Head and Neck Medicine by Alexandros G.Sfakianakis: 07/26/17

Τετάρτη 26 Ιουλίου 2017

Optimising the surgical outcome in a case of post-traumatic cataract using ultrasound biomicroscopy

A 12-year-old boy was brought with the chief complaint of diminution of vision in his left eye for the past 1 month. History revealed a blunt trauma to his left eye with a wooden stick 6âweeks ago.Visual acuity was 20/20 and hand movement close to face in right and left eye, respectively, without any relative afferent pupillarydefect. Slit-lamp examination showed a total cataractous lens with signs suggestive of suspected posterior capsular (PC) defect. The PC defect was screened initially using B-scan ultrasound of the posterior segment, followed by confirmation of the same using ultrasound biomicroscopy. Left eye lens aspiration along with limited anterior vitrectomy followed by placement of multipiece intraocular lens in the sulcus was performed. Best-corrected visual acuity at 6 months of follow-up was 20/20.

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Giant oesophageal gastrointestinal stromal tumour presenting with dyspnoea and clubbed fingers

Gastrointestinal stromal tumours (GISTs) are mesenchymal neoplasms of the gastrointestinal tract originating from the interstitial cells of Cajal. Giant oesophageal GISTs are rare since the oesophagus is rarely the primary site of GISTs, and they are usually diagnosed early due to complaints such as dysphagia. We present the case of a giant oesophageal GIST presenting with prominent clubbing. The case underlined the diagnostic importance of clubbing and the careful consideration of chemotherapy. Although clubbed fingers associated with GISTs are rare, our experience demonstrates the importance of physicians' recognition of clubbing as a paraneoplastic phenomenon for early diagnosis of malignancies since patients seldom notice their own clubbing by themselves. Chemotherapy using imatinib, an Bcr-Abl kinase inhibitor, is the standard option for unresectable giant GISTs. However, careful consideration must be made of the risk of complications associated with rapid mass reduction due to imatinib such as bleeding, oesophageal perforation and mediastinitis.

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Type I talon cusp on mandibular incisor

Description

Talon cusp is a comparably rare developmental dental anomaly assumed to arise because of evagination on the surface of a tooth crown during tooth calcification stage. Talon cusp also called as Eagle's is a well-defined extra cusp like structure located on lingual or palatal surface of deciduous or permanent anterior teeth. Its occurrence may be either unilateral or bilateral, single or multiple teeth in males or females. Prevalence of talon's cusp is reported to be between 0.06% to 7.7%. Eagle's talon is most commonly seen in maxillary lateral incisor >maxillary central incisor> maxillary canine> mandibular incisor.1

Mandibular talon cusp is a rare entity to occur. Mandibular talon cusps are more prevalent in men than women. Occurrence in talon cusp is more common in permanent dentition. Most of the mandibular talon cusp shows unilateral presentation. Talon cusp associated with permanent central incisor and primary lateral incisor...

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Between fire and ice: refractory hypothermia and warmth-induced pain in inherited erythromelalgia

Inherited erythromelalgia (IEM) is a well-described pain disorder caused by mutations of sodium channel Na_v1.7, a peripheral channel expressed within dorsal root ganglion and the sympathetic ganglion neurons. Clinically, IEM is characterised by paroxysmal attacks of severe pain, usually in the distal extremities, triggered by warmth or exercise. Pain is not adequately treated by existing pharmacological agents. Individuals with IEM classically cool their limbs for relief, in some cases resulting in tissue injury. We describe a patient from a family with IEM due to the L858F mutation of Na_v1.7 who presented with refractory hypothermia due to overcooling. This presentation of refractory hypothermia necessitating warming strategies, complicated by severe warmth-induced pain, posed a substantial therapeutic challenge. We report our experience in overcoming hypothermia lasting 3 weeks in a child with IEM, discuss possible pathophysiological mechanisms underlying this unusual complication and suggest potential therapeutic interventions.

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Through the Glass Brightly

Hospital-centered academic surgical pathologists are essential members of multidisciplinary head and neck tumor boards. A working, multidisciplinary head and neck tumor board is composed of many dedicated professionals who contribute their individual pieces of patient data. This weekly congregation of head and neck specialists results in a special, concerted, and dynamic process of data integration into a holistic matrix view of the patients. Despite all the technological advances in communication, the fundamentals of human interactions still apply: there is no better substitute for a regular, working, multidisciplinary head and neck tumor board.

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It Takes Two: One Resects, One Reconstructs

Care of patients with advanced head and neck cancer is a multidisciplinary effort through all phases of care. Head and neck cancer surgery involves balancing oncologic control, functional preservation, and aesthetics. Given the advances in free tissue reconstruction, the majority of defects can be reconstructed using free tissue transfer flaps. A 2-team approach allows for early, continual communication and meticulous operative planning. Operations can be combined into a single effort. This approach maximizes efficiency and enables multidisciplinary collaboration for comprehensive surgical treatment. We present our experience and an outline of how responsibilities between the ablative and reconstructive teams are shared.

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Multidisciplinary Approach to Head and Neck Cancer

The complexity of cancer care in the twenty-first century mandates the input of a spectrum of health care providers to achieve the best possible outcome. Head and neck cancer in particular occurs in an anatomical region unmatched in the number of physiological functions potentially affected with disease and treatment, including respiration, physical appearance, vocalization, gustation, olfaction, and alimentation. Further complicating treatment is the wide range of tumor types and tumor locations in head and neck cancer, all of which taken separately are relatively rare cancers.

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Contributors

SUJANA S. CHANDRASEKHAR, MD

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Systemic Treatment for Squamous Cell Carcinoma of the Head and Neck

In patients with locally advanced squamous cell cancer of the head and neck, a multimodality treatment approach is recommended. The addition of platinum-based systemic therapy concurrently with radiation has been shown to be superior to radiation alone and is considered standard therapy for locally advanced disease. No study has shown superiority of induction therapy followed by chemoradiotherapy versus chemoradiotherapy alone. In the adjuvant setting only patients with nodal extracapsular extension or positive margins seem to benefit from chemoradiotherapy versus radiotherapy alone. In the recurrent or metastatic setting, systemic treatment with chemotherapy is palliative. A subset of patients treated with PD-1 immunotherapy may achieve durable responses.

