Head and Neck Medicine by Alexandros G.Sfakianakis: 06/15/17

Πέμπτη 15 Ιουνίου 2017

Effects of glycolic acid peeling on the cutaneous manifestation of generalized acanthosis nigricans caused by FGFR3 mutation: A report of one sporadic and two familial cases

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Case of autoimmune autonomic ganglionopathy manifesting anhidrosis

Abstract

Autoimmune autonomic ganglionopathy (AAG), clinically characterized by gastrointestinal dysmotility, orthostatic hypotension and tonic pupils, is an idiopathic acquired disorder of the autonomic nervous system elicited by antibodies against ganglionic acetylcholine receptor (gAChR). We encountered a 60-year-old man who presented with severe anhidrosis, difficulty in thermoregulation, orthostatic hypotension, gastrointestinal dysmotility, tonic pupils and ptosis. Histologically, an anhidrotic skin sample was normal. Routine laboratory examinations of blood, urine and cerebrospinal fluid returned no abnormal findings. Serological examination revealed antibodies against α3 and β4 subunits of gAChR. The diagnosis was AAG. As sudomotor dysfunction reflects ganglionic neuropathy in AAG, we concluded that his anhidrosis was attributable to AAG. Anhidrosis is an important clue for the diagnosis of AAG, a rare neurological disorder.

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Isotretinoin and tattooing: a cautionary tale

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Real-world, single-centre experience of apremilast for the treatment of moderate to severe psoriasis

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Randomised controlled trial of a baked egg intervention in young children allergic to raw egg but not baked egg

Consumption of baked egg by raw egg allergic children is associated with immune changes suggesting development of tolerance. However, causation has not been tested using a double blind randomized controlled tr...

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The extended bundle of the tensor veli palatini: Anatomic consideration of the dilating mechanism of the Eustachian tube

The aim of this study was to analyze the topographical structures of the muscles surrounding the Eustachian tube.

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Metaplastic breast carcinoma with chondroid differentiation: a rare variant of infiltrative carcinoma in a 38-year-old woman

Metaplastic breast carcinoma (MBC) is a rare type of invasive breast carcinoma, and chondroid differentiation is even rarer. Here we report a case of MBC with extensive chondroid differentiation in a 38-year-old woman who presented with a lump in her left breast. Ultrasound findings were most compatible with those of giant fibroadenoma. A histopathological examination revealed a malignant lesion comprising neoplastic epithelial cells arranged in solid nests, with large areas of chondroid differentiation. Neoplastic chondroid cells exhibited a positive reaction for S-100, patchy positive reaction for pan-cytokeratin (AE1/AE3) and negative reaction for epithelial membrane antigen. Both carcinomatous and chondroid cells exhibited p53 overexpression. Sentinel lymph node biopsy revealed no tumorous involvement.

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It's a cod! Finding Nemo (impacted fishbone) in the emergency department

A 23-year-old woman presented to the emergency department (ED) with a sensation of a 'fish bone' stuck in her throat after eating cod. On physical examination, while she reported an uncomfortable sensation in her throat, no airway compromise was evident. Clinical examination, including ear, nose and throat (ENT) and oropharyngeal assessment, was unremarkable. A linear opacity consistent with a fishbone was visualised on a soft tissue lateral neck X-ray anterior to the vertebral body of C4–6. One attempt to visualise the fishbone on direct laryngoscopy failed in the ED. The fishbone was later removed the next day via direct visualisation with a flexible endoscope in the operating theatre by the ENT surgical team. The patient's recovery was uneventful.

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Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: An observational study in 29 countries.

BACKGROUND: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN: This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING: Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES: The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS: A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg-1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P

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Women awaken faster than men after electroencephalogram-monitored propofol sedation for colonoscopy: A prospective observational study.

BACKGROUND: Sedation for colonoscopy using intravenous propofol has become standard in many Western countries. OBJECTIVE: Sex-specific differences have been shown for general anaesthesia in dentistry, but no such data existed for gastrointestinal endoscopy. DESIGN: A prospective observational study. SETTING: An academic teaching hospital of Hannover Medical School. PATIENTS: A total of 219 patients (108 women and 111 men) scheduled for colonoscopy. INTERVENTION: Propofol sedation using electroencephalogram monitoring during a constant level of sedation depth (D0 to D2) performed by trained nurses or physicians after a body-weight-adjusted loading dose. MAIN OUTCOME MEASURES: The primary end-point was the presence of sex-specific differences in awakening time (time from end of sedation to eye-opening and complete orientation); secondary outcome parameters analysed were total dose of propofol, sedation-associated complications (bradycardia, hypotension, hypoxaemia and apnoea), patient cooperation and patient satisfaction. Multivariate analysis was performed to correct confounding factors such as age and BMI. RESULTS: Women awakened significantly faster than men, with a time to eye-opening of 7.3 +/- 3.7 versus 8.4 +/- 3.4 min (P = 0.005) and time until complete orientation of 9.1 +/- 3.9 versus 10.4 +/- 13.7 min (P = 0.008). The propofol dosage was not significantly different, with some trend towards more propofol per kg body weight in women (3.98 +/- 1.81 mg versus 3.72 +/- 1.75 mg, P = 0.232). CONCLUSION: The effect of sex aspects should be considered when propofol is used as sedation for gastrointestinal endoscopy. That includes adequate dosing for women as well as caution regarding potential overdosing of male patients. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT02687568). (C) 2017 European Society of Anaesthesiology

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Rocuronium is more hepatotoxic than succinylcholine in vitro.

BACKGROUND: The development of liver failure is a major problem in critically ill patients. The hepatotoxicity of many drugs, as one important reason for liver failure, is poorly screened for in human models. Rocuronium and succinylcholine are neuromuscular blocking agents used for tracheal intubation and for rapid-sequence induction. OBJECTIVE: We used an in-vitro test with a permanent cell line and compared rocuronium and succinylcholine for hepatotoxicity. DESIGN: In-vitro study. SETTING: A basic science laboratory, University Hospital Rostock, Germany. MATERIAL/(PATIENTS): The basic test compound is the permanent human liver cell line HepG2/C3A. In a standardised microtitre plate assay the toxicity of different concentrations of rocuronium, succinylcholine and plasma control was tested. INTERVENTIONS: After two incubation periods of 3 days, the viability of cells (XTT test, lactate dehydrogenase release and trypan blue staining), micro-albumin synthesis and the cytochrome 1A2 activity (metabolism of ethoxyresorufin) were measured. MAIN OUTCOME MEASURES: Differences between rocuronium and succinylcholine were assessed using the Kruskal-Wallis one-way test and two-tailed Mann-Whitney U test. RESULTS: Rocuronium, but not succinylcholine, led to a significant dose-dependent decrease of viability, albumin synthesis and cytochrome 1A2 activity of test cells. CONCLUSION: An in-vitro test with a cell line showed hepatotoxicity of rocuronium that was dose-dependent. Further studies are needed to investigate the underlying mechanisms of the effects of rocuronium on hepatic cellular integrity. TRIAL REGISTRATION: Not suitable. (C) 2017 European Society of Anaesthesiology

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Re: Segmental mandibulectomies made easier: a simple drill guide

We read with interest the paper by Gordon et al1 in which they proposed the use of a reconstruction plate to accurately position the remaining mandible after a segmental mandibulectomy. We agree that this method is easy, simple to do, and cost effective.

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Sialadenoma papilliferum in the buccal mucosa detected on 18F-fluorodeoxyglucose-positron emission tomography

An incidental discovery of an accumulation of 18F-fluorodeoxyglucose (FDG) in the oral cavity of patients with malignant tumours on FDG positron emission tomography (PET) can pose a problem regarding the differential diagnosis of metastatic lesions. Large accumulations can often be found even when tumours in the salivary or thyroid gland are benign, so FDG-PET is limited in its ability to differentiate between benign and malignant disease. This report describes a rare case of sialadenoma papilliferum in the buccal mucosa that was discovered incidentally on FDG-PET in a patient with multiple metastases to bone after an operation for rectal cancer.

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Diathermy of split-thickness skin graft donor site: a new technique

Split-thickness skin graft donor sites have always been problematic postoperatively because of scarring, bleeding that can continue for several days or even weeks, pain, and a reduction in mobility.1–3 Many attempts have been made to mitigate these complications, but most have concentrated on pain control with various dressings.4 We describe a method that reduces the size of the donor site, as well as bleeding and pain.

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Biomechanical comparison of a multidirectional locking plate and conventional plates for the osteosynthesis of mandibular angle fractures—a preliminary study

The objective of surgical fracture management is to reduce and fixate fractures accurately and rapidly. Two osteosynthesis plates are usually used in the treatment of mandibular angle fractures in order to enhance torsional stiffness. We conducted biomechanical tests under static and cyclic loading in order to assess whether a single locking plate is as efficacious as two conventional plates in the osteosynthesis of mandibular angle fractures.

