Head and Neck Medicine by Alexandros G.Sfakianakis: 07/14/17

Παρασκευή 14 Ιουλίου 2017

Cone beam computed tomography evaluation of midpalatal suture maturation in adults

The aim of this study was to evaluate midpalatal suture maturation in adults, as observed in cone beam computed tomography (CBCT) images. CBCT scans from 78 subjects (64 female and 14 male, age range from 18 to 66 years) were evaluated. Midpalatal suture maturation was verified on the central cross-sectional axial slice in the superior–inferior dimension of the palate, using methods validated previously. Intra-examiner agreement was analyzed by weighted kappa test. Multinomial logistic regression was used to test whether sex and chronological age (adults <30 years or ≥30 years) could be used as a predictor for the maturational stages of the midpalatal suture.

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Characteristics of mandibular injuries caused by bullets and improvised explosive devices: a comparative study

The purpose of this study was to investigate the difference in mandibular trauma caused by two mechanisms for the delivery of missile injuries: firearms and improvised explosive devices (IEDs). The data investigated included sex, age, mechanism of injury, and other clinical and radiographic manifestations. Seventy consecutive patients, predominantly male, with a mean age of 28.6±14 years (range 2–60 years) were enrolled: 38 patients (54.3%) sustained mandibular fractures caused by bullet injuries and 32 patients (45.7%) had mandibular fractures caused by IED explosion injuries.

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The bone lid technique in oral surgery: a case series study

The aim of this case series study was to illustrate the bone lid technique implemented using piezoelectric surgery to access mandibular alveolar bone diseases and to assess the clinical and radiographic outcomes. The technique was used to treat 21 consecutive patients with various conditions: cysts in six cases, impacted teeth with associated cysts in nine, keratocystic odontogenic tumours in three, impacted teeth in two, and an endodontic lesion in one. The bone lid was fashioned using piezoelectric surgery and a thin osteotomy insert.

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Clinical significance of preoperative serum C-reactive protein in oral squamous cell carcinoma

C-reactive protein (CRP) is an index of systemic inflammation. However, CRP is not usually assessed preoperatively. Hence the study intended to evaluate the preoperative serum CRP levels in oral squamous cell carcinoma (OSCC) patients and to analyse its relationship with the clinicopathologic characteristics. CRP values for 60 OSCCs and 30 healthy controls were evaluated using a CRP assessment kit and spectrophotometer. The Mann–Whitney U test, χ2 test, receiver operating characteristic (ROC) curve analysis, and logistic regression were applied.

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A common password improves validation rates for elogbook

A validated log of operations is an essential component of a surgical trainee's portfolio. For all specialties in the UK, the eLogbook1 is the official electronic version.

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Surgical treatment associated with improved survival in patients with cutaneous angiosarcoma

Abstract

Cutaneous angiosarcoma is a rare aggressive vasoformative neoplasm of the skin with a poor prognosis.¹ The neoplasm preferentially involves areas of head and neck and usually diagnosed in advanced stage.^{1, 2} The neoplasm accounts for only 2% of soft-tissue sarcomas in the U.S. and most often affects elderly white males, patients treated with radiation, and individuals with certain chronic lymphatic disorders.³ Surgery with or without adjuvant or neoadjuvant radiation therapy (RT) is considered the mainstay of therapy.^{1, 3} Due to low incidence rates, the clinical outcomes data has been limited to case reports and single institution studies, with a lack of direct comparison between various treatment modalities: surgery, RT, and chemotherapy (CT).^{4, 5} In this study, we aimed to investigate the impact of undergoing different therapeutic approaches on long-term overall survival (OS) using cross-institutional data.

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Severe sequelae of erythema multiforme: three cases

Abstract

Erythema multiforme (EM) is a skin condition for which main causes are infectious factors (Herpes simplex virus, Mycoplasma pneumoniae). Anti-plakin auto-antibodies are found in some patients ¹. EM must be distinguished from Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are drug-induced in most cases ^2-5.

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Narrow-band imaging with 4K technology in the head and neck: preliminary experience and technical settings

Publication date: Available online 13 July 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): G. Tirelli, M. Piovesana, A. Gatto, F. Boscolo Nata

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A common password improves validation rates for elogbook

Publication date: Available online 14 July 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): C. McDonald, A. Kamisetty, E. Twohig, M. Fullarton, W. Allen, K. Java, A. Begley

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Second Primary Cancer in Patients with Differentiated Thyroid Cancer: Does Radioiodine Play a Role?

Thyroid , Vol. 0, No. 0.

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Resveratrol inhibits IgE binding and down-regulates intracellular phosphorylation of Syk following IgE aggregation on human basophils

Publication date: Available online 14 July 2017
Source:Allergology International
Author(s): Sayaka Arakawa, Maho Suzukawa, Sayaka Igarashi, Hirotoshi Matsui, Masao Yamaguchi, Takahide Nagase, Ken Ohta

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Quality of Life, Anxiety Prevalence, Depression Symptomatology and Suicidal Ideation among Acne Patients in Lithuania

Abstract

Background/Objective

We aimed to determine the prevalence of anxiety, depression symptomatology and suicidal ideation among patients with acne and the impact of this skin condition on the quality of life in Lithuania.

Methods

The mental health of patients with acne was assessed using an adapted Hospital Anxiety and Depression Scale, the Dermatology Quality of Life Index, questions about characteristics of acne. The study was authorized by the Regional Biomedical Research Ethics Committee.

Results

A total of 255 responders out of 324 patients with acne included (84.4%) were assessed. 56.1% of the responders had comorbid anxiety, depression symptomatology or suicidal ideation related to acne; Among them 38.4% had anxiety symptoms, 23.1% had depression symptoms and 12.9% had suicidal thoughts due to acne. 96.5% of the responders had a reduced quality of life due to acne.

Conclusion

More than a half of the patients with acne who participated at the study had comorbid emotional disorders. Anxiety was the most prevalent sign, 1.7-fold more prevalent than depression and 3-fold more prevalent than suicidal ideation. Depression was prevalent in more than every fourth responder and suicidal ideation afflicted every eighth acne patient. More than 90% of the patients had impaired life quality.

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Chordoid Glioma: A Neoplasm Found in the Anterior Part of the Third Ventricle.

Chordoid glioma is a rare low-grade tumor that originates almost exclusively in the anterior part of the third ventricle. The diagnosis and treatment of the tumor remain controversial. In this article, the authors present a novel case of chordoid glioma of the third ventricle. The patient was treated with less invasive microsurgery followed by low-dose gamma knife radiosurgery. Magnetic resonance imaging revealed a decrease in tumor size and necrosis in the central region of the tumor, without significant complications at follow-up 14 months later. Based on these findings, the authors suggest that less invasive microsurgical resection followed by low-dose gamma knife radiosurgery is safe and effective for the treatment of chordoid glioma of the third ventricle. (C) 2017 by Mutaz B. Habal, MD.

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Pulp Vitality of Maxillary Canines After Alveolar Cleft Bone Grafting: Pulse Oximetry Versus Electric Pulp Test Versus Cold Test.

Objectives: Assessment of pulp vitality is necessary prior to any dental treatment. The purpose of this study was to assess pulp vitality of bilateral canines in unilateral cleft patients following alveolar bone graft surgery using pulse oximetry, electrical pulp test, and cold test. Methods: This analytical, cross-sectional study was conducted on canines of 20 unilateral cleft patients who had alveolar bone graft surgery. Pulp vitality of canines was evaluated postoperatively by pulse oximetry, electrical pulp test, and cold test. Data were analyzed using t test, Mann-Whitney test, and [chi]2 test. P

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Is Cleft Severity Correlated With Intrinsic Growth Pattern? Observation From Unoperated Adult Patients With Submucous Cleft Palate.

Objective: This study aimed to evaluate the craniofacial morphology of unoperated adult submucous cleft palate (SMCP) patients and to explore the possible correlation between the intrinsic growth insufficiency of the maxillofacial complex and the severity of the cleft. Materials and Methods: A total of 20 unoperated SMCP patients, 20 unoperated overt cleft palate (OCP) patients, and 32 normal controls, ages between 18 and 30, were included for cephalometric analysis. One-way ANOVA and rank-sum tests were used for comparison, and the threshold of significance was at 95% (P SMCP = OCP). Maxillary protrusion ([angle] S-N-ANS, [angle] S-N-ANS) was similar between the SMCP group and the control, but significantly reduced in the OCP group (normal = SMCP > OCP). Significant differences in [angle] A-N-B were found between each of the 3 groups (normal > SMCP > OCP). Conclusion: Compared with normal, unoperated adult SMCP patients were of smaller mandible and shorter maxillae, but almost normal maxillary protrusion. Overt clefts demonstrated significantly more evident maxillary retrusion and crossbite than SMCP, indicating a correlation between the cleft severity and the intrinsic growth pattern of the maxillofacial complex. (C) 2017 by Mutaz B. Habal, MD.

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Secondary Palatal Elongation: Improvement in Speech Quality.

Cleft palate is one of the challenging problems in the field of craniofacial surgery. In particular, the conventional methods of bilateral and severe cleft palate repairs have failed to achieve normal speech. In most instances, secondary procedures such as pharyngoplasty and pharyngeal flap surgery are performed to improve speech. This study introduces secondary palatal elongation (SPE) as a new approach to cleft palate repair. The patients included usually had a short palate and unrepaired palatal muscles. The authors' procedure involved dissecting the previously repaired palatal mucosa and pushing back and cutting the nasal mucosa of the palate horizontally and further pushing it back. Then, 1 or 2 buccal mucosal flaps were used to repair the nasal mucosal defect of the palate. In case of unrepaired veloplasty from the primary surgery, the levator muscles were dissected and sutured together to perform veloplasty. The range of palatal elongation was 15 to 25 mm. Secondary palatal elongation has been performed on 17 patients since 2007 with a high rate of speech improvement. Based on this 9-year experience with performing SPE, SPE is a radical anatomic technique of palatal elongation as compared with pharyngoplasty and pharyngeal flap surgery. All 17 patients who underwent SPE showed improvement in speech, from very poor to poor speech and from normal to good speech. (C) 2017 by Mutaz B. Habal, MD.