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Multidisciplinary Approach to Head and Neck Cancer

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

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Psychosocial Distress and Distress Screening in Multidisciplinary Head and Neck Cancer Treatment

Psychosocial distress screening (DS) for cancer and head and neck cancer (HNC) patients is rapidly becoming the standard of care. DS is of particular importance for patients with HNC, given their heightened incidence of distress, depression, anxiety, suicide, quality of life impacts, and negative medical outcomes. In the absence of DS, distress is frequently missed in oncology settings. However, when identified, distress is highly responsive to treatment, with cognitive behavioral and behavioral medicine interventions demonstrating evidence of efficacy. Multidisciplinary HNC teams are uniquely positioned to implement effective DS programs and treatment tailored to HNC patients' psychological and medical vulnerabilities.

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Forthcoming Issues

Simulation in Otolaryngology

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Survivorship

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

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CME Accreditation Page

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Immunotherapy

Recurrent and/or metastatic head and neck cancer portends a poor prognosis with traditional treatments, but current immunotherapy with immune checkpoint inhibitors has the potential to improve these clinical outcomes. This review focuses on the major breakthroughs that have led to the current understanding of immunotherapy in head and neck cancer as well as the future direction of the field. Ultimately, this understanding will guide clinicians on the selection of patients with head and neck cancer and practical considerations before starting immunotherapy.

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Copyright

Elsevier

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More than Just Mitoses: Complete Care of the Patient with Head and Neck Cancer

Dr Maie St John has put together a most comprehensive, readable "monograph" on care of the patient with head and neck cancer, in this issue of Otolaryngologic Clinics of North America.

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Sujana S. Chandrasekhar

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The effect of active components from citrus fruits on dentin MMPs

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Zhengya Liu, Fang Li, Ling Zhang, Haohan Yu, Fan Yu, Jihua Chen
ObjectivesThis study was aimed to evaluate the anti-matrix metalloproteinases (MMPs) ability of active components from citrus fruits (hesperetin: Hst, hesperidin: Hsd and naringenin: Nge).MethodsInactivation effects of citrus flavonoids (Hst, Hsd, Nge) at different concentrations on soluble collagenase were measured using a fluorometric assay. Matrix-bound endogenous MMPs activity was evaluated via dry mass loss and hydroxyproline (HYP) release of demineralized human dentin. Demineralized dentin beams were pretreated with 500μg/mL citrus flavonoids for 10min. Chlorhexidine (CHX) was used as inhibitor control. Beams pretreated with distilled water served as blank control. Dentin slabs were used for in situ zymography and evaluated under confocal microscopy. Ultrastructure of demineralized collagen fibers was exhibited by Transmission Electron Microscopy (TEM).ResultsCitrus flavonoids exhibited inactivation function on soluble MMPs and the extent of inactivation increased in a dose-dependent manner. The inactivation percent of citrus flavonoids reached above 90% at the concentration of 500μg/mL. Compared with control group, citrus flavonoids pretreated demineralized dentin beams exhibited less dry mass loss, lower hydroxyproline release and more intact collagen architecture after 15days storage. Dentin samples pretreated with citrus flavonoids showed lower enzymes activities in in situ zymography.ConclusionsHst, Hsd or Nge have anti-MMPs ability and can preserve dentin collagen from degradation.Clinical Significance: Hst, Hsd and Nge may have the potential to be used in dentin bonding systems and improve the resin-dentin bonding durability.

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Validation study of a new method for sexual prediction based on CBCT analysis of maxillary sinus and mandibular canal

Publication date: November 2017
Source:Archives of Oral Biology, Volume 83
Author(s): Thiago de Oliveira Gamba, Mayra Cristina Yamasaki, Francisco Carlos Groppo, Heraldo Luis Dias da Silveira, Solange Maria de Almeida Boscolo, Gerard C.H. Sanderink, W. Erwin R. Berkhout
ObjectiveThe aim of this study was to evaluate the accuracy of two craniometric methods for sexual prediction (SP) using cone-beam computed tomography (CBCT) in the Dutch population and to construct a formula for each method and then the two combined.DesignOne-hundred sixty CBCT images were selected from a Dutch database (80 males and 80 females). The images were analyzed by two examiners taking seven measurements in the maxillary sinus (MS) region (first method) and nine in the mandibular canal (MC) region (second method). The most predictive measurements in both methods were used to develop an equation to determine the accuracy of each method.ResultsAll measurements showed statistical difference between genders. Logistic regression results showed two variables with greater SP index with 75% accuracy in the first method and four variables with 71.9% accuracy in the second. The two methods combined showed another four variables with 78.5% accuracy.ConclusionAll measurements showed statistically significant differences between sexes. The SP accuracy values were 75% for first 71.9% for the second method. When the two methods were combined, the accuracy increased to 78.5%. The formulas developed in this study can be applied as a complementary method for human identification in the Dutch population.

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Th9 cells induce steroid-resistant bronchial hyperresponsiveness in mice

Publication date: Available online 26 July 2017
Source:Allergology International
Author(s): Mayumi Saeki, Osamu Kaminuma, Tomoe Nishimura, Noriko Kitamura, Akio Mori, Takachika Hiroi
BackgroundReduced responsiveness to corticosteroid therapy is a major problem for patients with severe asthma. Although Th9 cells, along with Th2 cells, facilitate antigen-induced airway eosinophilia and bronchial hyperresponsiveness (BHR), the sensitivity of Th9 cell-mediated responses to steroid therapy remains unknown. In this study, we investigated the effect of dexamethasone (Dex) on antigen-induced airway inflammation in Th9 cell-transferred mice.MethodsOvalbumin (OVA)-specific Th2 and Th9 cells were polarized from the CD4⁺ T cells of DO11.10/RAG-2^−/− mice. BALB/c mice were adoptively transferred with Th2 or Th9 cells and challenged with OVA. Dex treatment was performed twice, at 1 h before and at 24 h after the OVA challenge. Following treatment, the number of inflammatory cells in the bronchoalveolar lavage fluid and the bronchial responsiveness to inhaled methacholine were determined.ResultsIn both the Th2 and Th9 cell-transferred mice, substantial accumulation of eosinophils in the lungs and BHR were induced by challenge with the specific antigen. In the Th2 cell-transferred mice, these responses were significantly diminished by Dex treatment. In contrast, neither cellular infiltration nor BHR was affected by Dex treatment in the Th9 cell-transferred mice, although the Th9 cells substantially expressed glucocorticoid receptor α. Accordingly, antigen-induced interleukin-9 expression in the Th9 cells was attenuated by Dex treatment at least in vitro. Antigen-induced lung infiltration of infused Th2 cells but not Th9 cells was significantly suppressed by Dex.ConclusionsIn contrast to Th2-mediated responses, Th9-mediated airway inflammation was not affected by Dex. Th9 cells might be involved in the developmental mechanisms of steroid-resistant asthma.