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Reconstruction of the bony chin using sagittal split osteotomies of the remaining mandible─a new technique for a special indication: Case report

There are several indications for resecting the bony chin, such as squamous cell carcinoma, sarcoma, or benign tumors of the jaw such as ameloblastoma. Several techniques for reconstruction of the bony chin, such as the use of metal plates and also revascularized free bone grafts of the iliac crest, fibula, or scapula, are common. In the case of poor vascular supply, however, alternative techniques may be necessary. In this report, a new technique is described using pedicled bone flaps from both sagittally split mandibular stumps following chin resection.

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Adjuvants for Animal Vaccines

Viral Immunology , Vol. 0, No. 0.

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Update on the supraclavicular flap.

Purpose of review: The purpose of this study is to describe the supraclavicular flap and its utility in head and neck reconstruction in the context of recent studies. Recent findings: Current literature regarding the supraclavicular flap has described its expanded uses in a variety of head and neck reconstructive settings. Its reliability and limited morbidity have been well demonstrated, and it has been cited as a reasonable alternative to other reconstructive options including, in some situations, free tissue transfer. Summary: The supraclavicular flap has shown dependability in reconstruction of defects in the head and neck, and it warrants consideration among reconstructive surgeons, especially for circumstances in which free tissue or other pedicled flaps are less than ideal. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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In Response.

No abstract available

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Wind of Change or Siren Song?.

No abstract available

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In Response.

No abstract available

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In Response.

No abstract available

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Intraperitoneal Instillation of Local Anesthetics: Is This a Suitable Alternative for Postcesarean Pain Relief Without Toxicity Profiling?.

No abstract available

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Evaluation of the Temple Touch Pro, a Novel Noninvasive Core-Temperature Monitoring System.

BACKGROUND: The Temple Touch Pro (TTP) is a novel system that estimates core temperature from skin over the temporal artery. We tested the hypothesis that this noninvasive system estimates core temperature to an accuracy within 0.5[masculine ordinal indicator]C. METHODS: Core temperature was continuously monitored in 50 adult and pediatric surgical patients by positioning the sensor patch of a TTP over one temporal artery. The sensor consists of a thermistor array near the skin surface, another set of thermistors above an insulator, and a second insulator between the upper unit and the environment. The sensor measures skin temperature and heat flux, from which the monitor unit estimates core temperature from a proprietary algorithm. Reference core temperature was measured from the esophagus or nasopharynx. We conducted agreement analysis between the TTP and the reference core temperature measurements using the 95% Bland-Altman limits of agreement for repeated measurement data. The proportion of all differences that were within 0.5[masculine ordinal indicator]C and repeat measures concordance correlation coefficient (CCC) were estimated as well. RESULTS: TTP and the reference core temperature measurements agreed well in both adults and pediatric patients. Bland-Altman plots showed no evidence of systematic bias or variability over the temperature from 35.2[masculine ordinal indicator]C to 37.8[masculine ordinal indicator]C. The estimated 95% lower and upper limits of agreement were -0.57[masculine ordinal indicator]C (95% confidence interval [CI], -0.76 to -0.41) and 0.57[masculine ordinal indicator]C (95% CI, 0.44 to 0.71), indicating good agreement between the 2 methods. Ninety-four percentage (95% CI, 87% to 99%) of the TTP temperatures were within 0.5[masculine ordinal indicator]C of the reference temperature. Good agreement was also supported by an estimated repeated measures CCC of 0.82 (95% CI, 0.66 to 0.91). The TTP core temperature measurements also agreed well with nasopharyngeal reference temperatures. CONCLUSIONS: The noninvasive TTP system is sufficiently accurate and reliable for routine intraoperative core temperature monitoring. (C) 2017 International Anesthesia Research Society

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Update on the supraclavicular flap.

Langerhans und Merkel: a nervous epidermal dispute

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Transmission of a novel sonotubometry acoustic click stimulus in healthy and patulous eustachian tube subjects: a retrospective case -control study

Eustachian tube (ET) dysfunction can be very difficult to diagnose accurately. Our aim is to determine whether a newly developed sonotubometric test using clicks can reliably detect ET opening during swallowin...

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Clinical performance validation of PITX2 DNA methylation as prognostic biomarker in patients with head and neck squamous cell carcinoma

by Verena Sailer, Heidrun Gevensleben, Joern Dietrich, Diane Goltz, Glen Kristiansen, Friedrich Bootz, Dimo Dietrich

Background

Despite advances in combined modality therapy, outcomes in head and neck squamous cell cancer (HNSCC) remain dismal with five-year overall survival rates of less than 50%. Prognostic biomarkers are urgently needed to identify patients with a high risk of death after initial curative treatment. Methylation status of the paired-like homeodomain transcription factor 2 (PITX2) has recently emerged as a powerful prognostic biomarker in various cancers. In the present study, the clinical performance of PITX2 methylation was validated in a HNSCC cohort by means of an independent analytical platform (Infinium HumanMethylation450 BeadChip, Illumina, Inc.).

Methods

A total of 528 HNSCC patients from The Cancer Genome Atlas (TCGA) were included in the study. Death was defined as primary endpoint. PITX2 methylation was correlated with overall survival and clinicopathological parameters.

Results

PITX2 methylation was significantly associated with sex, tumor site, p16 status, and grade. In univariate Cox proportional hazards analysis, PITX2 hypermethylation analyzed as continuous and dichotomized variable was significantly associated with prolonged overall survival of HNSCC patients (continuous: hazard ratio (HR) = 0.19 [95%CI: 0.04–0.88], p = 0.034; dichotomized: HR = 0.52 [95%CI: 0.33–0.84], p = 0.007). In multivariate Cox analysis including established clinicopathological parameters, PITX2 promoter methylation was confirmed as prognostic factor (HR = 0.28 [95%CI: 0.09–0.84], p = 0.023).

Conclusion

Using an independent analytical platform, PITX2 methylation was validated as a prognostic biomarker in HNSCC patients, identifying patients that potentially benefit from intensified surveillance and/or administration of adjuvant/neodjuvant treatment, i.e. immunotherapy.

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Low-Dose Childhood Radiation Effects to the Thyroid Follow a Linear Dose–Response Trend and Persist Even 45+ Years After Exposure

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 235-236.

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Persistent Hyperthyroidism Is Associated with Increased Mortality

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 214-217.

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Patients with Toxic Nodular Goiter and Graves’ Disease Are at Increased Risk for All-Cause and Cardiovascular Mortality

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 218-220.

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Delaying Surgery by More Than 1 Year for Selected Patients with Papillary Thyroid Microcarcinoma Does Not Compromise Outcomes

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 241-243.

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Thyroid Cancer Incidence and Mortality Are Increasing

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 221-223.

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Does Core Needle Biopsy Have A Role in the Evaluation of Thyroid Nodules with Indeterminate Cytology?

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 232-234.

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Levothyroxine Does Not Lower Hypothyroidism Symptoms in Older Adults with Mild Subclinical Hypothyroidism

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 224-228.

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Thyroid Hormone Receptor Alpha Resistance Causes Variability in the Severity but Not the Nature of Clinical Features

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 237-240.

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High-Intensity Focused Ultrasound Is Useful in the Treatment of Symptomatic Benign Thyroid Nodules

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 229-231.

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Thyroid Tumor Board: The Pathologic Criteria of Poorly Differentiated Thyroid Cancer Can Be Difficult to Distinguish From Differentiated Thyroid Carcinoma

Clinical Thyroidology Jun 2017, Vol. 29, No. 6: 244-246.

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Clinical performance validation of PITX2 DNA methylation as prognostic biomarker in patients with head and neck squamous cell carcinoma

by Verena Sailer, Heidrun Gevensleben, Joern Dietrich, Diane Goltz, Glen Kristiansen, Friedrich Bootz, Dimo Dietrich

Background

Methods

Results

Conclusion

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Steroid Delivery to the Frontal Sinus Opening With a Bioabsorbable Implant vs. a Bioabsorbable Nasal Dressing

Condition: Chronic Rhinosinusitis (Diagnosis)
Interventions: Device: Bioabsorbable steroid releasing sinus implant; Device: Bioabsorbable nasal dressing impregnated with steroid
Sponsor: University of Rochester
Not yet recruiting - verified June 2017

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Submucosa/Mucosal Pharyngeal Flap Trial

Condition: Velopharyngeal Insufficiency
Interventions: Procedure: Mucosa/submucosa Pharyngeal Flap; Procedure: Standard of Care Pharyngeal Flap
Sponsor: Lawson Health Research Institute
Not yet recruiting - verified June 2017

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Clinical Study of Concurrent Radiotherapy With Concurrent Chemotherapy for Locally Advanced Nasopharyngeal Carcinoma

Conditions: Gastrointestinal Toxicity; Blood / Bone Marrow Toxicity
Interventions: Drug: Lobaplatin; Device: linear accelerator
Sponsor: Fifth Affiliated Hospital, Sun Yat-Sen University
Recruiting - verified June 2017

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Autologous Muscle Derived Cells for Gastro-Intestinal Repair (AMDC-GIR) for Tongue Dysphagia