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A Novel Rhinoplasty Sculpture Technique Using Ancient Chinese Architectural Technology.

Rhinoplasty is one of the most delicate procedures in plastic and reconstructive surgery. Precision in every millimeter is vital in ensuring a better quality of surgical outcome. Many methods have been developed to fulfill this requirement. One such method is an implant, whether autogenous or artificial. Artificial implants involve several surgical complications, such as recipient rejection of implant material, infections, and rigid feel of the nasal tip. Hence, autogenous implants were eventually more widely applied, with material being obtained from the septum, concha, or rib cartilages. Therefore, the authors developed a new technique of rhinoplasty, using the osteochondral rib as an autogenous implant based on the ancient Chinese architectural technology called the DouGong method. The authors hereby present the results of 288 patients treated in our faculty wherein the data from the patients and the preoperative and postoperative 3-dimensional computed tomography scans were processed using Mimics software. The uniqueness of these implants is that the joint between the nasal dorsum and the columella strut is fixated without any screw, stitches, or K-wire. This procedure proved to be very useful as this technique not only minimized the application of fixation techniques, but also helped achieve a better nasofrontal angle, nasolabial angle, and columella length. After monitoring follow-ups of our patients, the authors hereby propose the use of this DouGong-based novel technique to improve the overall quality and outcome of corrective rhinoplasty. (C) 2017 by Mutaz B. Habal, MD.

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Rare Complication in Third Maxillary Molar Extraction: Dislocation in Infratemporal Fossa.

Aim: Removal of impacted third maxillary molar is frequently carried out without difficulties and low rate of intraoperative complications. The rare and particularly challenger to manage it is the third molar dislocation into the infratemporal fossa (IF). In this clinical report, the authors present their solution to manage and resolve this particular complication. Methods: A 28-year-old woman was referred to the emergency rescue unit of the authors' hospital by her dentistry, after the attempt to extract the left impacted maxillary third molar. During the procedure the tooth accidentally dislodged and was lost sight of it. The patient had significant mouth-opening limitation, omolateral mid face swelling and pain. Computer tomography was immediately performed to determine the exact position of the tooth, showing the dental element dislocated into the IF. Results: Considering all of possible complications the best surgical option must guarantee a direct approach and a constant eye contact of the tooth, even in case of further displacement during the procedure, and allow early surgery. The authors used an endoscopic transoral approach through the preexisted access and solved all the issues reducing morbidity. Conclusion: Removing tooth from the IF could be burdened by serious risk of bleeding and/or nerve injury. The endoscopic approach provides direct view of the IF reducing morbidity. (C) 2017 by Mutaz B. Habal, MD.

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Comparison of the Effects of Local and Systemic Zoledronic Acid Application on Mandibular Distraction Osteogenesis.

Bisphosphonates are antibone resorptive drugs that are used to prevent bone tissue resorption in several skeletal diseases. The aim of this study was to examine the effects of systemic and local applications of zoledronic acid (ZA) on newly regenerated bone in a model of experimental distraction osteogenesis (DO). To do this mandibular DO was applied to 30 adult female Sprague Dawley rats, which were randomly divided into 3 groups: control, DO only, systemic zoledronic acid (SZA), and local zoledronic acid (LZA). In the LZA group, the gap between the bone fragments was filled with a gelatin sponge soaked in 2 mg of ZA and 0.1 mL of sterile saline. In the SZA group, a single dose of 0.1 mg/kg ZA was administered systemically. After the surgery, there was a 5-day latent waiting period and 10-day distraction phase. Following a 28-day consolidation period, the rats were euthanized and their mandibles were collected. The distracted bone area was seen to be filled with newly regenerated bone tissue in all 3 groups, both histologically and histomorphometrically. In addition, amounts of new bone formation, osteoblast cella, osteoclast (OC) cells, osteopontin, and vascular endothelial growth factor in the SZA and LZA groups were found to be higher when compared with the controls. Furthermore, in the SZA group, new bone formation, osteoblast, OC, osteopontin, and vascular endothelial growth factor were detected in significant amounts compared with the LZA group. Osteoclast numbers did not differ in a statistically significant manner in the SZA group with respect to the LZA group. Based on the results of this study, systemic and local applications of ZA could increase the formation of new bone in patients of DO, and systemic application is a more effective method compared with local application. (C) 2017 by Mutaz B. Habal, MD.

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A Digital Assessment of the Maxillary Deformity Correction in Infants With Bilateral Cleft Lip and Palate Using Computer-Aided Nasoalveolar Molding.

Objectives: To evaluate the maxillary alveolar repositioning of the infants with bilateral cleft lip and palate (BCLP) undergoing computer-aided nasoalveolar molding (CAD-NAM). Methods: A total of 19 BCLP infants undergoing CAD-NAM were recruited as the treatment group, and 21 nonpresurgically treated BCLP patients served as controls. The upper alveolar morphology was measured and evaluated. Changes in all variables between pre- and post-CAD-NAM were compared. Results: By the end of CAD-NAM, significant difference was found in the P-A, P'-A', and L-ideal midline (P

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Modified Technique of Cultured Epithelial Cells Transplantation on Facial Segmental Vitiligo.

Background: Cultured epithelial cells transplantation is a known surgical technique for vitiligo. Objective: To evaluate the factors influencing efficacy and safety of cultured epithelial cells transplantation in 9-month follow-up. Methods: Demographic, clinical, and repigmentation outcomes were reviewed for patients with facial segmental vitiligo who had undergone cultured epithelial cells transplantation from November 2013 to July 2015 at the clinic of the Department of Dermatology, Huashan Hospital, China. Results: Twenty-eight patients who had undergone cultured epithelial cells transplantation were included. A satisfactory result (>50% repigmentation) was achieved in 79% patients with facial segmental vitiligo in 9 months. The treatment effect was significantly different in 6th month (P = 0.032), 9th month (P = 0.006) compared with 3rd month. Disease stability did significantly affect repigmentation outcome in 9th month (Z = 2.113, P = 0.035). No significant difference was observed between single segmental type versus mixed type (Z = 1.081, P = 0.280). Adverse effects were nearly absent. Conclusion: Cultured epithelial cells transplantation is a relatively safe and effective therapy for facial segmental stable vitiligo patients. (C) 2017 by Mutaz B. Habal, MD.

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Pneumocephalus-Induced Oculomotor Nerve Palsy After Atlanto-Occipital Decompression With Dural Plasty.

Background: Pneumocephalus after posterior fossa craniotomy is very common. However, cranial nerve dysfunction secondary to pneumocephalus is a very rare phenomenon. Patient Presentation: This case reports a patient who suffers from Chiari I malformation with syringomyelia in cervical spinal cord and develops unilateral oculomotor nerve palsy after atlanto-occipital decompression with dural plasty. Conclusions: Cranial nerve dysfunction caused by pneumocephalus after craniotomy is rare and easily misdiagnosed. Timely head computed tomography or magnetic resonance imaging examination can exclude other causes and reveal the anatomic sites of pneumocephalus. Conservative treatment is available in most patients while sometimes it is necessary to drain the air. (C) 2017 by Mutaz B. Habal, MD.

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Oral Localization of Kaposi Sarcoma: Clinical Presentation and Conservative Management.

Kaposi sarcoma (KS) caused by human herpes virus type-8 is the most frequent immunosuppression-associated malignancy worldwide and its treatment is still controversial. We report on the clinical management of a patient who developed oral KS after liver transplantation. The disease appeared 1 month after the transplant and recurred after 4 months. The patient represents, to our knowledge, a rare case that was treated successfully only by shifting a conventional immunosuppressive therapy to everolimus alone. (C) 2017 by Mutaz B. Habal, MD.

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Global Craniofacial Care.

No abstract available

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Analysis of Stress Trajectories in Human Adult Cleft Skull.

The craniofacial skeleton is designed to withstand the functional forces during mastication. Distribution of these forces is along the stress trajectories that can vary in a cleft skull compared with a normal skull. In this study, the authors constructed finite element models of cleft and normal skull and subjected them for occlusal loading in the posterior teeth. The results showed variation in the trajectories between the models and between the cleft and noncleft sides within the cleft model. (C) 2017 by Mutaz B. Habal, MD.

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Locking Plate System Versus Standard Plate Fixation in the Management of Mandibular Fractures: Meta-Analysis of Randomized Controlled Trials.

Purpose: The aim of this meta-analysis was to evaluate the efficacy of the 2.0-mm locking miniplate system in comparison with the standard miniplate system in treatment of mandible fractures. Methods: A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and PubMed databases, eligible studies were restricted to comparative controlled trials. Inclusion criteria were based on humans randomized controlled trials, controlled clinical trials, with the aim of comparing 2 fixation techniques, namely locking miniplate and standard miniplate (nonlocking miniplate) techniques. In addition, the incidence of complications was evaluated. Results: Nine studies with 380 patients and 551 fracture sites were enrolled into the analysis. The results showed that there were no significant differences in overall complications (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.34-1.22; P = 0.2), postoperative infection (OR, 0.53; 95% CI, 0.23-1.23, P = 0.15), and occlusion discrepancy (P > 0.05) when comparing 2.0-mm locking miniplates with 2.0-mm nonlocking miniplates in treating mandible fractures. However, the use of 2.0-mm locking miniplates had a lower postoperative maxillomandibular fixation rate than the use of 2.0-mm nonlocking miniplates (OR, 0.43; 95% CI, 0.22-0.83; P

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Clinical Application of Multimodal Neuronavigation System in Neuroendoscope-Assisted Skull Base Chordoma Resection.