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The effect of active components from citrus fruits on dentin MMPs

Validation study of a new method for sexual prediction based on CBCT analysis of maxillary sinus and mandibular canal

Oral bexarotene for post-transplant cutaneous T-cell lymphoma

Abstract

Organ transplant recipients receiving immunosuppression have an increased risk of developing post-transplant lymphoproliferative diseases (PTLDs). Traditionally, PTLDs refer to Epstein-Barr virus (EBV)-induced B-cell lymphoma. However, post-transplant T-cell lymphoma may also occur and tends to have a poorer response to reduced immunosuppressive therapy. As such, additional therapy is often needed for post-transplant T-cell lymphoma, including post-transplant cutaneous T-cell lymphoma (PT-CTCL). We present only the third case of PT-CTCL occurring after liver transplantation. The patient was diagnosed with stage IB mycosis fungoides (MF). His lesions were refractory to multiple skin-directed therapies, and so he was given oral bexarotene 150 mg daily and his oral tacrolimus dose was decreased to 2 mg daily. Remarkably, his MF patches have demonstrated a complete response to oral bexarotene 75 mg daily without recurrence over 11 years of follow-up. He developed hypertriglyceridemia with bexarotene 150 mg, so his dose was decreased to 75 mg, without loss of response. Our report is the second to describe PT-CTCL demonstrating a long-term complete response to oral bexarotene. Given its anti-carcinogenic properties and favorable toxicity profile, oral bexarotene represents an appealing treatment option for PT-CTCL refractory to skin-directed therapies.

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“Analysis of the correlation between dental arch and articular eminence morphology: a cone beam CT study”

Publication date: Available online 26 July 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Francielle Silvestre Verner, Gina Delia Roque-Torres, Laura Ricardina Ramírez-Sotello, Karina Lopes Devito, Solange Maria Almeida
Objective.To assess the correlation between the morphology of the dental arches (DA) of patients with normal occlusion and the articular eminence (AE) through cone beam computed tomography (CBCT).Study Design.CBCT scans of 60 patients were evaluated in terms of height (AEh) and inclinations (angles α, β and δ) of the AE. DA were classified regarding shape (tapered, square, ovoid), and perimeters, widths, and depths were measured. One-way ANOVA, Pearson's correlation coefficients, simple and multivariate linear regression models were calculated.Results.Ovoid arch was the most predominant shape (n = 66/120). Inclination of the AE (angle β) had the greatest difference between DA shapes, with this angle usually being greater in the ovoid and smaller in the square arches (p<0.05). The AEh presented greater correlation with DA measurements, with tapered arches having the most significant correlations (p<0.05). DA depth had no influence on AE measurements (p>0.05). Perimeter and width of the DA had some influence (p<0.05).Conclusions.Correlations between DA and AE morphologies of were found. Although the results do not prove absolute association between the variables, the correlations should be taken into consideration. Whenever possible, morphological features of DA should be preserved to avoid possible changes in AE.

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Targeted next-generation sequencing of glandular odontogenic cyst: a preliminary study

Publication date: Available online 26 July 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Elisa Carvalho de Siqueira, Silvia Ferreira de Sousa, Josiane Alves França, Marina Gonçalves Diniz, Thaís dos Santos Fontes Pereira, Rennan Garcias Moreira, Pablo Agustin Vargas, Ricardo Santiago Gomez, Carolina Cavalieri Gomes
Background: Glandular odontogenic cyst (GOC) is an uncommon developmental cyst. Its molecular pathogenesis is unclear and deep sequencing technologies may identify causative low-frequency variants in tumors. Objective: We investigated in GOC mutations in 50 genes commonly altered in human cancers Methods: Targeted next-generation sequencing was used to interrogate a panel of approximately 2,800 mutations in GOC. Results: Six missense single nucleotide variations (SNVs) were reported. Three SNVs (TP53 rs1042522, KDR rs1870377 and KIT rs3822214) are listed as "common SNPs" at the UCSC Genome Browser. The other SNVs (PIK3CA p.Glu689Lys, PIK3CA p.Ala708Thr and TP53 p.Leu289Phe) are predicted to have deleterious or damaging effects on the proteins, but they showed very low frequency in our samples and could not be further validated by orthogonal methods. Conclusion: No pathogenic SNV was detected in this cohort of GOC. Further studies with larger gene panels or whole exome sequencing are needed in order to reveal the genetic basis of GOC.

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Impact of the Korean Diagnosis-Related Groups payment system on the outcomes of adenotonsillectomy: A single center experience

To report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea.

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Surgical considerations and safety of cochlear implantation in otitis media with effusion

To evaluate the effects of otitis media with effusion on surgical parameters, patient safety, perioperative and postoperative complications.

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Endoscopic contralateral transmaxillary approach for pterygoid process osteotomy in total maxillectomy: A technical case report

An approach for total maxillectomy with endoscopic transection of the pterygoid process via the contralateral maxillary sinus is described. In total maxillectomy, the resection of the pterygoid process of the sphenoid is a key step for successful resection. However, a conventional craniofacial approach requires extensive incision in the face, elevation of the lateral cheek flap. Even after elevation of the lateral cheek flap, visualization of this region is not good. An endoscopic approach through the contralateral maxillary sinus improved visualization of the pterygoid process, and osteotomy using a diamond-drilling bar was successfully performed.