Condition: Oropharyngeal Dysphagia
Intervention: Drug: Autologous Muscle Derived Cells for Gastro-Intestinal Repair (AMDC-GIR)
Sponsors: Peter Belafsky, MD; Cook MyoSite
Recruiting - verified June 2017

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Thyroid High-Impact Articles

FREE ACCESS through June 29, 2017.
Read now:

Latest Impact Factor: 5.515
The Official Journal of: American Thyroid Association

Updated American Joint Committee on Cancer/Tumor-Node-Metastasis Staging System for Differentiated and Anaplastic Thyroid Cancer (Eighth Edition): What Changed and Why?
R. Michael Tuttle, Bryan Haugen, Nancy D. Perrier

Racial Disparities in Differentiated Thyroid Cancer: Have We Bridged the Gap?
Syed A. Shah, Mohamed A. Adam, Samantha M. Thomas, Randall P. Scheri, Michael T. Stang, Julie A. Sosa, Sanziana A. Roman

Serial Neck Ultrasonographic Evaluation of Changes in Papillary Thyroid Carcinoma During Pregnancy
Hye-Seon Oh, Won Gu Kim, Suyeon Park, Mijin Kim, Hyemi Kwon, Min Ji Jeon, Jeong Hyun Lee, Jung Hwan Baek, Dong Eun Song, Tae Yong Kim, Young Kee Shong, Won Bae Kim

Identification of Three Novel Fusion Oncogenes, SQSTM1/NTRK3, AFAP1L2/RET, and PPFIBP2/RET, in Thyroid Cancers of Young Patients in Fukushima
Keita Iyama, Michiko Matsuse, Norisato Mitsutake, Tatiana Rogounovitch, Vladimir Saenko, Keiji Suzuki, Mai Ashizawa, Chiyo Ookouchi, Satoshi Suzuki, Hiroshi Mizunuma, Toshihiko Fukushima, Shinichi Suzuki, Shunichi Yamashita

Postoperative Outcomes in Graves' Disease Patients: Results from the Nationwide Inpatient Sample Database
Gustavo A. Rubio, Tulay Koru-Sengul, Tanaz M. Vaghaiwalla, Punam P. Parikh, Josefina C. Farra, John I. Lew

Changes in Hepatic TRβ Protein Expression, Lipogenic Gene Expression, and Long-Chain Acylcarnitine Levels During Chronic Hyperthyroidism and Triiodothyronine Withdrawal in a Mouse Model
Kenji Ohba, Rohit Anthony Sinha, Brijesh Kumar Singh, Liliana Felicia Iannucci, Jin Zhou, Jean-Paul Kovalik, Xiao-Hui Liao, Samuel Refetoff, Judy Chia Ghee Sng, Melvin Khee-Shing Leow, Paul Michael Yen

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Clinical Thyroidology for the Public – Highlighted Article

From Clinical Thyroidology for the Public: Exposure to radiation occurs with many imaging studies (like CT scans) and medical treatments (like radiation therapy for cancer). When radiation exposure involves the head and neck areas directly, the thyroid is exposed and there is an increased risk for the development of thyroid cancer in the future. Read More….

We welcome your feedback and suggestions. Let us know what you want to see in this publication.

Feedback & Suggestions

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Roadmap for the clinical application of the basophil activation test in food allergy

Abstract

The diagnosis of IgE-mediated food allergy based solely on the clinical history and the documentation of specific IgE to whole allergen extract or single allergens is often ambiguous, requiring oral food challenges (OFC), with the attendant risk and inconvenience to the patient, to confirm the diagnosis of food allergy. This is a considerable proportion of patients assessed in Allergy clinics. The basophil activation test (BAT) has emerged as having superior specificity and comparable sensitivity to diagnose food allergy, when compared with skin prick test and specific IgE. BAT, therefore, may reduce the number of OFC required for accurate diagnosis, particularly positive OFC. BAT can also be used to monitor resolution of food allergy and the clinical response to immunomodulatory treatments. Given the practicalities involved in the performance of BAT, we propose that it be applied for selected cases where the history, skin prick test and/or specific IgE are not definitive for the diagnosis of food allergy. In the cases that the BAT is positive, food allergy is sufficiently confirmed without OFC; in the cases that BAT is negative or the patient has non-responder basophils, OFC may still be indicated. However, broad clinical application of BAT demands further standardisation of the laboratory procedure and of the flow cytometry data analyses, as well as clinical validation of BAT as a diagnostic test for multiple target allergens and confirmation of its feasibility and cost-effectiveness in multiple settings.

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A novel frameshift mutation in the XPC gene in a Moroccan patient: a case report

Xeroderma pigmentosum is an autosomal recessive inherited disease. The diagnosis is essentially based on clinical findings and the family history. This genodermatosis is genetically heterogeneous; to date, nin...

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Patch testing in psoriasis patients: results of a 30-year retrospective study

Abstract

Psoriasis and allergic contact dermatitis (ACD) are common, chronic T-lymphocyte mediated conditions. Although psoriasis patients are commonly referred for patch testing, there are conflicting views on the relationship between contact allergy and psoriasis. Previous studies have suggested ACD is less common in psoriasis¹ and that psoriatics are more difficult to sensitize^1,2,3.

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Outcomes of radiation therapy for advanced T3/T4 non-melanoma cutaneous squamous cell and basal cell carcinoma

Abstract

Non-melanoma cutaneous squamous and basal cell carcinoma (NMSC) is common, and most patients present with early stage (T1/T2) NMSC, which has an excellent prognosis. However, a minority of NMSC patients present with an advanced stage (T3/T4) primary tumor, which may be surgically unresectable but potentially curable with radiation therapy (RT). Because advanced NMSC is rare, studies^1-5 examining the outcomes of RT for patients with T3/T4 tumors are limited. As the outcomes of RT in this patient cohort are unclear, this study was undertaken to examine survival in a large cohort of patients treated at our institution and to explore variables associated with survival outcomes.

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Atopic dermatitis and risk of hypertension, type-2 diabetes, myocardial infarction and stroke in a cross-sectional analysis from the Canadian Partnership for Tomorrow Project

Abstract

Background

Atopic dermatitis (AD) has been associated with cardiovascular risk factors and diseases, but epidemiologic studies to date have found conflicting results.

Objectives

We aimed to determine the associations of AD with hypertension, type-2 diabetes (T2D), myocardial infarction (MI) and stroke.

Methods

We conducted a cross-sectional analysis of baseline data from the Canadian Partnership for Tomorrow Project which includes Canadian residents aged 30-74 living in British Columbia, Alberta, Ontario, Quebec and the Atlantic Provinces. We excluded participants with incomplete data on AD, hypertension, T2D, MI or stroke, who had type-1 or gestational diabetes or who developed any of the outcomes at an age prior to a diagnosis of AD, leaving 259,119 participants in our analysis. We used logistic regression to calculate age and sex- and multivariable-adjusted odds ratios (OR) and 95% confidence intervals (CI) between AD and subsequent hypertension, T2D, MI and stroke.

Results

AD was reported by 21,379 (8.4%) participants. A total of 52,787 cases of hypertension, 12,739 cases of T2D, 4,390 cases of MI and 2,235 cases of stroke were reported by participants at enrollment. In the multivariable-adjusted model, AD was associated with decreased odds (OR, 95% CI) of hypertension (0.87, 0.83-0.90), T2D (0.78, 0.71-0.84), MI (0.87, 0.75-1.00) and stroke (0.79, 0.66-0.95).

Conclusions

We did not find evidence of a positive association between AD and subsequent hypertension, T2D, MI or stroke; AD was inversely associated with these outcomes in our study. Given our findings and the conflicting literature, AD is likely not a major risk factor for cardiovascular disease.

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Ig-seq: Deep sequencing of the variable region of Atlantic salmon IgM heavy chain transcripts

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Aleksei Krasnov, Sven Martin Jørgensen, Sergey Afanasyev
Immunoglobulin M plays a key role in systemic protection of Atlantic salmon against pathogens. Until recent, studies have focused on antigen-specific antibodies and little is known about the IgM repertoire: its size, developmental changes and responses to antigens. We report the development of deep sequencing protocol to characterize the repertoire of IgM heavy chain variable region. Its structure and changes were examined at the early stages of life and after infection with virus of cardiac myopathy. Clonotypes are identified by the V and J gene segments and amino acid sequences of CDR3, which determine the contribution of the heavy chain to the antigen binding properties. A major fraction of transcripts are functional while the rest are either sterile (transcribed from noncoding parts of Ig loci) or include stop codons. Despite marked difference in frequencies of combinations of V and J genes, the size of repertoire is large. The IgM diversity steadily increases after hatch followed with temporal reduction during smoltification and recovery after seawater transfer. Most clonotypes are present only in one fish. However multiple transcripts in uninfected fish are produced exclusively from a small fraction of shared clonotypes. While only 4.7% of clonotypes are detected in three and more fish, they comprise 35% of transcripts. Increased frequencies of most abundant clonotypes were detected in the head kidney and blood at ten weeks after viral infection and all were shared. Occurrence of the same clonotypes in multiple individuals can be explained with either their simple structure or exposure to common antigens. Complexity of CDR3 assessed by contents of non complementary nucleotides is slightly lower in shared clonotypes but difference is small. High nucleotide diversity of CDR3 with identical amino acid sequences suggests selection.

