical Thyroidology for the Public – Highlighted Article appeared first on American Thyroid Association.

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Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: A randomized, double-blinded clinical trial

The purpose of this study was to evaluate the effect of intravenous or perineural dexamethasone added to ropivacaine on the duration of ultrasound-guided interscalene brachial plexus blocks (BPB).

http://ift.tt/2lo6RpN

What is the place of clonidine in anesthesia? Systematic review and meta-analyses of randomized controlled trials

A place for clonidine has been suggested for many indications in perioperative medicine. The aim of this systematic review and these meta-analyses is to systematically, and quantitatively, evaluate these potential indications of clonidine.

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Phenytoin in topical formulations augments pain reduction of other topically applied analgesics in the treatment of trigeminal neuralgia

To the Editor:

http://ift.tt/2lnZLBN

Clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery

To the Editor

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Cutaneous squamous cell carcinoma: an epidemiological review

Summary

Cutaneous squamous cell carcinoma (SCC) is a common cancer in white populations and its disease burden is often substantially underestimated. SCC occurs more often in men than women and increases dramatically with age; those affected often develop multiple primaries over time, which increases the burden. The main external cause is solar ultraviolet radiation (UVR), with immunosuppression being the other established risk factor, shown by the high SCC rates in organ transplant recipients. Sunbed use and certain genetic disorders and medical conditions are also associated with SCC, while associations with human papillomavirus infection and high bodyweight are not established. The presence of actinic keratoses (AKs) on sun-damaged skin is one of the strongest predictors of SCC in unaffected people and a very small proportion of AKs are SCC precursors, although the true rate of malignant transformation of AKs is unknown. The mainstay of SCC prevention is protection of the skin from undue sun exposure by use of clothing cover and sunscreen during summer or in sunny places. Educational, behavioural and multicomponent interventions directed at individuals ranging from parents of newborns, to school children and adolescents, to outdoor workers, have repeatedly been shown to be effective in improving sun-protective behaviours. Health policies can facilitate SCC prevention by setting standards for relevant behaviours to reduce UVR exposure, for example, by legislated restriction of the tanning industry. Skin cancer prevention initiatives are generally highly cost-effective and public investment should be encouraged to control the growing public health problems caused by SCC.

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The resected area of the posterior wall of the external auditory canal during transcanal endoscopic ear surgery for cholesteatoma

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): Takao Imai, Suetaka Nishiike, Kazuo Oshima, Hidenori Tanaka, Yukinori Tsuruta, Yoichiro Tomiyama
ObjectiveThe aim of this study was to evaluate part of the area of the posterior wall of the external auditory canal (EAC) that is resected during transcanal endoscopic ear surgery (TEES) for cholesteatomas that extend to the mastoid cavity, and to determine whether TEES is a minimally invasive surgical procedure for cholesteatoma.MethodsThis was a retrospective study involving 25 patients with cholesteatoma that extended to the mastoid cavity, and who underwent surgery between October 2014 and October 2015. The patients' cholesteatomas were removed using TEES. In this procedure, the superoposterior wall of the EAC was resected in order to access the deepest part of the cholesteatoma. We made a paper template by tracing the shape of the resected EAC and then reconstructed the resultant defect with a piece of cartilage, the size of which was based on the size of the template. We evaluated the size and greatest dimension of the resected part of the EAC by measuring the template. Preoperatively, we also evaluated the volume of each cholesteatoma on computed tomography (CT) images.ResultsThe median size of the resected region was 37.3 (14.7–68.4)mm². The median length of the greatest dimension of the resected area was 8.7 (5.1–15.9)mm. The median cholesteatoma volume was 417 (43–1399)mm³. The correlation coefficient (R²) obtained using a two-thirds order approximation curve for the relationship between the resected tissue area and the cholesteatoma volume (0.617) was higher than that obtained by linear approximation (0.387).ConclusionThese results suggest that the resected area was minimal and of an appropriate size relative to the volume of the cholesteatoma.