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Unilateral Headache Status after Intra-Aortic Balloon Pump Placement

Introduction. Intra-aortic balloon pump (IABP) counterpulsation is a catheter-based treatment for coronary artery disease and decompensated heart failure to increase coronary blood flow and improve cardiac output. IABP is generally well tolerated, and complications are usually related to peripheral vasculature or red blood cell and platelet consumption. The usual insertion site via femoral artery renders the patient bedbound. Recently, axillary artery has been used in patients with atherosclerotic peripheral vascular disease and documented small arteries or in those awaiting transplant to ensure ambulation and prevent deconditioning. Case Report. We present a patient with ischemic cardiomyopathy and severe left ventricular dysfunction, awaiting Orthotropic Heart Transplant. His worsening intractable angina and dyspnea necessitated IABP placement via left axillary artery, significantly improving his condition. He subsequently experienced migraine-type persistent unilateral headache refractory to standard pain management. Multiple strategies were utilized to treat his pain, but the patient insisted that his pain commenced after IABP placement. Ultimately, the removal of the pump led to complete resolution with no recurrence. Conclusion. The authors hypothesize that the unilaterally directed blood flow and direct increase in cerebral perfusion from the intra-aortic balloon pump may have caused vasodilation of the extracranial arteries, leading to a persistent and debilitating headache in this susceptible patient.

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Impact of the Korean Diagnosis-Related Groups payment system on the outcomes of adenotonsillectomy: A single center experience

Publication date: Available online 26 July 2017
Source:Auris Nasus Larynx
Author(s): Sang Hyun Kwak, Ji Hoon Kim, Da Hee Kim, Jung Min Kim, Hyung Kwon Byeon, Won Shik Kim, Yoon Woo Koh, Se-Heon Kim, Eun Chang Choi
ObjectivesTo report outcomes with regard to clinical aspects and medical costs of adenotonsillectomy and tonsillectomy at a single institution before and after implementation of the Diagnosis-Related Groups (DRG) payment system in Korea.MethodsWe retrospectively reviewed the records of patients treated with adenotonsillectomy or tonsillectomy between July 2012 and June 2014. The Korean DRG payment system was applied to seven groups of specific diseases and surgeries including adenotonsillectomy and tonsillectomy from July 2013 at all hospitals in Korea. We divided patients into four groups according whether the fee-for-service (FFS) or DRG payment system was implemented and operation type (FFS-adenotonsillectomy (AT), DRG-AT, FFS-tonsillectomy (T), and DRG-T).ResultsA total of 1402 patients were included (485 FFS-AT, 490 DRG-AT, 203 FFS-T, and 223 DRG-T). The total medical cost of the DRG-AT group was significantly lower than that of the FFS-AT group (1191±404 vs. 1110±279 USD, P<0.05). There were no significant differences in length of hospital stay or postoperative complications among groups.ConclusionThe Korean DRG system for adenotonsillectomy and tonsillectomy reduced medical costs and clinical outcomes were not significantly altered by the adoption of the DRG system.Level of evidence4.

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The feasibility of cold atmospheric plasma in the treatment of complicated wounds in cranio-maxillo-facial surgery

Compromised wound healing in cranio-maxillo-facial surgery is a threat to the patient's rehabilitation. Therapy of chronic and/or infected wounds is time- and cost-consuming, burdensome and occasionally futile. Cold atmospheric plasma is a new approach that promises to overcome these limitations. The aim of this proof-of-concept study was to evaluate the clinical outcome of cold plasma irradiation in patients with impaired wound healing who are refractory to conservative wound therapy and/or revision surgery.

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Biomechanical evaluation of a novel hybrid reconstruction plate for mandible segmental defects: A finite element analysis and fatigue testing

This study develops a novel hybrid (NH) reconstruction plate that can provide load-bearing strength, secure the bone transplant at the prosthesis favored position, and also maintain the facial contour in a mandibular segmental defect. A new patient-match bending technique which uses a three-dimensional printing (3DP) stamping process is developed to increase the interfacial fit between the reconstruction plate and mandibular bone.

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Pathway discovery using transcriptomic profiles in adult-onset severe asthma

Publication date: Available online 26 July 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Pieter-Paul Hekking, Matt J. Loza, Stelios Pavlidis, Bertrand De Meulder, Diane Lefaudeux, Fred Baribaud, Charles Auffray, Ariane H. Wagener, Paul Brinkman, Rene. Lutter, ArunaT. Bansal, Ana R. Sousa, Steve. Bates, Yannis Pandis, Louise J. Fleming, Dominique E. Shaw, Stephen J. Fowler, Y. Guo, Andrea Meiser, Kai Sun, Julie. Corfield, Peter. Howarth, Elisabeth H. Bel, Ian M. Adcock, K.F. Chung, Ratko Djukanovic, Peter J. Sterk
RationaleAdult-onset severe asthma is characterized by highly symptomatic disease despite high intensity asthma treatments. Understanding of the underlying pathways of this heterogeneous disease needed for the development of targeted treatments. Gene Set Variation Analysis (GSVA) is a statistical technique to identify gene profiles in heterogeneous samples.ObjectiveTo identify gene profiles associated with adult-onset severe asthma.MethodsThis was a cross-sectional, observational study in which adult patients with adult-onset of asthma (defined as starting at ≥18yrs old) as compared to childhood-onset severe asthma (<18 yrs) were selected from the U-BIOPRED cohort. Gene expression was assessed on the total RNA of induced sputum (n=83), nasal brushings (n=41), and endobronchial brushings (n=65) and biopsies (n=47) (Affymetrix HT HG-U133+ PM). GSVA was used to identify differentially enriched pre-defined gene signatures of leukocyte lineage, inflammatory and induced lung injury pathways.ResultsSignificant differentially enriched gene signatures in patients with adult-onset as compared to childhood-onset severe asthma were identified in nasal brushings (5 signatures), sputum (3 signatures) and endobronchial brushings (6 signatures). Signatures associated with eosinophilic airway inflammation, mast cells and group 3 innate lymphoid cells (ILC3) were more enriched in adult-onset severe asthma, whereas signatures associated with induced lung injury were less enriched in adult-onset severe asthma.ConclusionsAdult-onset severe asthma is characterized by inflammatory pathways involving eosinophils, mast cells and ILC3s. These pathways could represent useful targets for the treatment of adult-onset severe asthma.

Graphical abstract

Teaser

This study elucidates distinct gene profiles in adult-onset severe asthma compared to childhood-onset severe asthma. Identified gene profiles include those associated with eosinophils, ILC3s and mast cells, and may represent targets for new treatments.