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A novel immune-related gene HDD1 of silkworm Bombyx mori is involved in bacterial response

Publication date: August 2017
Source:Molecular Immunology, Volume 88
Author(s): Kui Zhang, Guangzhao Pan, Yuzu Zhao, Xiangwei Hao, Chongyang Li, Li Shen, Rui Zhang, Jingjing Su, Hongjuan Cui
Insects have evolved an effective immune system to respond to various challenges. In this study, a novel immune-related gene, called BmHDD1, was first charactered in silkworm, Bombyx mori. BmHDD1 contained an ORF of 837bp and encoding a deduced protein of 278 amino acids. BmHDD1 was specifically expressed in hemocytes, and highly expressed at the molting and metamorphosis stages under normal physiological conditions. Our results suggested that BmHDD1 was mainly generated by hemocytes and secreted into hemolymph. Our results also showed that the expression level of BmHDD1 was significantly increased after 20E injection, which indicated that BmHDD1 might be regulated by ecdysone. More importantly, BmHDD1 was dramatically induced after injected with different types of PAMPs or bacteria, either in hemocytes or fat body. Those results suggested that BmHDD1 plays a role in developing and immunity system in silkworm, Bombyx mori.

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Carotid body tumors: Surgical experience in 215 cases

Publication date: Available online 13 June 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Luis A. Pacheco-Ojeda

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Cerebrospinal fluid volume does not have etiological role in the incidence of positional skull deformities

Publication date: Available online 13 June 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Guillaume Captier, Adrien Galeron, Gérard Subsol, Melissa Solinhac, Thomas Roujeau, Nicolas Leboucq, Christian Herlin
BackgroundPositional skull deformities (PSD) are becoming a daily health concern for craniofacial surgeons. Several reports have indicated that cerebrospinal fluid (CSF) space increases on computed tomography (CT) scans of infants suffering from PSD, suggesting a potential causal link. Here, we describe a semi-automatic method to estimate total brain and CSF volumes quantitatively. We tested the potential correlation between total CSF volume and the occurrence of PSD.MethodsA single-center retrospective study was carried out using 79 CT scans of PSD and 60 CT scans of control subjects. The endocranium was segmented automatically using a three-dimensional deformable surface model, and the brain was segmented using a semi-automatic threshold-based method. Total CSF volume was estimated based on the difference between endocranial and brain volumes.ResultsAutomatic segmentation of the endocranium was possible in 75 CT scans. Semi-automatic brain and CSF volume evaluations were performed in 40 CT scans of infants with PSD (18 = occipital plagiocephaly, 11 = fronto-occipital plagiocephaly, and 11 = posterior brachycephaly) and in six control CT scans. Endocranial and total CSF volumes were not significantly different between patients with PSD and controls. The occipital plagiocephaly group had an enlarged brain volume compared with that in patients in the other groups.ConclusionsTotal CSF volume did not change in infants with PSD, and the results do not support a role for volume changes in CSF in the etiology of PSD. Macrocephaly in patients with occipital plagiocephaly may be a specific etiological factor compared with that in other PSDs.

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Three-dimensional analysis of condylar remodelling and skeletal relapse following bimaxillary surgery: A 2-year follow-up study

Publication date: Available online 13 June 2017
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Tong Xi, Rik van Luijn, Frank Baan, Ruud Schreurs, Martien de Koning, Stefaan Bergé, Thomas Maal

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Reduction in the Age-Adjusted Prevalence of Hearing Impairment in the United States

In Reply We thank Dr Fuller-Thomson for her suggestion. Prior publications have found associations between hearing impairment (HI) and blood lead levels (BLL) and cadmium. If associations exist, it is unknown what proportion of HI in the population may be attributable to lead and/or cadmium or other heavy metals. Heavy metal exposures co-occur with other factors that increase HI risk, including noisy occupations (eg, manufacturing, construction, transportation), smoking, and lower socioeconomic status, hence BLL could be a proxy for other characteristics.

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The Reduction in the Age-Adjusted Prevalence of Hearing Impairment in the United States An Unexpected Dividend of Phasing Out Leaded Gasoline?

In their article, "Declining Prevalence of Hearing Loss in US Adults Aged 20 to 69 Years," Hoffman and colleagues concluded that there was a 25% reduction in high-frequency hearing impairment and a 30% reduction in speech frequency hearing impairment in respondents' worse ear between the 1999 to 2004 cycle of the National Health and Nutrition Examination Survey (NHANES) and the 2011 to 2012 NHANES cycle. I hypothesize that this beneficial trend may be partially owing to the phasing out of leaded gasoline which resulted in an 87% decline in the geometric mean blood lead levels (BLL) in American adults from 13.1 μg/dL in the late 1970s to 1.64 μg/dL by the year 2000.

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A Supraclavicular Mass

A man presented with a 6-year history of a painless lump in the supraclavicular region; palpation detected a smooth, soft, and fluctuant mass, and computed tomography revealed a poorly circumscribed, heterogeneous, and cystic mass near the sternocleidomastoid muscle. What is your diagnosis?

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Foreign Body in a Premature Infant

This case examines the unique challenges of treating airway obstruction in neonates and describes an innovative technique of foreign body removal.

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Somatization and the Review of Systems

This cohort study examines the association between patient responses on a form used for review of systems and somatization.

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Comprehensive Hearing Aid Intervention at a Free Subspecialty Clinic

This observational cohort study describes the structure, feasibility, and outcomes of a free subspecialty clinic providing hearing aids to develop a paradigm for other programs interested in implementing similar projects.

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Adjuvant Human Papillomavirus Vaccination for Secondary Prevention

This systematic review evaluates literature regarding human papillomavirus vaccination for secondary disease prevention after treatment of virus-related clinical disease.

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Support for the Diagnosis of CHARGE Syndrome—Reply

In Reply We appreciate the comments by Martin et al regarding our work and wish to respond to the excellent points that they raised.

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The 10 Commandments of Management for Acute Upper Airway Obstruction

This Viewpoint recommends 10 commandments or rules to follow when managing an acute upper airway obstruction in an infant or child.

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Slowly Enlarging Neck Mass

A man had an enlarging, nontender, neck mass at the angle of the mandible; computed tomography showed a heterogeneous mass adjacent to the tail of the left parotid, and pathologic findings revealed an encapsulated soft nodule within the specimen. What is your diagnosis?

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Learning Curves for Transoral Robotic Surgery for Oropharynx Carcinoma

This study assesses learning curves for 3 oncologic transoral robotic surgery specialists and assesses the number of cases needed to identify the learning phase.

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With Experience Comes Wisdom

What a pleasure it is to be able to comment on the Viewpoint by Grundfast et al, "The 10 Commandments of Management for Acute Upper Airway Obstruction in Infants and Children." Having just finished Michael Lewis's book The Undoing Project, which tells the story of Daniel Kahneman, Amos Tversky, and the birth of a new form of behavioral psychology and decision analysis, I am, of course, concerned about the inherent biases in trusting at face value the words of a senior statesman just because he looks and acts the part. Do we hold with heuristic beliefs that with an author's age and experience comes wisdom? I am now "trained" not to ask "who the author is" but "what has he or she actually done" before I trust the narrator that speaks to me.

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Otolaryngology Resident Duty Hour Restrictions and Outcomes

This study analyses the association of otolaryngology duty hour restrictions with surgery-specific outcomes, including complications following thyroid and parathyroid procedures performed before and after duty hour reform.

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Slow-Growing Infiltrative Sinonasal Mass

A man in his 50s was seen for a 6-month history of swelling involving the nasal bridge and right eye and intermittent ipsilateral epistaxis; endoscopy demonstrated a right-sided exophytic mass visible between the middle turbinate and nasal septum. What is your diagnosis?

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Definition of Close Surgical Margins in SCC of the Oral Tongue

This study evaluates specimens of squamous cell carcinoma of the oral tongue and compares close resection margins of less than 5.0 mm vs less than or equal to 2.2 mm for determination of risk for local recurrence as a positive margin.

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Conservative Treatment of Isolated Cricoid Cartilage Fractures From Blunt Trauma

This case series examines the conservative treatment of laryngotracheal traumas.

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Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea

This meta-analysis evaluates the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric obstructive sleep apnea.

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June 2017 Issue Highlights

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Traumatic Facial Injuries Among Elderly Nursing Home Residents

This population-based study estimates the incidence of facial trauma among elderly nursing home residents and details mechanisms of injury, injury characteristics, and patient demographic data.