Skull base chordoma is a rare tumor arising from embryonic remnants of the notochord with invasive potential. Due to the destruction of osseous landmarks and invasion of surrounding structures, surgical resection is challenging. The authors explored the clinical value of a multimodal neuronavigation system in skull base chordoma resection using a neuroendoscope. Between January 2012 and January 2016, the authors utilized neuroendoscopy to excise skull base chordoma in 93 patients. The authors performed 45 operations assisted by multimodal neuronavigation (neuronavigation group) and 48 without intraoperative imaging guidance (control group). In the control group, 35 patients (73%) underwent gross total resection. In the neuronavigation group, all patients underwent gross total resection without radiographically identified bleeding. Only 1 patient (2%) in the neuronavigation group showed a temporary reduction in vision, which improved after symptomatic treatment. In contrast, there were 4 patients (8%) with postoperative complication, including 2 patients with intracranial hematoma and 2 with neurological deficits. Complication rates were higher than the neuronavigation group. In the follow-up period, 2 patients in the control group with subtotal resection had recurrence within 24 months, but without extracranial metastases. The multimodal neuronavigation system could contribute intraoperative real-time guidance for spatial relationships between lesions and adjacent neurovascular structures, as well as eroded and distorted anatomical landmarks through multiple image fusion and 3-dimensional reconstruction. It significantly improves surgical outcome and provides a new insight into the management of skull base chordomas. (C) 2017 by Mutaz B. Habal, MD.

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The Current Challenge for Plastic and Reconstructive Surgery in China, the Biggest Developing Country.

No abstract available

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The Status of Affected Infraorbital Nerve and Inferior Alveolar Nerve in Patients With Jaw Fibrous Dysplasia: A Clinical and Radiographic Evaluation.

The affected infraorbital nerve (IFBN) and inferior alveolar nerve (IFAN) status in patients with jaw fibrous dysplasia has not been definitely depicted. In this study, the authors try to explore the status of affected IFBN and IFAN in patients with jaw fibrous dysplasia. Ten patients with jaw fibrous dysplasia were included in this study. The complaints of numbness in the IFBA and IFAN innervated area were asked and recorded, and careful clinical examination was performed to evaluate the touch sense, pain sense, pressure sense, and temperature sense in the IFBA and IFAN innervated areas. Computed tomography scans also were performed to evaluate the imaging characteristics of affected IFBA and IFAN. The results showed that 1 patient with maxillary lesion showed complaints of slight numbness, and clinical examination showed that the patient exhibited slight insensitive in pain sense. In addition, 1 patient with mandibular lesion showed relative obvious complaints of numbness, and clinical examination showed that the patient exhibited slight insensitive in pain sense and temperature sense, but not serious. All other patients exhibited no numbness in the IFBA and IFAN innervated area. Although the position and morphology changed in some patients, all neural canal of affected IFBA or IFAN existed and showed no invasion of lesion. Taking these findings together, it further confirmed that evaluation of the function of IFBAN and IFAN is necessary for patients with jaw fibrous dysplasia, and the affected IFBAN and IFAN may should be reserved in most patients with jaw fibrous dysplasia when resecting or recontouring the lesion. (C) 2017 by Mutaz B. Habal, MD.

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Utility of Brainstem Trigeminal Evoked Potentials in Patients With Primary Trigeminal Neuralgia Treated by Microvascular Decompression.

Objective: To investigate the characteristics of brainstem trigeminal evoked potentials (BTEP) waveform in patients with and without trigeminal neuralgia (TN), and to discuss the utility of BTEP in patients with primary TN treated by microvascular decompression (MVD). Methods: A retrospective review of 43 patients who underwent BTEP between January 2016 and June 2016, including 33 patients with TN who underwent MVD and 10 patients without TN. Brainstem trigeminal evoked potentials characteristics of TN and non-TN were summarized, in particular to compare the BTEP changes between pre- and post-MVD, and to discover the relationship between BTEP changes and surgical outcome. Results: Brainstem trigeminal evoked potentials can be recorded in patients without trigeminal neuralgia. Abnormal BTEP could be recorded when different branches were stimulated. After decompression, the original W2, W3 disappeared and then replaced by a large wave in most patients, or original wave poorly differentiated improved in some patients, showed as shorter latency and (or) amplitude increased. Brainstem trigeminal evoked potentials waveform of healthy side in patients with trigeminal neuralgia was similar to the waveform of patients without TN. In 3 patients, after decompression the W2, W3 peaks increased, and the latency, duration, IPLD did not change significantly. Until discharge, 87.9% (29/33) of the patients presented complete absence of pain without medication (BNI I) and 93.9% (31/33) had good pain control without medication (BNI I-II). Conclusion: Brainstem trigeminal evoked potentials can reflect the conduction function of the trigeminal nerve to evaluate the functional level of the trigeminal nerve conduction pathway. The improvement and restoration of BTEP waveforms are closely related to the postoperative curative effect. (C) 2017 by Mutaz B. Habal, MD.

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Osteoradionecrosis of the Zygoma.

Osteoradionecrosis occurs in 4.74% to 37.5% of patients following radiation therapy for head and neck cancer. Osteoradionecrosis mostly happens in the mandible but seldom occurs in other maxillofacial bones. Here, the authors reported a rare case of zygomatic osteoradionecrosis which occurred after maxillectomy and then radiotherapy because of maxillary myoepithelial carcinoma. After resection of zygoma sequestrum, the defect was repaired with forehead flap and healed uneventfully. (C) 2017 by Mutaz B. Habal, MD.

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Reconstruction of Facial-Cervical Scars With Pedicled Expanded Deltopectoral Flap.

The facial-cervical scars bring the suffering to the patients both physically and mentally. Choosing a proper donor soft tissue is always one of the critical issues, especially to Asian patients. Among the common used donor sites, the deltopectoral site was conceived as the most suitable donor tissue for the reconstruction in face and neck for its adjacent site and match in color and texture. There were 220 patients with facial-cervical scars reconstructed by the pedicled expanded deltopectoral flap between 2007 through 2015 in the authors' hospital. There are 4 stages, including tissue expansion, flap pedicled transfer, pedicle delaying, and pedicle division, for the reconstruction of the facial-cervical scars using the pedicled expanded deltopectoral flap. Good skin compliance, normal contours, and emotional expression were noted in all the patients after the reconstruction. However, there were complications including expander exposure, stretch marks, flap tip necrosis, and mild postoperative hypertrophic scars. The unpleasant skin wound or color caused by the complications was repaired by further treatments such as skin grafting and laser. In conclusion, the pedicled expanded deltopectoral flap is a reliable and excellent option for the reconstruction of the facial-cervical scars. (C) 2017 by Mutaz B. Habal, MD.

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Imaging Modalities for Correct Positioning of Percutaneous Right Ventricular Assist Device After Left Ventricular Assist Device Implantation.

No abstract available

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In Response.

No abstract available

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Esmolol Administration to Control Tachycardia in an Ovine Model of Peritonitis.

BACKGROUND: Excessive adrenergic signaling may be harmful in sepsis. Using [beta]-blockers to reduce sympathetic overactivity may modulate sepsis-induced cardiovascular, metabolic, immunologic, and coagulation alterations. Using a randomized ovine fecal peritonitis model, we investigated whether administration of a short-acting [beta]-blocker, esmolol, could control tachycardia without deleterious effects on hemodynamics, renal perfusion, cerebral perfusion, cerebral metabolism, or outcome. METHODS: After induction of fecal peritonitis, 14 anesthetized, mechanically ventilated, and hemodynamically monitored adult female sheep were randomly assigned to receive a continuous intravenous infusion of esmolol to control heart rate between 80 and 100 bpm (n = 7) or a saline infusion (control group, n = 7). Esmolol was discontinued when the mean arterial pressure decreased below 60 mm Hg. Fluid resuscitation was titrated to maintain pulmonary artery occlusion pressure at baseline values. Left renal blood flow and cerebral cortex perfusion and metabolism were monitored in addition to standard hemodynamic variables. RESULTS: Esmolol was infused for 11 (9-14) hours; the target heart rate (80-100 bpm) was achieved between 3 and 8 hours after feces injection. In the first 5 hours after the start of the infusion, the decrease in heart rate was compensated by an increase in stroke volume index; later, stroke volume index was not statistically significantly different in the 2 groups, so that the cardiac work index was lower in the esmolol than in the control group. Hypotension (mean arterial pressure

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Hyperbaric Versus Isobaric Bupivacaine for Spinal Anesthesia: Systematic Review and Meta-analysis for Adult Patients Undergoing Noncesarean Delivery Surgery.

BACKGROUND: It is widely believed that the choice between isobaric bupivacaine and hyperbaric bupivacaine formulations alters the block characteristics for the conduct of surgery under spinal anesthesia. The aim of this study was to systematically review the comparative evidence regarding the effectiveness and safety of the 2 formulations when used for spinal anesthesia for adult noncesarean delivery surgery. METHODS: Key electronic databases were searched for randomized controlled trials, excluding cesarean delivery surgeries under spinal anesthesia, without any language or date restrictions. The primary outcome measure for this review was the failure of spinal anesthesia. Two independent reviewers selected the studies and extracted the data. Results were expressed as relative risk (RR) or mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Seven hundred fifty-one studies were identified between 1946 and 2016. After screening, there were 16 randomized controlled clinical trials, including 724 participants, that provided data for the meta-analysis. The methodological reporting of most studies was poor, and appropriate judgment of their individual risk of bias elements was not possible. There was no difference between the 2 drugs regarding the need for conversion to general anesthesia (RR, 0.60; 95% CI, 0.08-4.41; P = .62; I2 = 0%), incidence of hypotension (RR, 1.15; 95% CI, 0.69-1.92; P = .58; I2 = 0%), nausea/vomiting (RR, 0.29; 95% CI, 0.06-1.32; P = .11; I2 = 7%), or onset of sensory block (MD = 1.7 minutes; 95% CI, -3.5 to 0.1; P = .07; I2 = 0%). The onset of motor block (MD = 4.6 minutes; 95% CI, 7.5-1.7; P = .002; I2 = 78%) was significantly faster with hyperbaric bupivacaine. Conversely, the duration of motor (MD = 45.2 minutes; 95% CI, 66.3-24.2; P

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Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery: A French Retrospective, Multicenter, Cohort Study.