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Liver disease predicts mortality in patients with XHIM but can be prevented by early hematopoietic stem cell transplantation

Publication date: Available online 26 July 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Vian Azzu, Lucinda Kennard, Beatriz Morillo-Gutierrez, Mary Slatter, J.David M. Edgar, Dinakantha S. Kumararatne, William JH. Griffiths

Teaser

In the largest detailed study of liver disease in X-linked immunodeficiency with hyper-IgM, we show that liver disease is commoner than generally recognized and that early hematopoietic stem cell transplantation may prevent liver disease progression and improve survival.

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Prevalence of clinic-defined food allergy in early adolescence: The SchoolNuts study

Publication date: Available online 26 July 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Mari Sasaki, Jennifer J. Koplin, Shyamali C. Dharmage, Michael J. Field, Susan M. Sawyer, Vicki McWilliam, Rachel L. Peters, Lyle C. Gurrin, Peter J. Vuillermin, Jo Douglass, Angela Pezic, Maia Brewerton, Mimi L.K. Tang, George C. Patton, Katrina J. Allen
BackgroundRising rates of food-induced anaphylaxis have recently been shown in the adolescent age group, following earlier descriptions of a rise in children younger than 5 years. However, few population-based studies have examined the prevalence of food allergy in adolescence using objective measures such as oral food challenge (OFC).ObjectiveWe sought to determine the prevalence of food allergy among a population-based sample of 10- to 14-year-old adolescents using clinical evaluation including OFC to confirm the diagnosis.MethodsSchools were randomly selected from greater metropolitan Melbourne, Australia. Students aged 10 to 14 years, and their parents, were asked to complete a questionnaire regarding the adolescent's food allergy or food-related reactions. Clinic evaluation, which consisted of skin prick tests and OFC where eligible, was undertaken if students were suspected to have current food allergy from parent response. Among 9816 students assessed, 5016 had complete parent response and clinic evaluation when eligible. An additional 4800 students had student questionnaires only.ResultsThe prevalence of clinic-defined current food allergy based on history, sensitization data, and OFC results was 4.5% (95% CI, 3.9-5.1), with the most common food triggers being peanut, 2.7% (95% CI, 2.3-3.2), and tree nut, 2.3% (95% CI, 1.9-2.8). Among the additional group of 4800 adolescents who had only self-reported food allergy status available, the prevalence of self-reported current food allergy was 5.5% (95% CI, 4.9-6.2), with peanut, 2.8% (95% CI, 2.3-3.3), and tree nut, 2.3% (95% CI, 1.9-2.8), the most common.ConclusionsApproximately 1 in 20 10- to 14-year-old school students in Melbourne has current food allergy. This high prevalence suggests that the previously reported rise in food-induced anaphylaxis in this age group may reflect an increasing prevalence of food allergy rather than simply increased reporting of anaphylaxis.

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A partially hydrolyzed 100% whey formula and the risk of eczema and any allergy: an updated meta-analysis

Recently, the role of using hydrolyzed formula for the prevention of allergic disease has been questioned. However, not all hydrolyzed formulas are equal. The efficacy of each hydrolyzed formula should be esta...

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New UV-B Laser Promising for Vitiligo

Reuters Health Information

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Topical tocopherol for the treatment of ROLP: randomozed,double-blind crossover study - A query

Abstract

In a recently published study "Topical tocopherol for treatment of reticular oral lichen planus: a randomized, double-blind, crossover study" (Oral Diseases, January 2017), the authors have assessed the efficacy of topical tocopherol acetate in improving the lesions and oral discomfort of patient's suffering from reticular oral lichen planus comparing it with the results achievable by administering placebo. ⁽¹⁾

In the study, 34 patients with clinically diagnosed and histologically confirmed ROLP were randomly assigned to two groups, which received first one of two treatments (treatment 1 or 2) for a month, then the other (treatment 2 or 1) for another month, with a two-week washout between them. One treatment contained tocopherol acetate, the other only liquid paraffin. The primary outcome was less discomfort, measured on a visual analog scale (VAS).

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Hemoglobin Himeji and inconsistent hemoglobin A1c values: a case report

Hemoglobin A1c is used to evaluate the glycemic control in patients with diabetes and is a risk marker for chronic complications of diabetes. Hemoglobin variants are reported to falsely lower or increase hemog...

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Hypercapnic respiratory failure during pregnancy due to polymyositis-related respiratory muscle weakness: a case report

Polymyositis is a rare medical disorder complicating pregnancy. Ventilatory muscle weakness leading to respiratory failure is an uncommon manifestation of this autoimmune disease. We report a case of life-thre...

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Predictions of Speech Chimaera Intelligibility Using Auditory Nerve Mean-Rate and Spike-Timing Neural Cues

Abstract

Perceptual studies of speech intelligibility have shown that slow variations of acoustic envelope (ENV) in a small set of frequency bands provides adequate information for good perceptual performance in quiet, whereas acoustic temporal fine-structure (TFS) cues play a supporting role in background noise. However, the implications for neural coding are prone to misinterpretation because the mean-rate neural representation can contain recovered ENV cues from cochlear filtering of TFS. We investigated ENV recovery and spike-time TFS coding using objective measures of simulated mean-rate and spike-timing neural representations of chimaeric speech, in which either the ENV or the TFS is replaced by another signal. We (a) evaluated the levels of mean-rate and spike-timing neural information for two categories of chimaeric speech, one retaining ENV cues and the other TFS; (b) examined the level of recovered ENV from cochlear filtering of TFS speech; (c) examined and quantified the contribution to recovered ENV from spike-timing cues using a lateral inhibition network (LIN); and (d) constructed linear regression models with objective measures of mean-rate and spike-timing neural cues and subjective phoneme perception scores from normal-hearing listeners. The mean-rate neural cues from the original ENV and recovered ENV partially accounted for perceptual score variability, with additional variability explained by the recovered ENV from the LIN-processed TFS speech. The best model predictions of chimaeric speech intelligibility were found when both the mean-rate and spike-timing neural cues were included, providing further evidence that spike-time coding of TFS cues is important for intelligibility when the speech envelope is degraded.

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4-month omalizumab efficacy outcomes for severe allergic asthma: the Dutch National Omalizumab in Asthma Registry

Omalizumab is licensed as add-on therapy for patients with severe allergic asthma. Response is in most studies scored by the physician's global evaluation of treatment effectiveness (GETE). A good clinical and...