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Endoscopic cartilage butterfly myringoplasty in children

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): Abdulvahap Akyigit, Turgut Karlidag, Erol Keles, Irfan Kaygusuz, Sinasi Yalcın, Cahit Polat, Orkun Eroglu
ObjectiveThe present study evaluated the results of the graft success rate and hearing gain of children who underwent endoscopic inlay butterfly myringoplasty due to chronic otitis media.MethodsThe study included 32 pediatric patients aged between 8 and 17, who had endoscopic inlay butterfly myringoplasty with the diagnosis of chronic otitis media between September 2012 and January 2015 in Elazig Training and Research Hospital Otorhinolaryngology Clinic and Firat University Otorhinolaryngology Clinic. All patients' demographics, perforation size, and hearing status were examined.ResultsTympanic membrane perforation was ≤3mm in 12 patients and between 3 and 6mm in 20 patients. The air-bone gap (ABG) of the patients was 18.5±6.29dB preoperatively, 8.81±3.53dB postoperatively second month, 8.09±3.55dB postoperatively sixth month, and 7.96±3.32dB postoperatively 12th month. Two (6.3%) of the patients had postoperative myringitis. Two (6.3%) patients had recurrent perforation in the postoperative follow-ups.ConclusionIn children, endoscopic inlay butterfly tympanoplasty is a surgical technique with short duration, high graft success, effective hearing reconstruction, and high levels of postoperative patient comfort.



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Clinical features of recurrence and osteoporotic changes in benign paroxysmal positional vertigo

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): So Young Kim, Seung Hoon Han, Young Ho Kim, Min-Hyun Park
ObjectiveSeveral previous studies have demonstrated that comorbidities, secondary causes, physical inactivity, and osteoporosis may cause recurrence of benign paroxysmal positional vertigo (BPPV). However, there has also been some controversy over the clinical course(s) and cause(s) of recurrent BPPV (rBPPV). We identified clinical features and associated factors, including decreased bone mineral density, in the recurrence of BPPV.MethodsIn total, 198 patients with idiopathic BPPV, diagnosed at the otolaryngology clinics of Seoul National University Boramae Medical Center, were enrolled. The medical data of these patients were reviewed retrospectively. Recurrent BPPV was defined as the recurrence of BPPV after at least 1 month of a symptom-free interval following previous successful treatment.ResultsOf the BPPV patients, 67 (33.8%) were classified as rBPPV. Among them, about 16% showed changes in the involved semicircular canals and about 6% showed multiple semicircular canal involvement. rBPPV was more common in patients with comorbidities (P<0.001). Involved semicircular canals showed no statistically significant difference according to the recurrence of BPPV. The mean symptom-free interval of the rBPPV group varied from 1 to 50.2 (mean, 11.6) months; however, 90% of BPPV recurrence occurred within 24 months. Bone mineral density in dual-energy X-ray absorptiometry (DEXA) was markedly decreased in BPPV patients versus normal controls, but there were no significant differences according to BPPV recurrence.ConclusionThe incidence of rBPPV in idiopathic BPPV patients was 33.8% in the present study. The mean period of recurrence after a symptom-free interval was about 11.6 months; most patients showed recurrence within 2 years after the first attack of BPPV. Furthermore, about 16% of patients suffered from rBPPV at a different kind or type of canal from the semicircular canal of the initial BPPV attack. Comorbidities, but not age, gender, or the involved semicircular canal, might be correlated with BPPV recurrence. Decreased bone mineral density did not show significant association with BPPV recurrence, but showed a significant relation with BPPV occurrence.



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Editorial Board

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2





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Taste detection and recognition thresholds in Japanese patients with Alzheimer-type dementia

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): Takao Ogawa, Naoya Irikawa, Daijiro Yanagisawa, Akihiko Shiino, Ikuo Tooyama, Takeshi Shimizu
ObjectiveAlzheimer-type dementia (AD) is pathologically characterized by massive neuronal loss in the brain, and the taste cortex is thought to be affected. However, there are only a few reports regarding the gustatory function of AD patients, and the conclusions of this research are inconsistent.MethodsThis prospective study enrolled 22 consecutive patients with mild to moderately severe Alzheimer-type dementia (AD) with mean age of 84.0 years, and 49 elderly volunteers without dementia with mean age of 71.0 years as control subjects. The control subjects were divided into two groups according to age: a younger group (N=28, mean age: 68.5) and an older group (N=21, mean age: 83.0). The gustatory function was investigated using the filter paper disc method (FPD) and electrogustometry (EGM).ResultsThe gustatory function as measured by the FPD was significantly impaired in patients with AD as compared with age-matched control subjects; no such difference was found between the younger and the older control groups. On the other hand, as for the EGM thresholds, there were no differences between the AD patient group and the age-matched controls.ConclusionThe FPD method demonstrated decreased gustatory function in AD patients beyond that of aging. On the other hand, EGM thresholds did not differ between the AD patient group and the age-matched controls. These results suggest that failure of taste processing in the brain, but not taste transmission in the peripheral taste system, occurs in patients with AD.