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Inaugural Symposium on Advanced Surgical Techniques in Adult Airway Reconstruction

This report communicates the findings of the North American Airway Collaborative Symposium on Advanced Surgical Techniques in Adult Airway Reconstruction.

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Association of Body Mass Index in Head and Neck Reconstructive Surgery

This cohort study examines whether elevated body mass index is an independent risk factor for perioperative and postoperative infections after free tissue transfer in patients undergoing head and neck reconstructive surgery.

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A Young Man With Proptosis Causing Decreased Visual Acuity

A teenage boy had deteriorating vision and swelling in his right eye, right ear pain, and forehead tenderness; endoscopy revealed a fleshy, red soft-tissue mass in the superior nasal cavity. What is your diagnosis?

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Transoral Robotic Surgery and Long-term Outcomes and Costs

This cross-sectional analysis investigates the association of transoral robotic surgery with short- and long-term outcomes and costs in surgically treated patients with oropharyngeal cancer.

http://ift.tt/2nDZECa

Trismus and Swelling on the Side of the Face

A woman presented with mild to moderate trismus and swelling on the left side of the face of a few months' duration; physical examination was remarkable for left-sided facial swelling, and no deficits of the facial or trigeminal nerves were detected. What is your diagnosis?

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Long-term Surveillance Following Intralesional Steroid Injection for Benign Vocal Fold Lesions

This cohort study reports the findings of a long-term surveillance following intralesional steroid injection for benign vocal fold lesions.

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Head and Neck Squamous Cell Carcinoma Therapy With a WEE1 Inhibitor

This study maps the cellular response to the WEE1 inhibitor and explores the contributions of p53 to its effect.

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Transmission of a novel sonotubometry acoustic click stimulus in healthy and patulous eustachian tube subjects: a retrospective case -control study

Abstract

Background

Methods

Sixteen subjects (19 normal ET ears and 6 PET ears) were individually placed in a sound-isolated audiometry booth and subjected to a 1000Hz click train stimulus, played through the nose. PET subjects were identified through the ET clinic at our institution, while healthy subjects were recruited. Transmission through the ET was recorded by a microphone in the ear ipsilateral to the presenting nostril, during no swallow and swallow states, and this was used to compute a power ratio (power in the frequency range of interest to the whole frequency range). The power transmission ratio both before and after the swallow was averaged, and represented the baseline (BaseR). The power transmission ratio during swallow represented the peak (PeakR). The same process was repeated in the absence of a stimulus to account for swallowing noise. Wilcoxon rank rum tests were performed to determine statistical significance.

Results

It was found that for healthy ET patients, the median difference between the PeakR and BaseR was 0.51 (p = 0.004). For the PET patients in this study, the median difference between the PeakR and the BaseR was 3.30 (p = 0.041). Comparing the baseline between groups revealed that PET patients had a median BaseR 1.05 higher than healthy ET patients. PET patients had a median PeakR of 3.84 higher than healthy ET patients. Both were deemed to be statistically significant (p = 0.003, p = 0.003 respectively). A significant difference was found between median PeakR for the stimulus and no-stimulus condition for the healthy ET group (0.59, p < 0.001) and for the PET group (4.39, p = 0.031), indicating that it was unlikely that swallowing noise caused false positive results.

Conclusion

The results of this study suggest that a novel click stimulus is capable of detecting ET opening during swallowing in healthy patients as well as highlighting PET in diseased subjects.

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Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery

Abstract

Background: Preoperative blood pressure (BP) thresholds associated with increased postoperative mortality remain unclear. We investigated the relationship between preoperative BP and 30-day mortality after elective non-cardiac surgery.Methods: We performed a cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13). Parsimonious and fully adjusted multivariable logistic regression models, including restricted cubic splines for numerical systolic and diastolic BP, for 30-day mortality were constructed. The full model included 29 perioperative risk factors, including age, sex, comorbidities, medications, and surgical risk scale. Sensitivity analyses were conducted for age (>65 vs <65 years old) and the timing of BP measurement.Results: A total of 251 567 adults were included, with 589 (0.23%) deaths within 30 days of surgery. After adjustment for all risk factors, preoperative low BP was consistently associated with statistically significant increases in the odds ratio (OR) of postoperative mortality. Statistically significant risk thresholds started at a preoperative systolic pressure of 119 mm Hg (adjusted OR 1.02 [95% confidence interval (CI) 1.01–1.02]) compared with the reference (120 mm Hg) and diastolic pressure of 63 mm Hg [OR 1.24 (95% CI 1.03–1.49)] compared with the reference (80 mm Hg). As BP decreased, the OR of mortality risk increased. Subgroup analysis demonstrated that the risk associated with low BP was confined to the elderly. Adjusted analyses identified that diastolic hypertension was associated with increased postoperative mortality in the whole cohort.Conclusions: In this large observational study we identified a significant dose-dependent association between low preoperative BP values and increased postoperative mortality in the elderly. In the whole population, elevated diastolic, not systolic, BP was associated with increased mortality.

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Cardiomyopathy and anaesthesia

1A012A033J02

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Mechanisms underlying induction of allergic sensitization by Pru p 3

Abstract

Background

Recently, the nature of the lipid-ligand of Pru p 3, one of the most common plant food allergens in Southern Europe, has been identified as a derivative of the alkaloid camptothecin bound to phytosphingosine. However, the origin of its immunological activity is still unknown.

Objective

We sought to evaluate the role of the Pru p 3 lipid- ligand in the immunogenic activity of Pru p 3.

Methods

In vitro cultures of different cell types (monocyte-derived dendritic cells (moDCs), PBMCs and epithelial and iNKT-hybridoma cell lines) have been used to determine the immunological capacity of the ligand, by measuring cell proliferation, maturation markers and cytokine production. To study the capacity of the lipid-ligand to promote sensitization to Pru p 3 in vivo, a mouse model of anaphylaxis to peach has been produced and changes in the humoral and basophil responses have been analyzed.

Results

The lipid-ligand of Pru p 3 induced maturation of moDCsc and proliferation of PBMCs. Its immunological activity resided in the phytosphingosine tail of the ligand. The adjuvant activity of the ligand was also confirmed in vivo, where the complex of Pru p 3-ligand induced higher levels of IgE than Pru p 3 alone. The immunological capacity of the Pru p 3 ligand was mediated by CD1d, as maturation of moDCs was inhibited by anti-CD1d antibodies and Pru p 3-ligand co-localized with CD1d on epithelial cells. Finally, Pru p 3-ligand presented by CD1d was able to interact with iNKTs.

Conclusions & Clinical Relevance

The Pru p 3 lipid-ligand could act as an adjuvant to promote sensitization to Pru p 3, through its recognition by CD1d receptors. This intrinsic adjuvant activity of the accompanying lipid cargo could be a general essential feature of the mechanism underlying the phenomenon of allergenicity.

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Editorial Board

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Training Groups

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Histamine Receptor 2 Modifies iNKT Cell Activity within the Inflamed Lung

Abstract

Background

Histamine is a key immunoregulatory mediator and can dampen proinflammatory responses via activation of histamine receptor 2 (H₂R). The aim of this study was to determine the role of H₂R in modulating lung inflammatory responses.

Methods

H₂R was blocked using famotidine or activated using dimaprit in both the ovalbumin (OVA) and house dust mite extract (HDM) murine models of respiratory inflammation. H₂R-deficient animals and CD1d/ H₂R-deficient animals were utilized to examine the CD1d presentation of lipid antigens (αGal-Cer or OCH) to invariant Natural Killer T (iNKT) cells.

Results

Famotidine treatment resulted in more severe airway disease in the OVA model, while dimaprit treatment significantly reduced disease severity. Both OVA and HDM-induced airway disease were more severe in H₂R-deficient animals. Flow cytometric analysis of lung tissue from H₂R-deficient animals revealed increased numbers of CD1d⁺ dendritic cells and increased numbers of iNKT cells. In vitro, αGal-Cer-stimulated iNKT cells from H₂R-deficient mice secreted higher levels of IL-4, IL-5 and GM-CSF. In vivo, αGal-Cer or OCH administration to the lung resulted in enhanced mucus secretion, inflammatory cell recruitment and cytokine production in H₂R-deficient or famotidine-treated animals, while dimaprit dampened the lung iNKT cell response to αGalCer. Removal of iNKT cells in H₂R-deficient (CD1d^-/-H₂R^-/-) animals normalized the lung response to HDM.

Conclusion

The deliberate activation of H₂R, or its downstream signaling molecules, may represent a novel therapeutic target for chronic lung inflammatory diseases, especially when CD1d-mediated presentation of lipid antigens to iNKT cells are contributing to the pathology.