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Predictions of Speech Chimaera Intelligibility Using Auditory Nerve Mean-Rate and Spike-Timing Neural Cues

Abstract

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Amelanotic Melanoma, MC1R Status, and Prior Amelanotic Melanoma

This cohort study investigates whether phenotypic characteristics, carriage of MC1R variants, and history of amelanotic melanoma are associated with histopathologically amelanotic melanoma.

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Fractional CO 2 Laser Treatment of Elastosis Perforans Serpiginosa

This case report describes the use of carbon dioxide laser to treat a patient with elastosis perforans serpiginosa.

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Erythematous, Burning and Painful Scrotal Nodules

A man in his 60s who had been treating intertrigo of the groin with a combination of clotrimazole and hydrocortisone developed bright red, burning and painful nodules around his scrotum. What is your diagnosis?

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Melanoma Metastases Treated With Checkpoint Inhibitors and Multisite Radiotherapy

This study examines the treatment of patients with metastatic melanoma receiving multisite radiotherapy with in conjunction with immunotherapy.

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Missing Conflict of Interest Disclosure

In the article titled "Efficacy and Tolerance of Anti–Tumor Necrosis Factor α Agents in Cutaneous Sarcoidosis: A French Study of 46 Cases," a conflict of interest disclosure was missing. "Dr Chosidow received personal honorarium fees from Abbvie in 2016" has been added to the Conflict of Interest Disclosures paragraph in the end matter. This article was corrected online.

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Radiotherapy for Extremity and Trunk Merkel Cell Carcinoma After Resection

This cohort study analyzes the National Cancer Database records of patients with Merkel cell carcinoma treated with curative radiation therapy to evaluate the overall survival of 4 different radiation dose regimens.

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Risk Factors for Melanoma in Renal Transplant Recipients

This cohort study uses data from the United States Renal Data System to investigate risk factors and characteristics of renal transplant recipients who develop melanoma.

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American Academy of Dermatology (AAD) 2017 Summer Meeting

Read clinically focused news coverage of key developments from AAD 2017.
Medscape Dermatology

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Tube feeding during treatment for head and neck cancer – Adherence and patient reported barriers

Publication date: September 2017
Source:Oral Oncology, Volume 72
Author(s): Teresa Brown, Merrilyn Banks, Brett G.M. Hughes, Charles Lin, Lizbeth Kenny, Judith Bauer
ObjectivesThe main aim was to investigate the incidence of patient adherence to nutritional tube feeding recommendations in patients with head and neck cancer and to determine patient barriers to meeting tube feeding prescription.Materials and methodsThis was an observational study from a randomised controlled trial in patients with head and neck cancer deemed at high nutritional risk with prophylactic gastrostomy (n=125). Patients were randomised to receive early tube feeding prior to treatment (intervention group) or standard care. All patients in the intervention and standard care groups then commenced clinical tube feeding as required during treatment. Patients maintained a daily record of gastrostomy intake, main nutrition impact symptom necessitating gastrostomy use, and reasons for not meeting nutrition prescription. Adherence was defined as meeting ≥75% of total prescribed intake.ResultsPatients were predominantly male (89%), median age 60, with oropharyngeal tumours (78%), stage IV disease (87%) treated with chemoradiotherapy (87%). Primary reasons for gastrostomy use were poor appetite/dysgeusia (week 2–3) and odynophagia/mucositis (week 4–7). Early tube feeding adherence was 51%. Clinical tube feeding adherence was significantly higher in the intervention group (58% vs 38%, p=0.037). Key barriers to both phases of tube feeding were; nausea, early satiety and treatment factors (related to hospital healthcare processes).ConclusionsEarly tube feeding can improve patient adherence to clinically indicated tube feeding during treatment. Low adherence overall is a likely explanation for clinically significant weight loss despite intensive nutrition interventions. Optimising symptom management and strategies to overcome other barriers are key to improving adherence.Clinical trial registration: This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.

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Post-operative therapy following transoral robotic surgery for unknown primary cancers of the head and neck

Publication date: September 2017
Source:Oral Oncology, Volume 72
Author(s): Sapna A. Patel, Aarthi Parvathaneni, Upendra Parvathaneni, Jeffrey J. Houlton, Ron J. Karni, Jay J. Liao, Neal D. Futran, Eduardo Méndez
ObjectivesOur primary objective is to describe the post- operative management in patients with an unknown primary squamous cell carcinoma of the head and neck (HNSCC) treated with trans-oral robotic surgery (TORS).Materials & MethodsWe conducted a retrospective multi-institutional case series including all patients diagnosed with an unknown primary HNSCC who underwent TORS to identify the primary site from January 1, 2010 to June 30, 2016. We excluded those with recurrent disease, ≤6months of follow up from TORS, previous history of radiation therapy (RT) to the head and neck, or evidence of primary tumor site based on previous biopsies. Our main outcome measure was receipt of post-operative therapy.ResultsThe tumor was identified in 26/35 (74.3%) subjects. Post-TORS, 2 subjects did not receive adjuvant therapy due to favorable pathology. Volume reduction of RT mucosal site coverage was achieved in 12/26 (46.1%) subjects who had lateralizing tumors, ie. those confined to the palatine tonsil or glossotonsillar sulcus. In addition, for 8/26 (30.1%), the contralateral neck RT was also avoided. In 9 subjects, no primary was identified (pT0); four of these received RT to the involved ipsilateral neck nodal basin only without pharyngeal mucosal irradiation.ConclusionSurgical management of an unknown primary with TORS can lead to deintensification of adjuvant therapy including avoidance of chemotherapy and reduction in RT doses and volume. There was no increase in short term treatment failures. Treatment after TORS can vary significantly, thus we advocate adherence to NCCN guideline therapy post-TORS to avoid treatment-associated variability.

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Therapeutic Effects of Topical Tranexamic Acid in Comparison with Hydroquinone in Treatment of Women with Melasma

Abstract

Introduction

Few studies have focused on therapeutic as well as side effects of tranexamic acid (TXA) as a topical drug compared to other topical drugs in treating melasma. The present study aimed to assess and compare the beneficial therapeutic effects and also side effects of local TXA in comparison with hydroquinone in treating women with melasma.