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Real-time dual visualization of two different modalities for the evaluation of vocal fold vibration – Laryngeal videoendoscopy and 2D scanning videokymography: Preliminary report

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): Geun-Hyo Kim, Soo-Geun Wang, Byung-Joo Lee, Hee-June Park, Yong-Cheol Kim, Hyung-Soon Kim, Keon-Tae Sohn, Soon-Bok Kwon
ObjectiveCurrently, various tools have been introduced for the assessment of vocal fold vibration: laryngeal videolaryngoscopy (LV), videokymography (VKG), high speed videoendoscopy (HSV), digital videokymography (DKG), and 2D scanning videokymography (2D VKG). Among these, the authors have recently designed a dual modality examination system using LV and 2D VKG for more detailed information regarding the vibrations of the vocal folds. The clinical availability of this hybrid system offers medical imaging departments a range of potential advantages in the evaluation of vocal fold vibration. The obvious benefit of simultaneous acquisition is the improved integration of information that allows not only optimal anatomic localization, but also physical movement patterns. Other advantages include the lessened inconvenience to patients due to no longer requiring repeated examinations and shortening the examination time, and increased profitability. The purpose of study was to identify the efficacy of real-time dual examination of two different modalities for the evaluation of vocal fold vibration in human subjects and vocal fold vibration simulator.MethodsOne vocally healthy subject and three patients with vocal fold nodules, a vocal cyst, and vocal fold paralysis took part in this study. The vibratory patterns of the vocal folds were visualized using simultaneous real-time examination of two different modalities. Additionally, qualitative and quantitative analyses of the dual LV and 2D VKG images were performed.ResultsReal-time dual examination using a two modality system provided high definition images of the vibratory movements of the vocal folds. By assessing the obtained images, we confirmed that the dual modality examination method was useful in the evaluation of pathologic vibratory patterns, even in non-periodic phonation.ConclusionThe present system might improve the understanding of the processes of vocal fold vibration and make a contribution to pathologic voice research, as well as clinical practice.



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Facial mimetic, cosmetic, and functional standardized assessment of the facial artery musculomucosal (FAMM) flap

Publication date: April 2017
Source:Auris Nasus Larynx, Volume 44, Issue 2
Author(s): Nathan Jowett, Tessa A. Hadlock, Eyal Sela, Miklos Toth, Rainald Knecht, Balazs B. Lörincz
ObjectiveTo objectively assess donor site morbidity after harvesting the facial artery musculomucosal flap. Use of the FAMM-flap in oral cavity reconstruction remains sporadic. This case series describes our newly developed standardized assessment of this flap in a floor of mouth (FOM) reconstructive setting.MethodsStandardized postoperative assessment of the FAMM flap for donor site wound complications, functional, facial mimetic and oncologic outcomes.ResultsThere were no wound complications. Oral competence remained intact, tongue mobility was good to excellent, average word articulation score was 98%, and mimetic function excellent in all patients. Three patients experienced ipsilateral upper lip anesthesia, and five patients were noted to have slight dysfunction of the orbicularis oris resulting in a loss of lip height at rest.ConclusionThe FAMM flap is a reliable option for reconstruction of ablative defects of the FOM, and should be considered a workhorse flap for oral cavity defects. Unlike the submental island flap, a complete level I dissection may be concurrently performed without compromising the vascular supply to the FAMM flap.



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Observational study of chondrodermatitis nodularis helicis treated with methyl aminolevulinate photodynamic therapy

Therapies used to treat chondrodermatitis nodularis helicis (CNH), such as surgical excision, pressure relief, or topical steroids report varying degrees of success.

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A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study

Cellulitis has many clinical mimickers (pseudocellulitis), which leads to frequent misdiagnosis.

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Status and perception of oral health in 6–17-year-old psychiatric inpatients—randomized controlled trial

Abstract

Aim

The following are the aims of the study: assessment of oral health status, oral health-related quality of life (OHRQoL) and the effect of oral health care training over OHRQoL in children and adolescents hospitalized with mental disorders.