BACKGROUND: Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy. Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor. METHODS: Data were from a cohort of 10,419 women who delivered between 2010 and 2011 in 4 public teaching hospitals in Paris. We used a deprivation index that included 4 criteria: social isolation, poor housing condition, no work-related household income, and state-funded health care insurance. Socioeconomic deprivation was defined as a deprivation index greater than 1. Preanesthetic evaluation was considered completed if performed more than 48 hours before delivery. The association between socioeconomic deprivation and completion of the preanesthetic evaluation and use of neuraxial labor analgesia was assessed by multivariable logistic regression adjusting for education level, country of birth, and maternal and pregnancy characteristics. RESULTS: Preanesthetic evaluation was completed for 8142 of the 8624 women (94.4%) analyzed and neuraxial labor analgesia was used by 6258 of the 6834 women analyzed (91.6%). After adjustment, socioeconomic deprivation was associated with reduced probability of completed preanesthetic evaluation (adjusted odds ratio 0.88 [95% confidence interval, 0.79-0.98]; P = .027) but not use of neuraxial labor analgesia (adjusted odds ratio 0.97 [95% confidence interval, 0.87-1.07]; P = .540). CONCLUSIONS: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation. (C) 2017 International Anesthesia Research Society

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Replication of Data Makes Statistical Analysis Difficult.

No abstract available

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Improving the Success Rate of Chest Compression-Only CPR by Untrained Bystanders in Adult Out-of-Hospital Cardiac Arrest: Maintaining Airway Patency May Be the Way Forward.

No abstract available

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Fixing Medical Prices.

No abstract available

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The effects of uvulopalatal flap operation on speech nasalance and the acoustic parameters of the final nasal consonants

Publication date: Available online 13 July 2017
Source:Auris Nasus Larynx
Author(s): Soo Kyoung Park, Yong Soo Lee, Young Ae Kang, Jun Xu, Ki Sang Rha, Yong Min Kim
ObjectiveThe acoustic characteristics of voice are determined by the source of the sound and shape of the vocal tract. Various anatomical changes after uvulopalatal flap (UPF) operation can change nasalance and/or other voice characteristics. Our aim was to explore the possible effects of UPF creation on speech nasalance and the resonatory features of the final nasal consonants, and thus voice characteristics.MethodsA total of 30 patients (26 males, 4 females) with obstructive sleep apnea who underwent UPF operation were recruited. A Nasometer II 3.4 instrument was used to assess nasalance pre- and post-operatively; the patients read standard Korean passages and the readings were recorded in Computer Speech Laboratory for later spectral analysis. Praat software was used to identify frequency bands affecting perioperative nasalance scores. Minima, maxima, and slopes were analyzed.ResultsWe found no significant correlation between nasalance scores (any passage) and the respiratory distress index or body mass index. No significant perioperative change in any nasalance score. The moment variations in the final consonants /m/ and /n/ did not change significantly postoperatively. However, the postoperative moment variation of the final consonant /ng/ differed significantly in the third formant (F3) and second bandwidth (BW2).ConclusionFew significant changes in nasal resonance speech quality were apparent after UPF operation. However, a postoperative acoustic change in the final sound /ng/ may be sustained. Patients may be preoperatively advised that the risk of voice change is very low, but not absent.

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The management of pediatric hearing loss caused by auditory neuropathy spectrum disorder.

Purpose of review: Auditory neuropathy spectrum disorder (ANSD) is a condition in which auditory testing reveals normal otoacoustic emissions, but auditory brainstem testing is abnormal or absent and speech discrimination is poor. This constellation of findings ostensibly suggests that the cochlea is healthy and an abnormality of conduction or processing of sound occurs along the nerve fibers. As more is learned about this condition, it is becoming clear that ANSD describes heterogeneous, distinct clinical entities that must be taken into account when devising treatment modalities. Recent findings: Modern auditory testing, genetic testing, and neuroimaging can allow for an accurate understanding of the location of the lesion causing ANSD in the auditory pathway. Contributing causes can include genetic mutations, absent or deficient cochlear nerve, hypoxia and jaundice among others. Hearing aids can be successful in the management of ANSD. Several studies suggest that cochlear implantation can lead to successful hearing outcomes in a subset of this patient population. Summary: Auditory neuropathy spectrum disorder represents a relatively rare but important diagnosis for clinicians. Treatment for this condition includes hearing aids and FM systems in more mild cases, and cochlear implants in severe cases. Cochlear implantation for many patients can lead to a good hearing outcomes but the outcome can vary greatly depending on the underlying etiology of ANSD. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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The impact of hearing loss on society in general: an underappreciated problem.

No abstract available

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The management of pediatric hearing loss caused by auditory neuropathy spectrum disorder.

The impact of hearing loss on society in general: an underappreciated problem.

No abstract available

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Chemotherapy-induced peripheral neuropathy: a review of recent findings.

Purpose of review: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, frequently chronic condition characterized by pain and decreased function. Given the growing number of cancer survivors and an increasing recognition of opioid therapy limitations, there is a need for critical analysis of the literature in directing an informed and thoughtful approach for the management of painful CIPN. Recent findings: A PubMed search for 'chemotherapy-induced peripheral neuropathy AND pain' identifies 259 publications between 1 January 2016 and 31 March 2017. Based on review of this literature, we aim to present a clinically relevant update of painful CIPN. Notably, the use of duloxetine as a first-line agent in treatment of CIPN is confirmed. Moreover, clinical trials focus on nonpharmacologic strategies for managing painful CIPN. Summary: Despite the volume of recent publications, there are limited preventive or therapeutic strategies for CIPN supported by high-level evidence. Duloxetine remains the only pharmacologic agent with demonstrated benefit; its clinical use should be routinely considered. Moving forward, nonopioid analgesic therapies will likely play an increasing role in CIPN treatment, but further research is necessary to confirm their utility. Promising therapies include vitamin B12 supplementation, physical therapy, and various forms of neuromodulation. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The courage to fail.

No abstract available

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FDA OKs Biologic Guselkumab (Tremfya) for Plaque Psoriasis

Guselkumab is the first and only approved biologic agent that selectively blocks interleukin-23, a key player in plaque psoriasis.
FDA Approvals

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Enhanced Pru p 3 IgE binding activity by selective free fatty acid-interaction

Publication date: Available online 14 July 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Pawel Dubiela, Roberta Aina, Dominika Polak, Sabine Geiselhart, Piotr Humeniuk, Barbara Bohle, Stefano Alessandri, Rebecca Del Conte, Francesca Cantini, Tomasz Borowski, Merima Bublin, Karin Hoffmann-Sommergruber

Teaser

Upon binding to certain lipids, the major peach allergen, Pru p 3, undergoes conformational changes thus exposing one dominant IgE epitope. This conformational change enhances the allergenicity of Pru p 3.

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Polarized microscope assisted study of collagen fibres in Oral Submucous Fibrosis and their clinico-pathologic correlation-An in-vitro study

Publication date: Available online 14 July 2017
Source:Journal of Oral Biology and Craniofacial Research
Author(s): Ameena Singh, Sukumar Singh, Susmita Saxena, Sanjeev Kumar, Akanksha Banga, Nitin Purohit
BackgroundThe present study was aimed to evaluate and analyze orientation and birefringence pattern of collagen fibers histopathologically in different grades of OSMF using the special stain (Picrosirius red) under polarizing microscope and relate these factors with the severity of OSMF.Materials and Method45 confirmed cases of OSMF were taken from the archives. The selection of clinical cases was done according to classification by J.N Khanna and Andrade (1999). These cases were correlated histopathologically as per the criteria given by Pindborg J.J and Sirsat S.M (1966). The sections were stained with H & E and Picrosirius red stains and assessment was done accordingly. 10 cases of normal mucosa were taken as control.ResultsIn clinical grade I, 60% of the cases showed histopathological grade II, while 53.4% cases in clinical grade II correlated with histopathological grade III and 33.4% of clinical grade III cases showed histopathological grade IV. Upon application of Fisher's exact test a significant P value <.01 was obtained suggesting no statistical significant correlation between these two parameters. However, the orientation pattern revealed a parallel orientation as OSMF advanced. Also as the severity of the disease increased, there was a gradual shift from green- greenish yellow colour of the fibres and a shift to orange red-red colour.ConclusionUpon correlation of clinical grades with histopathological grades, no statistically significant difference was found. Birefringence pattern of collagen revealed similar findings as other studies in case of clinical grades but histopathological grades showed a contrast finding.

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A rare case of gastric mixed adenoneuroendocrine carcinoma (MANEC) with gastric Helicobacter pylori-negative mucosa-associated lymphoid tissue (MALT) lymphoma

Description

A 47-year-old African-American man presented to the emergency department with upper abdominal pain, nausea and vomiting. His symptoms were aggravated by eating. He reported 32 kg unintentional weight loss over 2 months' period. Abdominal examination revealed tenderness in the epigastric region. Abdominal CT scan showed mural wall thickening involving the gastric antrum and pylorus (figure 1). Subsequent oesophagogastroduodenoscopy (EGD) revealed a large mass occupying the gastric antrum (figure 2). Initial biopsy from the gastric mass showed poorly differentiated adenocarcinoma.

Figure 1

(A) Coronal section of the CT abdomen with intravenous and oral contrast showing wall thickening at the level of the gastric antrum. (B) Axial section of the CT abdomen with intravenous and oral contrast showing wall thickening at the level of the gastric antrum and pylorus.

Figure 2

Upper gastrointestinal endoscopy showing a mass in...

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Takotsubo cardiomyopathy and transient global amnesia: a shared aetiology

Takotsubo cardiomyopathy (TTC) is associated with acute, reversible left ventricular (LV) dysfunction, while transient global amnesia (TGA) is a reversible disorder of the brain characterised by anterograde amnesia. We report an unusual case of TTC occurring concurrently in a patient with TGA, and propose that catecholamine surge induced cerebral venous congestion and cardiotoxicity is the shared aetiology that leads to the concurrent manifestation of these conditions. TTC and TGA are reversible disorders that can occur concurrently in a subset of patients due to a unifying aetiology, catecholamine excess, leading to pathophysiological changes within the brain and the myocardium.