Methods

This randomized double-blinded clinical trial was performed on 60 women who suffered from melasma and were referred to the skin disorders clinic at the Rasoul-e-Akram hospital in Tehran in 2015. The patients were then randomly assigned via computerized randomization to two groups: group A received TXA%5 (topically twice a day for 12 weeks in the location of the melasma) and group B (received hydroquinone 2% with the same treatment order). Prior to intervention and at 12 weeks after intervention, the intensity and extension of melasma were assessed based on the Melasma Area and Severity Index (MASI) scoring method.

Results

The mean MASI score in both treatment groups decreased considerably after completion of treatment and was not significant between the two groups. No side effects were detected in group A, but 10% of those in group B complained of drug-related side effects including erythema and skin irritation (p = 0.131). Regarding the level of patient satisfaction, the patients in group A had a significantly higher level of satisfaction level of 33.3% compared with 6.7% in group B (p = 0.015) (Fig. 9). Multivariate linear regression modeling with the presence of age, history of systemic disorder, drug history, and family history of melasma demonstrated no difference in the mean MASI between the two groups.

Conclusion

Topical use of TXA significantly reduced both melanin level and MASI score. Given its high efficiency and low drug side effects, this regimen results in high patient satisfaction compared with topical hydroquinone. IRCT code: IRCT2016040627220N2.

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The Burden of Chronic Urticaria from Brazilian Patients’ Perspective

Abstract

Introduction

Chronic urticaria (CU), a proxy for chronic spontaneous urticaria, has been associated with a negative impact on health-related quality of life (HRQoL) and costs, but there is limited evidence on the burden of CU in Brazil. The objective of this study was to estimate the prevalence of CU and assess the burden of CU on HRQoL and healthcare resource utilization (HRU) among adults in Brazil.

Methods

This retrospective, cross-sectional study, pooled data from the 2011, 2012, and 2015 National Health and Wellness Survey in Brazil (n = 36,000). Respondents (aged ≥18 years) diagnosed with and treated for CU provided data on demographics, health history, HRQoL (mental and physical health status) on Short-Form SF-36v2, presence of psychological complaints, work impairment, activity impairment, and HRU. Generalized linear models, controlling for covariates, examined differences between those treated for CU and matched controls on the outcome variables.

Results

The prevalence of diagnosed CU was 0.41% (n = 249) and treated CU was 0.21% (n = 127). After adjustments, CU (currently treated for CU) was associated with worse mental functioning, physical functioning, and health utilities compared with controls (all p < 0.01). CU had over twice the odds of anxiety and sleep difficulties, over 1.5 times the work and activity impairment, twice the number of total physician visits, eight times the number of allergist visits, and twice the number of emergency room visits as controls (all p < 0.01).

Conclusions

Many CU patients using prescription treatment experienced anxiety and sleep disturbances, poorer HRQoL, significant work and activity impairment, and high HRU, compared with matched general population controls. Findings suggest an unmet need for more effective treatment and management of CU in Brazil.

Funding

Novartis Pharma AG and Genentech.

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A rare case of an ectopic pregnancy in the rudimentary tube of a patient with an isolated unicornuate uterus

Uterine anomalies are relatively uncommon and go undiagnosed in many cases. Ectopic pregnancies have been reported in such patients, although rarely, in the non-communicating rudimentary horns of unicornuate uteri. However, the case presented is of an ectopic pregnancy in the rudimentary fallopian tube related to an undescended ovary in a patient with an isolated unicornuate uterus, a phenomenon which is extremely rare.

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Migration of intraocular silicone oil into brain

Description

An 84 -year-old woman was admitted following a slight mechanical fall while she was in her garden. She had banged the back of her head followed by a brief period of nausea and vomiting which was self-limiting.

One year before, the patient underwent surgical repair for retinal detachment of left eye with involvement of the macula. She underwent a vitrectomy, endolaser therapy and injection of silicone oil into the vitreous. There was no recovery of vision in the left eye. Medical history included hypertension and bilateral glaucoma.

On examination, she looked well. She had no light perception in the left eye and the visual acuity in the right eye was N10 on the near reading chart with normal peripheral fields of vision. She was managed conservatively but died shortly due to bowel ischaemia, that was unrelated to her presentation.

A CT scan of brain at presentation revealed hyperdensity in...

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Severe asymptomatic rhabdomyolysis complicating a mycoplasma pneumonia

Rhabdomyolysis is a very rare and serious extrapulmonary manifestation of a Mycoplasma pneumoniae infection. We describe a case of a 47-year-old male patient who presented with progressive dyspnoea, hypoxaemia and cough during the last 3 days. He had no relevant muscular complaints but was diagnosed with severe rhabdomyolysis for which he was treated with hyperhydration. Molecular diagnostics confirmed M. pneumoniae as the causative agent and our patient was successfully treated with doxycycline.

Only a few cases of rhabdomyolysis complicating a M. pneumoniae infection have been described, mostly in infants. In this case, typical suggestive complaints of rhabdomyolysis were absent suggesting that the complication might be underdiagnosed.

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Stroke of the inferiomedial temporal lobe causing word agnosia

A 69-year-old man presented with sudden loss of ability to recognise written words and remember the meaning of words and names. He could not name the town he lived in nor name his children. It was difficult for him to remember the meaning of concrete and abstract nouns. His speech fluency and understanding of casual talks were normal. He remembered that he had a conversation with his family that morning, but not the exact content. He was referred to the transient ischaemic attack clinic by his general practitioner as he scored low on the abbreviated mental test score. He underwent a brain MRI scan (T2 weighted, diffusion weighted and fluid-attenuated inversion recovery) which showed an acute infarction in the left medial temporal region affecting the fusiform and parahippocampal gyri. He also noticed that it was easier to retrieve numbers, for example, his mobile number. He recovered on waking up the next day.

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Barium aspiration through a tracheo-oesophageal fistula caused by percutaneous tracheostomy

Description

A healthy 43-year-old gravida 14, para 12+1 woman, developed Sheehan syndrome followed by disseminated intravascular coagulopathy and sepsis post-Caesarean section. Her postoperative course was further complicated by a hospital-acquired pneumonia for which she required endotracheal intubation and mechanical ventilation. Enteral feeding and medications were administered via a nasogastric tube (NGT). After three failed attempts at extubation, a tracheostomy was inserted percutaneously. Over the next 2 weeks, she improved and was successfully weaned off ventilatory support. She was transferred to a medical ward with the tracheostomy in situ with minimum oxygen requirement.