Methodology

This randomized case controlled prospective interventional study involved 81 child and adolescent psychiatric inpatients (CAP) aged between 6 and 17 years (mean age 10.6 ± 2.4 years), compared to 81 mentally healthy patients attending routine dental examinations (DC group) matched according to age and sex of the CAP group. Oral examinations were performed by two calibrated dentists. OHRQoL was assessed with the German version of the Child Perceptions Questionnaire. CAP inpatients were randomly divided in two equal subgroups, an intervention (IG) and a non-intervention group (non-IG). The IG received oral health care training at admission to the hospital.

Results

CAP inpatients, especially those with stress-related disorders, revealed significantly higher caries prevalence and experience than DC patients. Although OHRQoL did not differ from the German reference values, CAP inpatients compensated higher impairment due to oral symptoms and functional limitations with lower impairment due to emotional and social well-being. OHRQoL increased in all CAP patients during hospitalization, regardless of receiving oral health care training.

Conclusion

Poorer oral health of CAP inpatients was not accompanied by higher impairment of OHRQoL. Oral problems seem to be overshined by better self-perceived emotional and social well-being. OHRQoL was not improved by individualized oral health care training.

Clinical relevance

Children and adolescents with mental disorders are at risk for oral diseases and need referral to dental services.

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Technique of primary operation for a patient with an oblique facial cleft (Tessier number 2 cleft)

An oblique facial cleft is rare. Natsume et al1 reported that they constitute about O.2% of all cases of malformation of the face in Japan, and about O.22% of those in other countries. The most common classification categorises craniofacial clefts according to their anatomical site.2

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Craniofacial implants at a single centre 2005-2015: retrospective review of 451 implants

Craniofacial endosseous implants are regularly used to support prostheses in the rehabilitation of complex defects, but reported success rates vary. To review our own clinical practice over 10 years, and particularly to examine the impact of radiotherapy and the timing of placement on the survival of implants, we retrospectively audited the records for all patients who had endosseous implants for prosthetic rehabilitation in our unit between 2005 and 2015. We reviewed 167 records, which gave 451 implants, of which, 222 (49%) were auricular, 98 (22%) nasal, and 131 (29%) orbital.

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Re: Cross-cover of oral and maxillofacial surgery out-of-hours: an audit of a new adult treatment clinic

We congratulate Abou-Foul et al on their success in teaching medical foundation trainees within their department in Oxford.1 We agree that the specialist nature of OMFS requires good training, and it is unfortunate that unfounded fear has created doubt over the safety of patients under the care of singly-qualified trainees.

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Rare anatomical variant of the cervical internal carotid artery

Neck dissection is routine for the management of cancers of the head and neck. Knowledge of anatomical variants in the carotid artery system at various levels of dissection should prevent inadvertent injury to major blood vessels, which can cause massive bleeding. We report a rare 180° sharp bend in the cervical course of the internal carotid artery at level II, which we found during a modified neck dissection.

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Measurement of generic compared with disease-specific quality of life after removal of mandibular third molars: a patient-centred evaluation

Our aim was to evaluate patients' perceptions and their responsiveness to a generic quality of life (QoL) scale after removal of mandibular third molars. We asked 40 consecutive patients who met NICE guidelines for removal of third molars to rank items from the generic EuroQuol three-dimensional questionnaire (EQ 5D 3L) and the disease-specific Oral Health Impact Profile (OHIP-14) based on what they perceived to be important outcomes. Each item was then assigned a numerical value that depended on its rank, and an overall score calculated.

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Measurement of generic compared with disease-specific quality of life after removal of mandibular third molars: a patient-centred evaluation

Publication date: Available online 16 February 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): A.N. Beech, S. Haworth, G.J. Knepil
Our aim was to evaluate patients' perceptions and their responsiveness to a generic quality of life (QoL) scale after removal of mandibular third molars. We asked 40 consecutive patients who met NICE guidelines for removal of third molars to rank items from the generic EuroQuol three-dimensional questionnaire (EQ 5D 3L) and the disease-specific Oral Health Impact Profile (OHIP-14) based on what they perceived to be important outcomes. Each item was then assigned a numerical value that depended on its rank, and an overall score calculated. Fifty consecutive patients were then invited to complete a paper-based EQ 5D 3L QoL questionnaire daily for seven days after removal of third molars. Most of the generic QoL items ranked more highly than disease-specific ones. The generic EQ 5D 3L questionnaire indicated an initial fall in QoL after removal of the teeth, before improving for all participants over the first seven postoperative days. The responses to questions about "overall QoL", "pain/discomfort", and "anxiety/depression" in the EQ 5D 3L tool were strongly correlated. The EQ 5D 3L is used to assess fluctuations in QoL during the early postoperative period after removal of third molars, and describes items that are perceived by patients to be more important than those recorded by the disease-specific OHIP-14 QoL questionnaire. It is therefore more relevant for counselling patients preoperatively. Development of measures of early outcomes after removal of third molars should incorporate generic items to remain useful.