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Lupus miliaris disseminatus faciei: a distinctive facial granulomatous eruption

Facial granulomatous papules are important to recognise, as some of them are associated with significant systemic association, particularly sarcoidosis and certain infectious conditions. Lupus miliaris disseminatus faciei (LMDF) is a benign granulomatous disorder of unknown aetiology characterised by symmetrical, monomorphic, reddish-brown papules on the face. It is not associated with any underlying systemic involvement. We report a case of LMDF in a middle-aged man who presented to us with multiple asymptomatic and monomorphic reddish papules on the face for 3 months. Skin biopsy showed well-formed perifollicular epithelioid cell granulomas with focus of necrosis suggestive of LMDF. The lesions significantly responded to oral steroids.

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Renal fistulae: different aetiologies, similar management

Iatrogenic renocolic fistulae, although have been described in literature, is a rare clinical complication. Recently its incidence is on rise due to advent of minimally invasive surgery and percutaneous surgery of kidney. It has been reported after percutaneous nephrolithotomy but its incidence after percutaneous nephrostomy is quite uncommon and rarely reported. Though spontaneous renocutaneous fistula has been reported, acquired renocutaneous fistula is very uncommon and fistula after gun shot injury has not been reported to the best of our knowledge. Herein, we present two different varieties of renal fistula with completely different history and presentation. But the interesting point is that both were managed conservatively in a similar fashion and both of them responded well

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Pseudomonas aeruginosa as an unusual cause of cavitating lung lesion

A 31-year-old woman with systemic lupus erythematosus presented to the emergency department with cough for 1âweek. Chest radiograph demonstrated cavitating lesion in the right upper zone with surrounding ground-glass change. Blood culture results from the day of hospital presentation grew Pseudomonas aeruginosa. Sputum sample and pleural fluid grew P. aeruginosa and were negative for acid-fast bacilli. P. aeruginosa is a rare cause of cavitating lung lesion and has been associated with immunocompromised hosts. Most reports of cavitating P. aeruginosa lesions have been identified in patients who are immunocompromised secondary to HIV.The current case highlights the potential for infection in patients who are immunosuppressed therapeutically and appropriate investigations are necessary to rule out common causes of cavitating lung lesions.

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Complement factor B mutation-associated aHUS and myocardial infarction

A 6-month-old female infant was referred with a 3-day history of low-grade fever, slight nasal congestion and rhinorrhoea. On admission, the clinical findings were unremarkable and she was discharged home. However, she became progressively more listless with a decreased urine output and was once again seen in the emergency department. Analytically she was found to have metabolic acidosis, hyperkalaemia, thrombocytopaenia, anaemia and schistocytes in the peripheral blood smear. Based on these findings, the diagnosis of haemolyticâ-uremic syndrome was made. A few hours postadmission, there was an abrupt clinical deterioration. She went into cardiorespiratory arrest and she was successfully resuscitated. An ST-segment elevation was noted on the ECG monitor and the troponin I levels were raised, suggesting myocardial infarction. Despite intensive supportive therapy, she went into refractory shock and died within 30 hours.

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Anaphylaxis secondary to Parietaria judaica (wall pellitory)

Aeroallergens are an unusual cause of anaphylaxis with sparse reports in the literature. We describe a case of suspected anaphylaxis to Parietaria judaica pollen and the difficulties encountered in confirming this diagnosis.

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Focal neurological presentation in Hashimoto's encephalopathy mimicking a vascular occlusion of the middle cerebral artery

Hashimoto's encephalopathy is a rare form of autoimmune encephalopathy. It is likely an underdiagnosed entity especially in the setting of focal neurological defects. We report a case of a 49-year-old man who presented with "strange behavior"of a day's duration. Examination was significant only for lethargy, poor attention span and agitation. Routine labs revealed leucocytosis. Head CT scan was unremarkable. Lumbar puncture showed high white blood cells with lymphocytosis and elevated protein level. The patient was empirically treated for meningitis without improvement. His symptoms progressed to sudden right-sided weakness, ataxia and right facial droop. The MRI and magnetic resonance angiogram (MRA)were normal. The patientâ™s focal neurological signs improved spontaneously. Encephalopathy work-up was negative except for positive anti-Thyroid Peroxidaseand antithyroglobulin. The patient was treated as Hashimoto encephalopathy with steroids and azathioprine with marked improvement. Our case highlights how focal neurological findings can potentially mislead the provider to consider vascular aetiologies in Hashimoto's encephalopathy.

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Peritoneal tuberculosis as a cause of ascites in a patient with cirrhosis

A 59-year-old Portuguese Caucasian man with a history of heavy alcohol intake and no significant medical history presented with ascites, weight loss and general malaise. The ascitic fluid analysis showed 921 cells/mm³ with mononuclear predominance (93.6%), elevated total proteins and a slightly elevated serum-ascites albumin gradient. The abdominal ultrasound confirmed the presence of chronic liver disease with ascites, and additionally on CT there was evidence of peritoneal thickening. On repeat paracentesis, the ascitic fluid analysis showed elevated adenosine deaminase but it was negative for the presence of mycobacteria by Ziehl-Neelsen stain, Löwenstein-Jensen culture and PCR amplification. Due to the persistent suspicion of tuberculosis, a laparoscopy was performed showing multiple small white tubercles scattered over the peritoneum. Peritoneal biopsies showed the presence of necrotising granulomas and cultures were positive for Mycobacterium tuberculosis complex. After a 6-month course of tuberculostatics, the ascites resolved completely. The patient remained asymptomatic.

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Is FCH PET able to identify foci of infection superiorly to FDG PET?

We report a case of a brain abscess identified on fluorine-18 choline (FCH) positron emission tomography (PET) scan, which was not identified on fluorodeoxyglucose (FDG) PET scan. To our knowledge, there are no previous case reports of incidental brain abscess identified by FCH PET imaging. A 51-year-old man, with liver cirrhosis complicated by hepatocellular carcinoma (HCC) was enrolled in a research trial comparing HCC detection in FCH PET versus FDG PET. During the course of the trial, he underwent radiofrequency ablation (RFA) for HCC. A repeat FCH PET scan post-RFA incidentally revealed a 2.5âcm lesion with avid uptake in the left occipital area of the brain. The patient was asymptomatic. MRI suggested this was an abscess. A craniotomy and drainage was performed, with culture of Streptococcus intermedius (S. milleri group) from the thick-walled collection, a causative organism for previous episode of pneumonia. He successfully completed a 6 week course of antibiotics.

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External revascularisation for pseudochronic total occlusion of the dorsal pedis artery due to foot drop with severe diabetes mellitus

Description

A 45-year-old woman with end-stage renal disease and severe diabetes mellitus (haemoglobin A1c (HbA1c) 9.5%) suffered from critical limb ischaemia (CLI). Her right ankle brachial pressure index (ABPI) was 0.77; however, her left ABPI was immeasurable with flat waveform. Additionally, skin perfusion pressure was 34 mm Hg on the left dorsal and 22 mm Hg on the left planter. The angiography showed chronic total occlusion (CTO) of the dorsal pedis artery (DPA) (figure 1, left panel). We electively performed endovascular therapy. The soft wire smoothly passed the CTO of the DPA. We dilated the CTO with a 2.0 mm balloon several times; however, blood flow could not be restored. This discrepancy suggested an unusual CTO. Intravascular ultrasound showed an intact DPA. She also had foot drop due to diabetic neuropathy. Since the entry of CTO was at the dorsal ankle joint, this joint abnormality was considered the cause of the CTO....

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Abciximab-induced acute profound thrombocytopenia postpercutaneous coronary intervention

Abciximab (c7E3 Fab) is one of the three potent intravenous glycoprotein IIb/IIIa receptor inhibitors (along with eptifibatide and tirofiban) that have shown significant positive outcomes when used in patients with intracoronary thrombus. However, major side effects have been reported with its use including hypotension, major bleeding and thrombocytopenia. This case is a 53-year-old man presenting with acute chest pain diagnosed with non-ST-elevation myocardial infarction, who underwent percutaneous coronary intervention with abciximab and heparin infusion and developed acute profound thrombocytopenia (platelet count <20,000/L) within 9 hours of infusion. This case demonstrates the importance of routinely monitoring the platelet count prior to and 2–4 hours following abciximab infusion and differentiating other causes of acute profound thrombocytopenia, particularly pseudothrombocytopenia and heparin-induced thrombocytopenia.

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Venobiliary fistula with haemobilia: a rare complication of percutaneous liver biopsy

We describe a case of a 36-year-old man with a history of chronic hepatitis C who presented with abdominal pain 3 days after undergoing a percutaneous ultrasound-guided liver biopsy. Initial investigations revealed a venobiliary fistula with haemobilia and obstructive jaundice with direct bilirubin peaking at 9.2 mg/dL. He underwent an endoscopic retrograde cholangiopancreatography with sphincterotomy and stent placement, bilirubin decreased to 3.7 mg/dL, and the patient was discharged. The patient returned with recurrent abdominal pain and upper gastrointestinal bleeding with haemoglobin of 8.6 g/dL, requiring multiple transfusions. He underwent transcatheter arterial embolisation but continued bleeding. Radiofrequency ablation was pursued and was able to achieve haemostasis. The patient was discharged. The patient returned again with a fever of 39.2 °C and was found to have a large right hepatic lobe abscess. The patient underwent abscess drainage with drain placement and was treated with antibiotics for 6 weeks. He followed up in the clinic with resolution of symptoms and infection.