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Is the atopic march related to confounding by genetics and early life environment? A systematic review of sibship and twin data

Abstract

A popular hypothesis known as the atopic march proposes a set of sequential allergy and respiratory disorders in early childhood contributes enormously to the burden of disease in developed countries. Although the concept of the atopic march has been refined and strengthened by many cross-sectional and longitudinal studies linking eczema as the initial manifestation with progression to hay fever and then asthma, there is yet no definitive proof that the atopic march is the primary causal factor in childhood allergic disease. This debate is mainly related to the controversy around potential confounding of these associations by genetic and environmental factors. Family studies are ideally suited to unravelling the role of these factors. While multiple reviews have synthesised evidence from studies investigating this question, no review to date has explored specific evidence generated by twin and sibling studies to understand the aetiology of atopic march diseases. Our aim was to conduct a systematic review of twin and sibling studies that examine the allergic phenotypes that form the atopic march, to determine whether such analyses of data from these studies attempt to control for the effect confounding by shared factors, and to report estimates the magnitude of associations between multiple phenotypes. Our review suggests that (1) genetics play a bigger role predisposing eczema to hay fever and eczema to asthma than environmental factors; and (2) the link between eczema, and asthma and hay fever is independent of shared early life environmental factors and genetics.

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Editorial Board/Aims & Scope

Publication date: July 2017
Source:Oral Oncology, Volume 70

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Postgastric bypass hypoglycaemia in a patient with end-stage renal disease: a diagnostic and management pitfall

Roux-en-Y gastric bypass (RYGB) surgery is currently one of the most popular procedures to aid weight loss. Hypoglycaemia associated with gastric bypass surgery is an underdiagnosed but life-threatening potential consequence of the surgical procedure. We present a case of a 44-year-old woman with end-stage renal disease presenting with refractory hypoglycaemia after 10 years of RYGB. Extensive history and work-up excluded medications, renal disease, insulinoma and dumping syndrome as the cause of hypoglycaemia. Dietary modifications or pharmacological trial of drugs did not ameliorate her symptoms with progressive worsening of hypoglycaemia leading to continuous dextrose infusion. Distal pancreatectomy was performed with subsequent resolution of hypoglycaemia. Surgical pathology results showed diffuse hyperplastic islet cells, confirming the diagnosis of postgastric bypass hypoglycaemia.

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Saddle-nose and bilateral cauliflower ear deformities with pyoderma gangrenosum-like ulcers, cavitary pulmonary lesions, digital gangrene and pulselessness in a young female

We report a young female who presented with saddle-nose and bilateral cauliflower ear deformities along with pyoderma gangrenosum-like ulcers, digital gangrene and pulselessness. Subsequently, she was found to have bilateral conductive hearing loss, a corneal opacity, mild aortic regurgitation and radiological evidence of cavitary changes in lungs and aortoarteritis. Our patient had a constellation of symptoms which posed a diagnostic challenge. Finally, a diagnosis of relapsing polychondritis with several unusual features was made. Overlap with Takayasu's arteritis and granulomatosis with polyangitis, which has been reported rarely in the literature, cannot be excluded.

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Renal cell carcinoma with isolated breast metastasis

Renal cell carcinoma (RCC) is a highly prevalent disease worldwide with many cases being metastasised to various organs during the time of initial presentation. Metastatic RCC to the breast is a rare entity and can mimic primary breast carcinoma. In this article, we present a 63-year-old Caucasian woman presented with a breast mass that was detected by screening mammography and found to have a biopsy proven grade-II clear RCC in the breast tissue. Despite the high incidence and prevalence of primary breast cancer, metastasis from extramammary should be suspected in patients with a prior history of other cancers. In this brief literature review, we also highlight the survival benefit from surgery and close follow-up in selected group of patients with metastatic, metachronous and solitary RCC.

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Gamma-delta T-cell lymphoma of skin, eye and brain presenting with visual loss

A young man presented with rapid, predominantly right-sided visual loss with a background of multifocal skin lesions. Visual acuity was right hand movements, left 6/5 Snellen, deteriorating to 6/38. He showed panuveitis with bilateral multifocal retinal infiltrates and retinal vasculitis. Multifocal brain lesions were identified. Biopsy of both skin and vitreous showed atypical lymphocytes, and immunohistochemistry confirmed T-cell lymphoma of gamma–delta subtype. Management with the CODOX-M/IVAC polychemotherapy regimen achieved rapid response including resolution of intraocular changes and substantial improvement of visual acuity to right 6/7.5, left 6/6. However, he relapsed before planned stem cell transplantation. Salvage with the gemcitabine/dexamethasone/cisplatin regimen, although temporarily effective, was followed by further relapse including widespread brain involvement, and he succumbed 10 months after presentation.

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Acute massive gastric dilatation causing ischaemic necrosis and perforation of the stomach

Acute massive gastric dilatation (AMGD) is a rare distinctive condition but associates with high morbidity and mortality. Though usually seen in patients with eating disorders, many aetiologies of AMGD have been described. The distension has been reported to cause gastric necrosis with or without perforation, usually within 1–2 days of an inciting event of AMGD.

We report the case of a 58-year-old male who presented with gastric perforation associated with AMGD 11 days after surgical relief of a proximal small bowel obstruction. The AMGD arose from a closed loop obstruction between a tumour at the gastro-oesophageal junction and a small bowel obstruction as a result of volvulus around a jejunal feeding tube.

To our knowledge, this is the first case of a closed loop obstruction of this aetiology reported in the literature, and the presentation of this patient's AMGD was notable for the delayed onset of gastric necrosis. The patient underwent an exploratory laparotomy and a partial gastrectomy to excise a portion of his perforated stomach. Surgeons should be aware of the possibility of delayed ischaemic gastric perforation in cases of AMGD.

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Fingolimod-associated macular oedema

Description

A 54-year-old female with history of relapsing remitting multiple sclerosis (MS) was switched from interferon beta-1A (Avonex, Biogen) to fingolimod (Gilenya, Novartis) therapy after having two clinical relapses within 2 years while on treatment. As part of her treatment protocol, she was referred to the local ophthalmology unit for a baseline screen and periodic review thereafter. Three months into her treatment, she complained of blurring of vision in her right eyeA visual acuity assessment showed a reduction in best-corrected visual acuity (BCVA) from 6/6 to 6/12. An optical coherence tomography (OCT) scan showed evidence of oedema and cystic changes within her right macula (figure 1). She was diagnosed with fingolimod-associated macular oedema (FAME) and was started on topical steroids (prednisolone acetate 1% four times a day) and non-steroidal treatment to her right eye. The patient showed an initial response to treatment in the first month and was closely...

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Bacterial colonization of resin composite cements: influence of material composition and surface roughness

So-called secondary caries may develop in the cement gap between the tooth and the bonded restoration. Cement materials with a low susceptibility to biofilm formation are therefore desirable. In the present study, the adhesion of Strepococcus mutans onto three adhesive (Multilink Automix, RelyX Ultimate, and Panavia V5) and three self-adhesive (Multilink Speed Cem, RelyX Unicem 2 Automix, and Panavia SA plus) resin composite cements was evaluated. Previous studies have failed to evaluate concomitantly the effect of both the composition of the cements and their surface roughness on biofilm formation. The presence of S. mutans on cement surfaces with differing degrees of roughness was therefore recorded using fluorescence microscopy and crystal violet staining, and the composition of the cements was analyzed using energy-dispersive X-ray spectroscopy mapping. Biofilm formation on resin composite cements was found to be higher on rougher surfaces, implying that adequate polishing of the cement gap is essential. The use of copper-containing cements (Multilink Automix, Panavia V5, and Panavia SA plus) significantly reduced biofilm formation.

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Case 18-2017 — An 11-Year-Old Girl with Difficulty Eating after a Choking Incident

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Presentation of Case. Dr. Lazaro V. Zayas (Psychiatry): An 11-year-old girl was seen in an outpatient clinic of this hospital because of difficulty eating solid food and associated weight loss after an acute choking incident. The patient had been in her usual health until 14 days before this…

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Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infections in Solid Organ Transplantation.

Antibiotic prophylaxis in the perioperative period is the standard of care for nearly all surgical procedures and routinely prescribed during solid organ transplantation (SOT). The primary goal of perioperative antibiotic prophylaxis is to minimize postoperative surgical site infections (SSIs). SSIs are a significant issue in SOT. Depending on the organ transplanted, SSIs occur in 3 to 53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. SOT recipients are also at increased risk of developing SSIs with antimicrobial-resistant organisms. In this manuscript, we describe the epidemiology and risk factors for SSIs in SOT, and examine the available literature to guide the use of different regimens for perioperative antibiotic prophylaxis for each organ. We have further addressed specific situations that are unique to each organ transplant type, such as the use of extracorporeal membrane oxygenation in thoracic organ transplantation, as well as an approach to perioperative antibiotic prophylaxis in the setting of recipient and/or donor infection prior to transplantation. We provide potential approaches to the selection, dosing, and duration of perioperative antibiotic prophylaxis for each of these clinical situations. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Anti-CD20 blocker Rituximab in Kidney Transplantation.