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Re: Cross-cover of oral and maxillofacial surgery out-of-hours: an audit of a new adult treatment clinic

Publication date: Available online 16 February 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): S. Chegini, M. Heliotis




http://ift.tt/2kE94Je

Technique of primary operation for a patient with an oblique facial cleft (Tessier number 2 cleft)

Publication date: Available online 16 February 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): N. Natsume, H. Imura




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Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting

Abstract

Purpose of Review

A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively.

Recent Findings

Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents.

Summary

The present review focuses on the many roles of local anesthetics in current ambulatory practice.

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Polyglycolic acid sheet attached with fibrin glue can facilitate faster epithelialization of the mastoid cavity after canal wall-down tympanoplasty

This study retrospectively investigated whether polyglycolic acid (PGA) sheet attached to the bone surface using fibrin glue facilitate faster epithelialization of the mastoid bowl after canal wall-down (CWD) tympanoplasty compared to a simple dressing using poly-N-acetyl-glucosamine (Kichin) sheet.

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Oncogenic growth factor signaling mediating tumor escape from cellular immunity

Fernando Concha-Benavente | Robert L Ferris

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A comparative study for post operative analgesia in the emergency laparotomies: Thoracic epidural ropivacaine with nalbuphine and ropivacaine with butorphanol

Saravana Babu, Bikram Kumar Gupta, Gyanendra Kumar Gautam

Anesthesia: Essays and Researches 2017 11(1):155-159

Background: Adequate postoperative pain therapy for emergency abdominal surgeries is important far beyond the perioperative period because sensitization to painful stimuli can cause postoperative morbidity. A prospective, double-blind, randomized study was carried out to compare the quality of postoperative analgesia and side-effect profile between epidurally administered butorphanol and nalbuphine as an adjuvant to 0.2% ropivacaine. Materials and Methods: A total of eighty patients, 43 men and 37 women between the age of 18 and 65 years of American Society of Anesthesiologists (ASA) Class I E and II E, who underwent intestinal perforation repair surgery were randomly allocated into two groups ropivacaine with butorphanol (RB) and ropivacaine with nalbuphine (RN), comprising of 40 patients each. Group RB received 0.2% ropivacaine containing 2 mg butorphanol while Group RN received 0.2% ropivacaine containing 10 mg nalbuphine through thoracic epidural catheter. Quality of analgesia, cardiorespiratory parameters, side-effects, and the need of rescue intravenous analgesia were observed. Results: The demographic profile and ASA Class were comparable between the groups. RN group had good quality of analgesia and stable cardiorespiratory parameters for the initial 6 h of postoperative period, after which they were comparable in both groups. Furthermore, the need of rescue analgesia was higher (20%) in the RB group during the first 6 h. The side-effect profile was comparable with a little higher incidence of nausea in both groups. Conclusion: Thoracic epidurally administered ropivacaine with nalbuphine is more effective than ropivacaine with butorphanol for immediate postoperative pain relief in patients undergoing emergency exploratory laparotomy.

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Comparison of king vision and truview laryngoscope for postextubation visualization of vocal cord mobility in patients undergoing thyroid and major neck surgeries: A randomized clinical trial

Anto Sahaya Priyanka, Kusha Nag, VR Hemanth Kumar, Dewan Roshan Singh, Senthil Kumar, T Sivashanmugam