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Prognostic significance of central venous-to-arterial carbon dioxide difference during the first 24 hours of septic shock in patients with and without impaired cardiac function

Abstract

Objective: To investigate the prognostic significance of central venous-to-arterial carbon dioxide difference (cv-art CO₂ gap) during septic shock in patients with and without impaired cardiac function.Methods: We performed a prospective cohort study in 10 French intensive care units. Patients suffering from septic shock were assigned to the impaired cardiac function group ('cardiac group', n=123) if they had atrial fibrillation (AF) and/or left ventricular ejection fraction (LVEF) <50% at study entry and to the non-cardiac group (n=240) otherwise.Results: Central venous and arterial blood gases were sampled every 6 h during the first 24 h to calculate cv-art CO₂ gap. Patients in the cardiac group had a higher cv-art CO₂ gap [at study entry and 6 and 12 h (all P<0.02)] than the non-cardiac group. Patients in the cardiac group with a cv-art CO₂ gap >0.9 kPa at 12 h had a higher risk of day 28 mortality (hazard ratio=3.18; P=0.0049). Among the 59 patients in the cardiac group with mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg and central venous oxygen saturation (ScvO₂) ≥70% at 12 h, those with a high cv-art CO₂ gap (>0.9 kPa; n=19) had a higher day 28 mortality (37% vs. 13%; P=0.042). In the non-cardiac group, a high cv-art CO₂ gap was not linked to a higher risk of day 28 death, whatever the threshold value of the cv-art CO₂ gap.Conclusion: Patients with septic shock and with AF and/or low LVEF were more prone to a persistent high cv-art CO₂ gap, even when initial resuscitation succeeded in normalizing MAP, CVP, and ScvO₂. In these patients, a persistent high cv-art CO₂ gap at 12 h was significantly associated with higher day 28 mortality.

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The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery

Abstract

Background. A simple and accurate scoring system to predict risk of transfusion for patients undergoing cardiac surgery is lacking.We conducted a retrospective analysis of data collected from the ACTA National Audit. For the derivation dataset, we included data from 20 036 patients, which we then externally validated using a further group of 1047 patients.Methods. We identified independent risk factors associated with transfusion by performing univariate analysis, followed by logistic regression. We then simplified the score to an integer-based system and tested it using the area under the receiver operator characteristic (AUC) statistic with a Hosmer-Lemeshow goodness-of-fit test. Finally, the scoring system was applied to the external validation dataset and the same statistical methods applied to test the accuracy of the ACTA-PORT score.Results. Several factors were independently associated with risk of transfusion, including age, sex, body surface area, logistic EuroSCORE, preoperative haemoglobin and creatinine, and type of surgery. In our primary dataset, the score accurately predicted risk of perioperative transfusion in cardiac surgery patients with an AUC of 0.76. The external validation confirmed accuracy of the scoring method with an AUC of 0.84 and good agreement across all scores, with a minor tendency to under-estimate transfusion risk in very high-risk patients.Conclusions. The ACTA-PORT score is a reliable, validated tool for predicting risk of transfusion for patients undergoing cardiac surgery. This and other scores can be used in research studies for risk adjustment when assessing outcomes, and might also be incorporated into a Patient Blood Management programme.

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Reproducibility of science and developmental anaesthesia neurotoxicity: a tale of two cities

Editor—Reproducing scientific observations is the foundation of trusted discoveries. In clinical sciences, specific questions are repeatedly asked by a multitude of observational studies or trials, and the rigorous meta-analysis of these multicentre datasets leads us closer toward the application of evidence-based medicine in our patients. A similar approach is less frequently applied to basic and even translational research, where differences in experimental protocols used, species studied, and outcome measures reported make direct comparison of laboratory studies at best very difficult.¹ The seeming lack of interest in thoroughly replicating experiments produced by other laboratories can be explained by a multitude of factors, amongst which the difficulties to obtain funding and dedicated researchers to conduct highly time- and money-consuming "non-innovative" projects are probably the most important. It is increasingly acknowledged that many preclinical studies are statistically underpowered and cannot be reproduced.² ³ The absence of confirmation of an experimental finding by other independent laboratories can greatly weaken the confidence in any particular observation. Importantly, many clinical trials are fuelled by translational experimental datasets, and these preclinical works should be reliable and of the highest quality to provide a solid base for human studies.

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Fading whispers down the lane: signal propagation in anaesthetized cortical networks

An active area of enquiry in the neuroscientific investigation of general anaesthesia is the question of whether anaesthetic-induced unconsciousness is mediated by bottom-up or top-down mechanisms in the brain. Candidates for the bottom-up approach include suppression of arousal centres in the brainstem and diencephalon,¹ ² activation of sleep-promoting neurones or nuclei in similar locations,¹ ³ blockade of sensory information en route from the thalamus to the cortex,⁴ and a disabled thalamic conductor for the neuronal orchestra of the cortex.⁵ Candidates for the top-down approach include direct effects on long-latency activity in cortical networks,⁶ with a consequent disruption of higher-order information synthesis that occurs beyond the level of the primary sensory cortex.^7–9 This bottom-up vs top-down distinction is almost surely artificial given the integrated circuits required for the normal function of neural systems and the widespread effects of general anaesthetics on the brain. We recently proposed that anaesthetics alter the level of consciousness (e.g. awake vs somnolent) through bottom-up mechanisms while degrading the contents of consciousness (e.g. the particular qualities of experience) through top-down mechanisms.¹⁰ Developing a clearer understanding of these processes is important because it can inform (i) the neurobiology of consciousness, a fundamental question in science, and (ii) our approach to brain monitoring, a fundamental and unmet challenge in clinical anaesthesia. However, it is difficult to address this question by investigating individual brain areas or molecular targets in the laboratory and also difficult to distinguish cortical and subcortical mechanisms through human neuroimaging and neurophysiology. In this issue of the British Journal of Anaesthesia, Hentschke and colleagues¹¹ examine an intermediate level of neuroanatomy and neurophysiology in a cortical slice model, finding more profound effects of isoflurane on signal propagation through the cortex than to the cortex.

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21st Annual Scientific Meeting of the Difficult Airway Society: lessons learned and glimpses of the future

The 21st Annual Scientific Meeting of the Difficult Airway Society (DAS) took place in Torquay (Devon, UK) on November 16–18, 2016. The workshop day included traditional workshops, a tracheostomy workshop, and a 'can't intubate, can't oxygenate' (CICO) workshop. The next 2 days encompassed a variety of stimulating sessions, presentations, lunchtime symposia, a pro–con debate, free paper presentations, and poster presentations.

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Brugada syndrome in a patient with amyotrophic lateral sclerosis: a case report

Amyotrophic lateral sclerosis is a fatal neuromuscular disorder characterized by progressive death of the upper and lower motor neurons in the central nervous system. Patients with this disease die mostly as a...

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Streptococcal toxic-shock syndrome due to Streptococcus dysgalactiae subspecies equisimilis in breast cancer-related lymphedema: a case report

Breast cancer-related lymphedema often causes cellulitis and is one of the most common complications after breast cancer surgery. Streptococci are the major pathogens underlying such cellulitis. Among the stre...

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A total of 56 tumors were collected (94,6% AK and 5,4% SCC). Thirty-seven (66.1%) lesions were non-pigmented and 19 (33.9%) pigmented. The most common dermoscopic findings were erythema (53; 94.6%) and scale (42; 75%). White circles were present in 21 lesions (37.5%); pigmented pseudonetwork in 18 (32.1%) and multiple gray-to-brown dots and globules in 14 (25%). Rosettes were distributed focally in 9 (16.1%) and generalized in 47 (83.9%). The rosette pattern (rosettes as the main structure) was observed only in AK (19; 35.8%).

Limitations

The analysis was not blinded. The distinction between focal distribution (up to 3 rosettes) or generalized could be considered arbitrary.

Conclusion

The rosette pattern identified in AK may be a specific pattern for AK.

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Paraneoplastic systemic lupus erythematosus in association with oat cell tumour of the lung

A 63-year-old man presented in the emergency department with general malaise, asthenia, an erythematosquamous rash on face and forearms and severe hyponatremia. The rash appeared after working in his garden on a sunny afternoon without sunscreen protection (Figure 1A/B/C). Furosemide was stopped and once daily mometason furoate cream was prescribed. Hyponatremia was corrected by IV hypertonic fluids. Five days later, the rash spread to the upper legs, chest and back. Histopathology revealed damage of the basal layer with necrotic keratinocytes and dermal perivascular and adnexal infiltrates (Figure 2).

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Psoriasis and migraine

Abstract

Background

Psoriasis and migraine share several pathogenetic mechanisms due to systemic inflammation, which increase the risk of developing cardiovascular disease.

Objective

Our aim is to investigate the prevalence of migraine with (MA) and without aura (MO) in the psoriatic population, investigating a possible new comorbidity of the psoriatic disease.

Methods

We referred 68 psoriatic patients to a 9 questions survey formulated on the basis of the International Headache Society (IHS) diagnostic criteria for migraine. Than, in the case of MA, the mean monthly number of migraine crises was assessed. Data of psoriatic patients were than compared with those of a psoriasis free control group composed of 235 migraine patients (with and without aura).

Results

A clinical diagnosis of migraine was performed in 32 psoriasis patients with a great prevalence in women (F: 87.50% - M: 12.5%). Moreover we found a much higher prevalence (62.5%) of MA, with the remaining 37.5% diagnosed with MO. Comparing the prevalence of MA between psoriasis + migraine patients and the control group we observed a statistical significative difference (p<0.0001); furthermore the number of MA crises was significantly higher (p<0.0001) in patients with psoriasis with respect to the MA control group.

Conclusions

We showed a significant association between psoriasis and migraine, especially MA, probably due to common pathogenetic mechanisms, but further studies are needed to assess their interplay in developing cardiovascular diseases.