Rituximab is a chimeric anti-CD20 monoclonal protein used in various clinical scenarios in kidney transplant recipients. However, its evidence-based use there remains limited due to lack of controlled studies, limited sample size, short follow-up and poorly defined endpoints. Rituximab is indicated for CD20+ PTLD. It may be beneficial for treating recurrent MN and recurrent allograft ANCA vasculitis and possibly for recurrent FSGS. Rituximab, in combination with IVIG/PP, appears to decrease antibody level and increase the odds of transplantation in sensitized recipients. The role of Rituximab in ABOi transplant remains unclear, as similar outcomes are achieved without its use. Rituximab is not efficacious in ABMR/CAMR. Strict RCTs are necessary to elucidate its true role in these settings. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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An Institution-Wide Rule-Based Protocol for Early Detection of Esophageal Intubation.

No abstract available

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Inguinal Hernia Surgery: Updates in Surgery series.

No abstract available

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In Response.

No abstract available

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Real-Time Ultrasound-Guided Right Supraclavicular Approach to the Central Vein: An Alternative Option.

No abstract available

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In Response.

No abstract available

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Development and Validation of a Risk Scale for Emergence Agitation After General Anesthesia in Children: A Prospective Observational Study.

BACKGROUND: Emergence agitation (EA) is a common complication in children after general anesthesia. The goal of this 2-phase study was (1) to develop a predictive model (EA risk scale) for the incidence of EA in children receiving sevoflurane anesthesia by performing a retrospective analysis of data from our previous study (phase 1) and (2) to determine the validity of the EA risk scale in a prospective observational cohort study (phase 2). METHODS: Using data collected from 120 patients in our previous study, logistic regression analysis was used to predict the incidence of EA in phase 1. The optimal combination of the predictors was determined by a stepwise selection procedure using Akaike information criterion. The [beta]-coefficient for the selected predictors was calculated, and scores for predictors determined. The predictive ability of the EA risk scale was assessed by a receiver operating characteristic (ROC) curve, and the area under the ROC curve (c-index) was calculated with a 95% confidence interval (CI). In phase 2, the validity of the EA risk scale was confirmed using another data set of 100 patients (who underwent minor surgery under general anesthesia). The ROC curve, the c-index, the best cutoff point, and the sensitivity and specificity at the point were calculated. In addition, we calculated the gray zone, which ranges between the two points where sensitivity and specificity, respectively, become 90%. RESULTS: In phase 1, the final model of the multivariable logistic regression analysis included the following 4 predictors: age (logarithm odds ratios [OR], -0.38; 95% CI, -0.81 to 0.00), Pediatric Anesthesia Behavior score (logarithm OR, 0.65; 95% CI, -0.09 to 1.40), anesthesia time (logarithm OR, 0.60; 95% CI, -0.18 to 1.19), and operative procedure (logarithm OR, 2.53; 95% CI, 1.30-3.75 for strabismus surgery and logarithm OR, 2.71; 95% CI, 0.99-4.45 for tonsillectomy). The EA risk scale included these 4 predictors and ranged from 1 to 23 points. In phase 2, the incidence of EA was 39%. The c-index of phase 1 was 0.84 (95% CI, 0.74-0.94), and the c-index of phase 2 was 0.81 (95% CI, 0.72-0.89). The best cutoff point for the EA risk scale was 11 (sensitivity = 87% and specificity = 61%). The gray zone ranged from 10 to 13 points, and included 38% of patients. CONCLUSIONS: We developed and validated an EA risk scale for children receiving sevoflurane anesthesia. In our validation cohort, this scale has excellent predictive performance (c-index > 0.8). The EA risk scale could be used to predict EA in children and adopt a preventive strategy for those at high risk. This score-based preventive approach should be studied prospectively to assess the safety and efficacy of such a strategy. (C) 2017 International Anesthesia Research Society

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Surveying the Literature: Synopsis of Recent Key Publications.

No abstract available

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A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care.

Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering and manufacturing-derived redesign approaches such as Six Sigma and Lean can be applied to hospitals and perioperative services just as they have been applied in factories. However, a hospital is not merely a factory but also a complex adaptive system (CAS). The hospital CAS has many subsystems, with perioperative care being an important one for which concepts of factory redesign are frequently advocated. In this article, we argue that applying only factory approaches such as lean methodologies or process standardization to complex systems such as perioperative care could account for difficulties and/or failures in improving performance in care delivery. Within perioperative services, only noncomplex/low-variance surgical episodes are amenable to manufacturing-based redesign. On the other hand, complex surgery/high-variance cases and preoperative segmentation (the process of distinguishing between normal and complex cases) can be viewed as CAS-like. These systems tend to self-organize, often resist or react unpredictably to attempts at control, and therefore require application of CAS principles to modify system behavior. We describe 2 examples of perioperative redesign to illustrate the concepts outlined above. These examples present complementary and contrasting cases from 2 leading delivery systems. The Mayo Clinic example illustrates the application of manufacturing-based redesign principles to a factory-like (high-volume, low-risk, and mature practice) clinical program, while the Kaiser Permanente example illustrates the application of both manufacturing-based and self-organization-based approaches to programs and processes that are not factory-like but CAS-like. In this article, we describe how factory-like processes and CAS can coexist within a hospital and how self-organization-based approaches can be used to improve care delivery in many situations where manufacturing-based approaches may not be appropriate. (C) 2017 International Anesthesia Research Society

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Threshold Concepts for Anesthesiologists.

No abstract available

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Perioperative Low Arterial Oxygenation Is Associated With Increased Stroke Risk in Cardiac Surgery.

BACKGROUND: Both patient characteristics and intraoperative factors have been associated with a higher risk of stroke after cardiac surgery. We hypothesized that poor systemic oxygenation in the perioperative period is associated with increased risk of stroke following cardiopulmonary bypass. METHODS: In this study of 251 adult patients who underwent cardiopulmonary bypass procedures at a single center from 2003 to 2006, cases (patients with a postoperative stroke at least 24 hours after surgery) were matched 1:2 to controls without stroke. Minimum and average partial pressure of oxygen in arterial blood (PaO2) values, from arterial blood gas values during and up to 24 hours after surgery, were evaluated as continuous and categorical predictors. Conditional logistic regression models adjusted for potential confounders (demographics, comorbidities, and intraoperative variables) were used to evaluate associations between PaO2 variables and stroke status. RESULTS: Lower nadir PaO2 values were associated with postoperative stroke, with estimated odds of stroke increasing over 20% (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.07-1.41) per 10 mm Hg lower nadir PaO2, and similarly increased odds of stroke per lower quartile of nadir PaO2 (OR, 1.60; 95% CI, 1.19-2.16). When average PaO2 was considered, odds of stroke was also increased (adjusted OR, 1.39 per lower quartile of mean PaO2; 95% CI, 1.05-1.83). Having a nadir PaO2 value in the lowest versus any other quartile was associated with an estimated 2.41-fold increased odds of stroke (95% CI, 1.22-4.78). Quartile of nadir but not average PaO2 results remained significant after adjustment for multiple comparisons. CONCLUSIONS: Odds of stroke after cardiac surgery are increased in patients with a low minimum PaO2 within 24 hours of surgery. Results should be validated in an independent cohort. Further characterizing the underlying etiology of hypoxic episodes will be important to improve patient outcomes. (C) 2017 International Anesthesia Research Society

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A Perspective on Hypercapnia Events After Cesarean Delivery in Women Receiving Intrathecal Morphine.

No abstract available

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Importance of Catheter Length for Ultrasound-Guided Cannulation of Peripheral Veins.

No abstract available

http://ift.tt/2s3SR7j

The Effect of Chronic Opioid Use on End-Tidal Concentration of Sevoflurane Necessary to Maintain a Bispectral Index Below 50: A Prospective, Single-Blind Study.

BACKGROUND: Opioid analgesics decrease the minimum alveolar concentration of inhalation agents during the acute phase response. However, the effect of chronic opioid exposure on minimum alveolar concentration of inhalation agents remains unknown. This study aimed to determine the concentration of sevoflurane necessary to maintain a bispectral index (BIS)

http://ift.tt/2ryQPsb

Pump Priming Practices and Anticoagulation in Cardiac Surgery: Results From the Global Cardiopulmonary Bypass Survey.