Anesthesia: Essays and Researches 2017 11(1):238-242

Background: Visualization of vocal cords following extubation after thyroid and major neck surgeries is highly desirable for the surgeon as well as the anaesthesiologist to rule out vocal cord palsy or oedema. As the patient is emerging from general anaesthesia, it may be challenging for the anaesthesiologist to optimally visualise and grade vocal cord movement following extubation. Setting: Randomized clinical trial at a tertiary care centre. Methodology: After obtaining institutional ethics committee approval, 60 patients posted for thyroid and major neck surgeries under American Society of Anesthesiologists (ASA) grade I and II were recruited for the study. Written informed consent was obtained. Pre-operatively indirect laryngoscopy was performed in all the patients to assess baseline vocal cord function. All patients were premedicated and induced and maintained as per standardized anaesthesia protocol. Patients were randomized using a sealed envelope technique to either Group K where intubation was performed using Kings vision laryngoscope or Group T where intubation was performed using True view laryngoscope. Glottis visualization was graded in all patients and intubated. Ten minutes prior to extubation injection. dexmedetomidine 1 μg/kg was administered. Once patients satisfied extubation criteria, laryngoscopy was performed using respective video-laryngoscope in each group, patient extubated under vision and assessed for vocal cord visualization and mobility grade (VMG) and patient reactivity score (PRS). Heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure was also noted. Total intraoperative morphine consumption was recorded. Vocal cord function was assessed again before the day of discharge by indirect laryngoscopy. Results: Age (P = 0.27), sex (P = 0.08), body mass index (P = 0.70), ASA (P = 0.39), mallampati class (P = 0.72) and morphine used (P = 0.39) were comparable in both groups. There was no statistically significant difference among the two groups with respect to VMG (P = 0.18). There was no statistical difference in the PRS (P = 0.06) in both groups. Increase in heart rate or mean arterial pressure from baseline was not significant statistically in both groups. Time taken for laryngoscopy during extubation was significantly less with group T as compared to group K (P = 0.000). Conclusion: Both Kings Vision and Truview Video-laryngoscopes provide comparable laryngoscopic view with similar patient comfort, although clinically Truview may be a better choice due to less time consumed for visualisation and rating vocal cord movement during extubation.

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Benefits and pitfalls of cadavers as learning tool for ultrasound-guided regional anesthesia

Chhavi Sawhney, Sanjeev Lalwani, Bikash Ranjan Ray, Sumit Sinha, Abhyuday Kumar

Anesthesia: Essays and Researches 2017 11(1):3-6

Ultrasound-guided regional anesthesia (UGRA), like other basic skills, should be learnt in a simulation laboratory before performing on the patient. Cadavers provide an ideal tool for learning sonoanatomy and skills required for performing UGRA. On the basis of preservation technique used, the cadavers can be formalin embalmed cadavers, Thiel cadavers (soft cadavers), and fresh frozen cadavers. We compared three types of cadavers for performing ultrasound-guided upper and lower limb blocks. We observed that fresh frozen and Thiel cadavers were less smelling and had more realistic appearance as compared to formalin embalmed cadavers. It was seen that Thiel cadavers were more flexible and hence, rotation of neck, shoulder and knee was easier. Although images seen in most cadavers were comparable with live subjects but, Thiel cadavers provided more realistic model.

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Ventilation of nonparalyzed patients under anesthesia with laryngeal mask airway, comparison of three modes of ventilation: Volume controlled ventilation, pressure controlled ventilation, and pressure controlled ventilation-volume guarantee

Maroun Badwi Ghabach, Elie M El Hajj, Rouba D El Dib, Jeanette M Rkaiby, May S Matta, May R Helou

Anesthesia: Essays and Researches 2017 11(1):197-200

Background: Pressure controlled ventilation (PCV) is the preferable mode of ventilation of nonparalyzed patients undergoing anesthesia with laryngeal mask airway (LMA) as compared to volume controlled ventilation (VCV) and spontaneously breathing patient. In this study, we compared the PC–volume guarantee (PC-VG) mode of ventilation with VCV and PCV modes. Materials and Methods: A total of 30 patients, American Society of Anesthesiologists (ASA) physical status Classes I and II, scheduled for elective surgery under general anesthesia with a classic LMA were ventilated, subsequently, with the three modes of ventilation: VCV, PCV, and PC-VG for 10 min each mode. Tidal volume set for all patients was 8 ml/kg of ideal body weight. Parameters measured with modes of ventilation include peak inspiratory pressure (PIP), compliance, measured tidal volume, O2saturation, end-tidal CO2, and presence of an oropharyngeal leak. Results: The PIP was significantly higher with the application of VCV mode of ventilation than PCV and PC-VG modes. The compliance was significantly lower when using the mode of ventilation VCV than PCV and PC-VG. The PIP and the compliance were not statistically different between the PCV and PC-VG modes of ventilation. Conclusions: Ventilation of nonparalyzed patients with LMA under anesthesia with PC-VG is advantageous over VCV in reducing PIP and increasing lung compliance. No difference was noted between PCV and PC-VG in ASA Classes I or II under the adequate depth of anesthesia in patients with normal pulmonary function.

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