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Study to Evaluate the Safety and Tolerability of Avelumab in Combination With Other Anti-Cancer Therapies in Patients With Advanced Malignancies

Conditions: Malignant Neoplasm of Breast; Malignant Neoplasms of Bone and Articular Cartilage; Malignant Neoplasms of Digestive Organs; Malignant Neoplasms of Eye Brain and Other Parts of Central Nervous System; Malignant Neoplasms of Female Genital Organs; Malignant Neoplasms of Ill-defined Secondary and Unspecified Sites; Malignant Neoplasms of Independent (Primary) Multiple Sites; Malignant Neoplasms of Lip Oral Cavity and Pharynx; Malignant Neoplasms of Male Genital Organs; Malignant Neoplasms of Mesothelial and Soft Tissue; Malignant Neoplasms of Respiratory and Intrathoracic Organs; Malignant Neoplasms of Thyroid and Other Endocrine Glands; Malignant Neoplasms of Urinary Tract; Neoplasms of Uncertain or Unknown Behavior
Interventions: Drug: Avelumab; Drug: Utomilumab; Drug: PF-04518600; Radiation: Radiation; Drug: Cisplatin
Sponsors: M.D. Anderson Cancer Center; Pfizer
Not yet recruiting - verified July 2017

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Proton Re-Irradiation for Recurrent Head and Neck Cancer

Condition: Head and Neck Cancer
Interventions: Radiation: conventionally fractionated full dose re-irradiation; Radiation: hypofractionated palliative re-irradiation
Sponsor: Memorial Sloan Kettering Cancer Center
Recruiting - verified July 2017

http://ift.tt/2tahUYx

Effectiveness of Proprioceptive Exercise in Neck Pain

Condition: Neck Pain
Interventions: Other: Mobility exercises; Other: Proprioception exercises
Sponsor: University of Valencia
Recruiting - verified July 2017

http://ift.tt/2tTdx16

MRG HIFU With Radiotherapy for Palliation of H&N Cancer

Condition: Head and Neck Cancer
Intervention: Other: MR Guided HIFU
Sponsors: Sunnybrook Health Sciences Centre; Focused Ultrasound Foundation
Recruiting - verified July 2017

http://ift.tt/2taO4mB

Behandlungsergebnisse bei rezidivierender respiratorischer Papillomatose

Zusammenfassung

Hintergrund

Die rezidivierende respiratorische Papillomatose (RRP) ist eine seltene chronische Erkrankung viraler Ätiologie, die durch das multiple, rezidivierende Auftreten von Plattenepithelpapillomen charakterisiert ist.

Material und Methoden

Retrospektiv wurden die Behandlungsergebnisse und Rezidivraten von 106 Patienten mit RRP des Larynx ausgewertet. Sie wurden zwischen 1983 und 2014 wegen RRP an der Uniklinik Magdeburg behandelt. Verglichen wurden die konventionelle und Laserchirurgie bezüglich der Rezidivintervalle und der Komplikationen sowie der Effekt der Gardasil®-Impfung bei 10 Patienten.

Ergebnisse

Bei Kindern mit RRP erfolgten signifikant mehr Eingriffe lebenslang als bei erwachsenen Patienten. Es gab keine signifikanten Unterschiede in der Zeit bis zum Rezidiv oder in der Anzahl der Eingriffe/Jahr bei der adulten (n = 79) und bei der juvenilen (n = 27) RRP. Die verschiedenen chirurgischen Methoden hatten keinen Einfluss auf die Zeit bis zum Rezidiv oder die Anzahl der Eingriffe/Jahr. Komplikationen traten ohne signifikanten Unterschied sowohl nach konventioneller Chirurgie als auch nach Laserchirurgie auf. Ernste Komplikationen und die Notwendigkeit einer Tracheotomie wurden nur selten beobachtet. Durch die Gardasil®-Impfung wurde bei den 10 Patienten eine signifikante Reduktion der Eingriffe/Jahr nach der Impfung erreicht.

Schlussfolgerung

Die RRP ist eine seltene Krankheit. Die Behandlung benötigt Erfahrung und kann sehr schwierig sein. Nach Auswertung der Ergebnisse ist die Behandlung der Wahl die laserchirurgische Ablation der Papillomherde in Kombination mit der quadrivalenten bzw. polyvalenten Impfung. Möglicherweise kann durch eine konsequente Impfung sowohl von Mädchen als auch Jungen das Auftreten der RRP reduziert werden.

http://ift.tt/2umvxDi

Fractional Er:YAG laser assisting topical betamethasone solution in combination with NB-UVB for resistant non-segmental vitiligo

Abstract

Resistant non-segmental vitiligo is difficult to be treated. Ablative erbium-YAG (Er:YAG) laser has been used in the treatment of vitiligo, but the ablation of entire epidermis frustrated the compliance of patients. The purpose of this study is to investigate the effects of fractional Er:YAG laser followed by topical betamethasone and narrow band ultraviolet B (NB-UVB) therapy in the treatment of resistant non-segmental vitiligo. The vitiligo lesions of each enrolled patient were divided into four treatment parts, which were all irradiated with NB-UVB. Three parts were, respectively, treated with low, medium, or high energy of Er:YAG laser, followed by topical betamethasone solution application. A control part was spared with laser treatment and topical betamethasone. The treatment period lasted 6 months. The efficacy was assessed by two blinded dermatologists. Treatment protocol with high energy of 1800 mJ/P of fractional Er:YAG laser followed by topical betamethasone solution and in combination with NB-UVB made 60% patients achieve marked to excellent improvement in white patches. The protocol with medium energy of 1200 mJ/P of laser assisted approximate 36% patients achieve such improvement. The two protocols, respectively, showed better efficacies than NB-UVB only protocol. However, fractional Er:YAG laser at low energy of 600 mJ/P did not provide such contributions to the treatment of vitiligo. The fractional Er:YAG laser in combination with topical betamethasone solution and NB-UVB was suitable for resistant non-segmental vitiligo. The energy of laser was preferred to be set at relatively high level.

http://ift.tt/2uZaqVc

Comparison between inflammation-related markers in peri-implant crevicular fluid and clinical parameters during osseointegration in edentulous jaws

Abstract

Objectives

The aim of this study is to improve the understanding of interleukin mechanisms during osseointegration to enhance the monitoring of implant failure and success. Clinical parameters, implant stability, and cytokine levels in peri-implant crevicular fluid (PICF) during early bone healing after implant placement were investigated.

Material and methods

Sixty narrow implants were placed in mandible anterior region of 30 edentulous patients (67.23 ± 7.66 years). Bone type, insertion torque, and primary stability were registered during surgery. Clinical measurements of peri-implant health and the secondary implant stability quotient (ISQ) were recorded. Samples from the PICF were collected 1, 2, 4, 8, and 12 weeks after surgery and analyzed for IL-1β, IL-6, IL-10, and TNF-α levels using ELISAs.

Results

The gingival index increased significantly during the first week (p = 0.05), while the plaque index increased significantly between 4 to 8 and 8 to 12 weeks (p < 0.05). The probing depth and the ISQ also reduced significantly (p < 0.05) over time. The TNF-α release increased significantly after the 2nd week for non-atrophic patients and 4th week for atrophic patients (p < 0.05). The IL-1β concentrations showed a short-lived peak after 1st week (p = 0.003), specially in atrophic patients and sites with bone type I (p = 0.034; p = 0.007). The IL-6 concentrations peaked during the 1st and 2nd weeks (p < 0.05; p = 0.005) in atrophic patients and in bone type II (p = 0.023; p = 0.003). The IL-10 concentrations increased gradually over time, showing the highest concentrations at the 12th week (p < 0.005). A total of 12 implants failed at different periods.

Conclusion

While the clinical measurements presented differences between the evaluation periods, these were not indicative of early dental implant failure or peri-implant diseases. Smoking, bone atrophy, and bone type can greatly influence the cytokines concentrations during the healing time.

http://ift.tt/2uqyOCb

A comprehensive study of smoking-specific microRNA alterations in head and neck squamous cell carcinoma

Publication date: September 2017
Source:Oral Oncology, Volume 72
Author(s): Aswini R. Krishnan, Hao Zheng, James G. Kwok, Yuanhao Qu, Angela E. Zou, Avinaash Korrapati, Pin Xue Li, Joseph A. Califano, Melbourne F. Hovell, Jessica Wang-Rodriguez, Weg M. Ongkeko
ObjectiveWhile tobacco smoking is a well-known risk factor for head and neck squamous cell carcinoma (HNSCC), the molecular mechanisms underlying tobacco-induced HNSCC remain unclear. This study sought to comprehensively identify microRNA (miRNA) alterations and evaluate their clinical relevance in smoking-induced HNSCC pathogenesis and progression.Materials and methodsUsing small RNA-sequencing data and clinical data from 145 HNSCC patients, we performed a series of differential expression and correlation analyses to identify a panel of tobacco-dysregulated miRNAs associated with key clinical characteristics in HNSCC. We then examined the expression patterns of these miRNAs in normal epithelial cell lines following exposure to cigarette smoke extract.ResultsOur analyses revealed distinct panels of miRNAs to be dysregulated with smoking status and associated with additional clinical features, including tumor stage, metastasis, anatomic site, and patient survival. The differential expression of key miRNAs, including miR-101, miR-181b, miR-486, and miR-1301, was verified in cigarette-treated epithelial cell lines, suggesting their potential roles in the early development of smoking-related HNSCCs.ConclusionSpecific alterations in miRNA expression may be traced to tobacco use and are associated with important HNSCC clinical characteristics. Future studies of these miRNAs may be valuable for furthering the understanding and targeted treatment of smoking-associated HNSCC.

http://ift.tt/2uqCTGw

Pica, constipation and cardiorespiratory arrest

Description

Pica is an eating disorder typically defined as the persistent ingestion of non-nutritive substances, for at least 1 month, at an age of which this behaviour is inappropriate. It may be benign or may have life-threatening consequences.1 2 The clinical presentation is highly variable and is associated with the specific nature of the resulting medical conditions and the ingested substances. The signs and symptoms can be from toxic, infectious, dental or gastrointestinal conditions.3

The authors present a clinical case of a 61-year-old man with clinical history of cognitive impairment and pica, admitted in an intensive care unit after cardiorespiratory arrest. The initial hospital admission was for constipation and abdominal pain. Abdominal and pelvic CT scan revealed 'significant colonic dilatation with a sigmoid size of 14.5 cm, with evidence of abundant intraluminal faecal content at this level—aspects suggestive of translating obstructive process by faecaloma,...

http://ift.tt/2tTruvJ

Marantic endocarditis and paraneoplastic pulmonary embolism

Cancer is frequently associated with a hypercoagulable state. Almost 15% of patients with cancer will suffer a thromboembolic event during their clinical course. The aetiology of this hypercoagulable state is multifactorial and includes procoagulant factors associated with malignancy as well as the host's inflammatory response. Cancer-associated thrombophilia can present as venous thromboembolism, migratory superficial thrombophlebitis, arterial thrombosis, disseminated intravascular coagulation, thrombotic microangiopathy and rarely non-bacterial thrombotic endocarditis (NBTE). In this paper, we will describe an uncommon presentation of lung cancer on a non-smoker middle-aged woman, with recent diagnosis of pulmonary embolism, who develops malignant recurrent pleural effusion, NBTE with cutaneous and neurological manifestations, with a rapid evolution into shock, culminating in death. Diagnosis of NBTE requires a high degree of clinical suspicion. The mainstay of treatment is systemic anticoagulation to prevent further embolisation and underlying cancer control whenever is possible.

http://ift.tt/2ta9xfk

Leucocytoclastic vasculitis following influenza vaccination

Background

Influenza vaccinations are commonly administered and effectively prevent influenza. Most vaccine reactions are mild and self-limiting with few reported cases of vasculitis. We present a case of vasculitis post-vaccination unique for its dramatic visual presentation and rapid response to treatment with the aim to emphasise possible causation and timely treatment.