BACKGROUND: Regional patterns of practice in cardiopulmonary bypass remain poorly understood with conflicting evidence regarding the best choices in pump priming preferences with respect to colloid and crystalloid and different types of fluid within these categories. In light of the variation in the literature, we hypothesized there would be considerable regional differences in cardiopulmonary bypass practice, particularly with respect to the type of fluid used to prime the extracorporeal circuit. METHODS: A 16-question, Internet-based survey was distributed by various regional specialist societies, targeting adult cardiac anesthesiologists. One question was directly relevant to activated clotting time and 5 concerned pump priming choices with respect to crystalloid and colloid types and additives. The remaining questions concerned cardioplegia choices. The survey remained open from June 2015 to May 2016. RESULTS: A total of 923 responses were analyzed. Estimated response rates from Europe, North America, Australia/New Zealand, and South America were 19.77%, 8.06%, 16.30%, and 1.68%, respectively. The majority of respondents worldwide considered an activated clotting time of

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Vesical dermoid: a rare bladder tumour

Dermoid cysts are benign developmental lesions consisting of tissues of more than one germ cell lineage origin. The urinary bladder is a very rare location of dermoid cysts. We report a case of an 18-year-old woman who presented with suprapubic pain, dysuria and turbid urine. Blood and serum chemistry was normal. Contrast-enhanced CT revealed a heterogeneously enhancing mass of 2.5x2 cm within the urinary bladder infiltrating fundus of urinary bladder with extraluminal extension. At cystoscopy, an irregular mass arising from the dome of the urinary bladder with a covering of hair and whitish scales was seen. The patient was managed by transperitoneal laparoscopic partial cystectomy with left oophorectomy. Histology revealed dermoid cyst arising from the urinary bladder and simple serous cyst in the ovary. Postoperative course was uneventful.

http://ift.tt/2srpvQF

Large bladder calculus masking a stone in single-system ureterocele

Ureterocele in an elderly is a rare entity. The presence of stone within ureterocele along with a large bladder calculus is an even rarer presentation. This phenomenon has not been reported so far to the best of our knowledge. We present an unusual case of a large bladder calculus with a concomitant stone in the associated ureterocele. The diagnosis was missed in the first instance due to the masking effect by the larger bladder calculus. Herein, we discuss this case and its management.

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Tension enterothorax and hepatothorax due to a diaphragmatic hernia: successful emergency repair of a life-threatening condition

A 70-year-old female patient presented with acute severe respiratory distress at a district general hospital. Medical history included type 2 diabetes, recurrent pulmonary embolisms and pre-existing diaphragmatic hernia containing part of the liver. Despite initial treatment with steroid inhalers, her clinical picture rapidly deteriorated requiring emergency intubation and positive pressure ventilation. Imaging investigations revealed tension enterothorax and hepatothorax with tracheal deviation. The patient was transferred and underwent an emergency laparotomy at the Regional Oesophagogastric Unit. A large diaphragmatic hernia (central tendon defect) which contained the duodenum, porta hepatis, right lobe of liver, gallbladder and right colon was reduced and successfully repaired. Her postoperative course was uneventful with no signs of recurrence at 2 months follow-up.

This case describes an extremely rare and life-threatening condition of tension enterothorax and hepatothorax, which should be considered in the differential diagnosis of acute respiratory distress with tracheal deviation.

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McSwain type V appendix intussusception

Description

Intestinal intussusception consists of distal migration of a segment from the intestine to the adjacent intestinal lumen. Appendicular intussusception (AI) is a rare disease that constitutes a clinical challenge. The incidence of AI is estimated at 0.01%.1 It is five times more frequent in men.2 Despite imaging and endoscopic advances, diagnosis remains a difficult challenge. The presentation of AI varies from asymptomatic to chronic pain.3 This case reports a 33-year-old woman with past gastro-oesophageal surgery and complementary appendectomy, which was evaluated for the chronic pain in the right lower quadrant. Colonoscopy (figure 1A,B) revealed intussusception of appendix type V. A laparoscopic caecum resection was performed. The postoperative was uneventful. Histology revealed AI with lumen obliteration by foreign body (suture of previous intervention).

Figure 1

Colonoscopy: (A, B) finger-like polypoid tumour.

McSwain's classification is anatomical...

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Rheumatoid arthritis causing diffuse alveolar haemorrhage: a novel therapeutic approach

Pulmonary vascular involvement due to rheumatoid arthritis, presenting as diffuse alveolar haemorrhage (DAH), is a rare phenomenon, especially if there are no signs of systemic vasculitides. Furthermore, how to proceed with the management of these patients is challenging, as in the case of our patient, who had recurrent DAH. We present a case of a patient with known rheumatoid arthritis who had recurrence of DAH that spanned over several years, often presenting with life-threatening respiratory failure. While her DAH presentation improved with high-dose glucocorticoids, to resolve her recurrence, we opted to initiate treatment with rituximab, with a short course of azathioprine. After the second round of rituximab, the patient continues to do well without any further DAH-related complications. We also summarise prior cases of such patients to highlight variable treatment options.

http://ift.tt/2srwBV8

Staged curative treatment of a complex direct carotid-cavernous fistula with a large arterial defect and an 'oversized' internal carotid artery

This is a case of a high-flow, post-traumatic direct carotid-cavernous fistula with a widened arterial defect and a large-diameter internal carotid artery (ICA). The unique aspect of this case is the oversized ICA, >8mm in diameter, which is both a pathological and a therapeutic challenge, given the lack of available neuroendovascular devices for full vessel reconstruction. We present a planned two-stage embolisation paradigm for definitive treatment. Transarterial coil embolisation is performed as the first stage to disconnect the fistula and normalise flow in the ICA. A 3-month recovery period is then allowed for reduction in carotid diameter. Repair of the large vessel defect and pseudoaneurysm is performed as a second stage in a delayed fashion with a flow-diverting device. Follow-up angiography at 6 months demonstrates obliteration of the fistula and curative ICA reconstruction to a diameter <5mm.

http://ift.tt/2toRM7F

Antibiotic-associated haemorrhagic colitis: not always Clostridium difficile

Antibiotic-associated colitis is a gastrointestinal complication of antibiotic use commonly seen in hospitalised patients, with Clostridium difficile (C. difficile) colitis being the most common type. We present a case of haemorrhagic colitis secondary to Klebsiella oxytoca following self-initiated amoxicillin–clavulanic acid use. An 85-year-old woman presented to the emergency department with abdominal pain and mucobloody diarrhoea. History was notable for an ongoing 5-day course of amoxicillin–clavulanic acid use. The CT scan of her abdomen revealed extensive diffuse thickening of the ascending and transverse colon. Stool culture grew K. oxytoca, an established cause of haemorrhagic colitis. She declined colonoscopy but recovered with withdrawal of all antibiotics and conservative treatment. We should be vigilant to haemorrhagic colitis following antibiotic use which is not always C. difficile related.

http://ift.tt/2srh7AI

Marjolins squamous cell carcinoma of the hallux following recurrent ingrown toenail infections

Marjolin's squamous cell carcinoma (SCC) affecting the toe is rare. Due to resemblance with benign conditions it can often result in misdiagnosis. We report a case of Marjolin's SCC affecting the proximal hallux in a patient with recurrent ingrown toenail infections. A 58-year-old woman with a background of wedge resections for ingrown toenail and distal phalanx amputation for osteomyelitis presented with pain and hyperkeratotic raised ulcer around the proximal phalanx. MRI scan revealed soft tissue mass infiltrating the proximal phalanx with biopsies confirming a SCC. The patient underwent first ray amputation and made a good clinical recovery and remains disease free. Due to clinical similarities with benign conditions, awareness of Marjolin's SCC as a potential diagnosis when treating patients with recurrent ingrown toenail is imperative. We recommend patients with recurrent ingrown toenail or ulceration with a background of chronic infection have biopsies performed to exclude potential malignancy.

http://ift.tt/2srlnjF

Infectious crystalline keratopathy after Descemeta{euro}™s stripping endothelial keratoplasty

A 68-year-old woman presented with infectious crystalline keratopathy 4 months after she underwent a combined phacoemulsification and Descemet's stripping endothelial keratoplasty for Fuch's endothelial dystrophy in her left eye. After 5 months of topical moxifloxacin 1%, the infiltrate responded well but had not completely resolved, with the resulting endothelial failure requiring a penetrating keratoplasty 9 months after the initial operation. Microbiology identified Enterococcus faecalis with the histopathology demonstrating bacterial colonies within the graft interface. Postoperatively she developed endophthalmitis, needing vitrectomy and intravitreal antibiotics. The infection settled with no recurrence, with topical and oral antibiotics continued for 2 months. A sutured toric piggyback intraocular lens was performed 18 months postvitrectomy for graft astigmatism, achieving a best-corrected vision of 6/15.

Infectious crystalline keratopathy can occur following Descemet's stripping endothelial keratoplasty, requiring long-term topical therapy and potentially leading to graft failure with the necessity for further keratoplasty.

http://ift.tt/2tp8zHD

Twenty-nine-month follow-up of a paediatric zirconia dental crown

The aim of this paper is to present the long-term follow-up of one paediatric zirconia crown on a deciduous molar. Preformed crowns are part of the armamentarium in paediatric dentistry. In recent years, aesthetic alternatives to preformed metal crowns have been developed, first preveneered crowns and then zirconia crowns. This paper describes the restoration of a primary molar with a zirconia crown (EZ-Pedo, Loomis, California, USA) in an 8-year-old boy. In this clinical case, the protocol for the implementation and maintenance of zirconia crowns is detailed. The patient was followed up for 29 months until the natural exfoliation of his primary molar. The adaptation of the zirconia crown, the gingival health and the wear on the opposing tooth were considered. In this case, the paediatric zirconia crown allowed sustainable functional restoration while restoring a natural appearance of the tooth.

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Αρχειοθήκη ιστολογίου

Πέμπτη 15 Ιουνίου 2017

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