Case presentation

This is a case of a 60-year-old man with chronic idiopathic pulmonary fibrosis, with fever, arthralgias and rash characterised by extensive erythematous plaques on his limbs and trunk 5âdays after influenza vaccination. Skin biopsy revealed leucocytoclastic vasculitis. Rash and symptoms resolved 10 days after initiating treatment with oral prednisone.

Conclusions

Influenza vaccines can potentially precipitate cutaneous vasculitis, and timely treatment reduces morbidity in the elderly.

http://ift.tt/2tThliF

Ciliated foregut cyst of the gall bladder: the largest ever described

A 78-year-old man presented to the accident and emergency department with acute abdominal pain. A CT scan done to investigate the pain showed an intra-abdominal abscess medial to the caecum and an incidental exophytic lesion in the gall bladder. This was excised during surgery and sent for histological examination. Histology showed a ciliated foregut cyst of the gall bladder. A literature review revealed that this was the 13th case worldwide, as ciliated foregut cysts are usually found either above the diaphragm or in the liver. It was also the largest cyst described, with 45âmm diameter. So far none of these cysts found in the gall bladder have shown malignant transformation, though those found in the liver have been known to become malignant. Due to histological similarity, excision of ciliated foregut cysts of the gall bladder should be considered as there is still a risk of malignant transformation.

http://ift.tt/2ta9wYO

Cervical shock: a complication of incomplete abortion

A case of a 37-year-old female primagravida who attended the emergency department (ED) via ambulance in hypotensive shock. She was 10 weeks pregnant, but had an inevitable miscarriage confirmed in the local Early Pregnancy Unit 3 weeks previously. She was hypotension (90/60âmm Hg), bradycardic (45 bpm) and was peripherally shut down. A provisional diagnosis of haemorrhagic shock was made, but despite intravenous fluid challenges, she appeared to be deteriorating, so a major haemorrhage protocol was activated. On examination, there was some vaginal bleeding and a protruding sac noted. The gynaecology registrar was informed and performed an Evacuation of the Retained Products of Conception in the ED. This gave instant relief to the patient and her blood pressure and heart rate became normal over a few minutes. She went on to make a full recovery. This case provides useful learning points for doctors working in the ED and other urgent care settings.

http://ift.tt/2tTrufd

Use of cabergoline for the management of persistent Cushings disease in pregnancy

Cushing's disease (CD) is rare during pregnancy and is associated with significant maternal and fetal complications. It is important to control hypercortisolism during pregnancy, either surgically or medically, for a successful maternal and fetal outcome. We report a patient with recurrent CD who was treated with low-dose cabergoline (CAB) for persistent hypercortisolism throughout pregnancy. A 36-year-old woman was diagnosed with CD at the age of 23. She underwent trans-sphenoidal surgery with initial complete remission. However, 4 years after surgery, CD recurred and she underwent Gamma Knife radiosurgery (GKRS). Following GKRS, her cortisol levels remained elevated despite no evidence of visible tumour on pituitary MRI. Medical treatment was commenced with ketoconazole and cyproheptadine. This was changed to CAB as she was keen for pregnancy. She conceived spontaneously and was on CAB throughout pregnancy. She delivered a healthy male neonate, weighing 3195 g at 40 weeks of gestation.

http://ift.tt/2taJODK

Stigma kills! The psychological effects of emotional abuse and discrimination towards a patient with HIV in Uganda

Our patient is a 58-year-old Ugandan woman. After her husband's death in 1994, the patient was forced to leave her home by her late husband's family and arrangements were made for her mother to provide care until her inevitable death. The patient suffered from multiple mental health disturbances as a result of discrimination. Socially isolated after years of self-neglect, she prepared to overdose. In 2007, she became open regarding her status after receiving psychosocial support from various sources. She opened her home as an HIV clinic with the help of a local doctor, and subsequently the majority of her psychological symptoms were resolved. This case illustrates the negative impact that stigma and discrimination can have on mental and consequently physical health, both acutely and chronically. It also highlights the importance of social and psychological support in maintaining the well-being of patients with HIV globally.

http://ift.tt/2tTxjti

Laparoscopic excision of an inflammatory myofibroblastic tumour of the bladder disguised as deep infiltrating endometriosis

Inflammatory myofibroblastic tumour (IMT) of the bladder is a rare tumour of indeterminate malignant potential with myofibroblastic differentiation, with a generally benign but rarely aggressive behaviour. Vesical IMT is usually treated by transurethral resection or partial cystectomy. Herein we describe a case of a woman who underwent laparoscopic excision of an IMT of the bladder, initially diagnosed as deep infiltrating endometriosis.

http://ift.tt/2taJk0f

Unusual sensory variant of Guillain-Barre syndrome

We describe a 52-year-old woman presenting with acute onset of severe burning paraesthesia in the hands and feet associated with allodynia and antalgic gait. At the time of admission to hospital no motor weakness was present. A diagnosis of Guillain-Barré syndrome (GBS) was considered when neurophysiological studies were completed showing convincing evidence of demyelination on motor conduction studies and sural sparing on sensory nerve studies.¹ We describe this case as a sensory variant of GBS. Clinical improvement followed treatment with a single course of intravenous immunoglobulin (IVIG). The patient made a complete clinical recovery within 6 months of onset and repeat neurophysiological studies showed marked improvement. We encourage clinicians to consider an atypical variant of GBS in patients presenting with acute sensory complaints.

http://ift.tt/2tTdz8S

Disseminated histoplasmosis presenting as multiple oral ulcers

A 61-year-old female with a history of advanced HIV disease and chronic hepatitis B was presented with an 8-week history of painful oral ulcers. She appeared systemically well but examination revealed multiple well-demarcated clean-based ulcers on the tongue and hard palate. Biopsy of one of the lesions showed numerous histiocytes containing intracellular yeast forms consistent with Histoplasma capsulatum var. capsulatum. Fungal blood cultures subsequently grew H. capsulatum var. capsulatum, confirming a diagnosis of disseminated histoplasmosis. She was treated with intravenous amphotericin B for 2 weeks followed by a prolonged course of oral itraconazole, with which her ulcers resolved completely and have not recurred. This case exemplifies how oral ulcers may be a manifestation of an underlying systemic disease and demonstrates the utility of biopsy in establishing a diagnosis.

http://ift.tt/2taN3L7

Organ-sparing surgery for large cell calcifying Sertoli cell tumour in a patient with Carney complex

Carney complex is a rare genetic disease characterised by a complex of myxomas, spotty pigmentation and endocrine overactivity. At diagnosis, about one-third of male patients presents with testicular tumours, namely large cell calcifying Sertoli cell tumours, which are often multicentric and/or bilateral and have a low malignant potential. Although radical orchiectomy is the gold standard for the treatment of testicular neoplasms, a conservative approach with partial orchiectomy or tumourectomy may be the best treatment option for these patients, allowing the preservation of endocrine function, fertility and body image. We present a case of a 19-year-old man with a known history of Carney complex with early identification of a small testicular tumour treated with organ-sparing surgery.

http://ift.tt/2tT3dpv

IVC tumoural thrombosis: an unusual complication of testicular tumour

Description

A 30-year-old man presented with right scrotal mass and bilateral leg oedema for the last 3 months. CT scan showed a heterogeneously enhancing lesion in the right testis with retroperitoneal and mediastinal lymph node (LN) mass with enhancing tumorous thrombus filling the common iliac veins and inferior vena cava (IVC) up to the infrahepatic region with pulmonary metastases (figure 1). The preoperative tumour markers including lactate dehydrogenase, alpha-fetoprotein and human chorionic gonadotropin were 2270 U/L, 28 214 ng/mL and 6253 mIU/mL, respectively. High inguinal orchidectomy was carried out which revealed mixed germ cell tumour (GCT) (pT3N3M1aS3, poor risk as per International Germ Cell Cancer Collaborative Group). Chemotherapy including four cycles of VIP (etoposide, ifosfamide and cisplatin) with anticoagulation was started in the immediate postoperative period. Standard BEP (bleomycin, etoposide and cisplatin) xfour regimen could not be given because of poor pulmonary function. Postchemotherapy CT scan after 4 weeks revealed complete resolution of IVC thrombus with small residual...

http://ift.tt/2ta9wrM

Chilaiditi syndrome mimicking congestive heart failure

Description

An 85-year-old man presented with orthopnoea and dyspnoea, symptoms of which were suspicious for heart failure. He was in respiratory distress and oxygen saturation was 85% on 4 L oxygen. On initial assessment, lungs were clear and heart sounds were normal. What was immediately evident was a distended abdomen. Digital rectal examination revealed hard faeces in rectum. He had a history of chronic constipation and last bowel movement was over 5 days ago.

Chest X-ray (figure 1) showed raised diaphragms with loops of large bowel interposed between the right hemidiaphragm and liver. An abdominal X-ray (figure 2) confirmed faecal impaction. Brain natriuretic peptide, d-dimer and echocardiogram were normal. He eventually underwent manual evacuation following failure of oral laxatives and enemas (figure 3 for follow-up chest X-ray).

Figure 1

Chest X-ray on presentation showing Chilaiditi sign and lungs compressed.

...

http://ift.tt/2tTsxvI

Αρχειοθήκη ιστολογίου

Παρασκευή 14 Ιουλίου 2017

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