Her rehabilitation progressed slowly while the NGT was kept in situ in view of recurrent aspiration with oral intake. A barium study was performed via the NGT after she developed severe vomiting and CT of the abdomen was reported as normal. This demonstrated mild gastritis and delayed gastric emptying due to ileus. No immediate complications were apparent during...

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Discitis and Clostridium perfringens bacteraemia

The authors present a case involving an 80-year-old man with infectious T10/T11 discitis on the background of a recent Clostridium perfringens bacteraemia. This case report describes a case of probable C. perfringens discitis as further investigations failed to identify any causative agents. He was treated with intravenous piperacillin/tazobactam to good effect, achieving favourable clinical outcome. Diagnosis of discitis/osteomyelitis can often be delayed and mismanaged due to its non-specific presentations. Timing of empirical antimicrobial therapy requires careful consideration based on haemodynamic stability and neurological function to maximise microbiological yield.

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Muscular sarcocystosis: an index case in a native Malaysian

A previously healthy 20-year-old man presented with prolonged intermittent low grade fever and cough for 6months. He had bilateral calf pain and lower limb weakness 2days prior to admission. Physical examination revealed multiple enlarged lymph nodes with hepatomegaly. There was bilateral calf tenderness with evidence of proximal myopathy. Full blood picture showed lymphocytosis with reactive lymphocytes and eosinophilia. Creatine kinase and lactate dehydrogenase were markedly elevated. Over 2 weeks of admission, patient was treated symptomatically until the muscle biopsy of right calf revealed eosinophilic myositis with muscular sarcocystosis. He was treated with albendazole and high-dose corticosteroids. Symptoms subsided on reviewed at 2weeks and the dose of corticosteroid was tapered down slowly over a month. Due to poor compliance, he was readmitted 1month later because of relapsed. High-dose corticosteroid was restarted and duration for albendazole was prolonged for 1month. His symptom finally resolved over 2weeks.

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A complication of meningitis and infective endocarditis due to Streptococcus pyogenes

We described a rare case of meningitis and infective endocarditis (IE) due to Streptococcus pyogenes. An 80-year-old woman was admitted to our hospital with unconsciousness. Glasgow Coma Scale was E1V3M5. We diagnosed her with acute meningitis due to S. pyogenes and started treatment using ceftriaxone. In spite of the improvement of her unconscious state, she developed a new-onset systolic murmur on day 13, and echocardiography revealed severe mitral valve regurgitation with vegetation. Therefore, we also diagnosed her with IE and continued the antibiotics for 6 weeks after we confirmed the negative blood cultures. The patient was finally transferred to another hospital for rehabilitation 57 days after admission. Considering that the number of S. pyogenes infections has been reported to increase in Japan and worldwide, we need to be more careful about the rare complication of meningitis and IE due to S. pyogenes.

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Unusual case of odontogenic maxillary sinusitis

Description

A 76-year-old woman presented with intermittent infection around the upper right 2 (UR2) area of the maxilla for several years. She also complained of persistent rhinorrhoea and right-sided facial pain.

Seven years previously, she had presented with similar right maxillary pain, after undergoing root canal treatment of the UR2, 3 and 4 teeth. An orthopantomogram had shown uptake around the UR2 region (figure 1). There was a suspicion of retained tooth fragment, and she underwent a Caldwell-Luc procedure under local anaesthetic but no tooth fragment was identified at surgery.

Figure 1

Orthopantomogram.

Examination revealed a sinus draining buccally around UR2 and a fluctuant swelling of the palate. She was tender over the right maxilla. Nasal endoscopy did not demonstrate any purulent discharge from the right middle meatus.

A CT scan identified (1) opacification of the sinus, (2) a calcified...

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Long-term adverse effects of intramuscular oil injection

Description

A 33-year-old male former bodybuilder presented with painful deformities located to his arms. Roughly a decade ago, he had injected liquid paraffin into his biceps and triceps as a shortcut to achieve muscular enhancement. Today, some of the oil has descended to the forearms, leaving him with painful swellings (paraffinomas) (figure 1) and paraesthesia. MRI revealed localised intramuscular distribution of liquid paraffin in the upper arm muscles (figure 2) and diffuse and localised subcutaneous distribution in the forearms. The patient is currently reviewed regularly as an outpatient and is still able to work as an engineer. A careful history has not revealed any overt systemic complications related to the injections and, so far, he has not required active treatment for his condition.

Figure 1

Muscular hypertrophy and swellings (arrows) after liquid paraffin injection.

Figure...

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Top Reviewers

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Computed Tomography Score an Excellent Marker: Differentiates Eosinophilic and Non-eosinophilic Variants of Chronic Rhinosinusitis with Nasal Polyp

Abstract

Eosinophilic and non-eosinophilic subtypes of chronic rhinosinusitis with nasal polyp (CRSwNP) have different clinical profile and management. Currently the 2 subtypes are differentiated based on tissue eosinophilic infiltration, which is identified after surgery by histopathological examination. Hence this study was conducted to compare utility of computed tomography (CT) scans, serum IgE levels, absolute eosinophil count (AEC) and Sino-nasal Outcome Test (SNOT)-20 score for discriminating the 2 subtypes. In this prospective study of 1 year duration, patients suspected of CRSwNP were recruited. Serum IgE levels and AEC estimation were performed by ELISA and standard numerical formula respectively, along with histopathological examination of nasal polyp biopsies. CT score and ratio of CT score for ethmoid sinus and maxillary sinus (E/M ratio) were calculated. Patients were asked to fill SNOT-20 questionnaire. Receiver-operating characteristic (ROC) curve analysis was performed. Out of 52 patients studied, 38 and 14 were no. of eosinophilic and non-eosinophilic CRSwNP cases respectively on the basis of histopathological examination. E/M ratio and overall CT score were found to be highly accurate with area under ROC curve of 0.990 and 0.964 respectively, while rest 3 parameters had low accuracy. Optimal cut-off of CT score and E/M ratio for eosinophilic CRSwNP were 6 and 2.065 respectively. This study demonstrated E/M ratio and total CT score as the most useful surrogate markers for preoperative differentiation of eosinophilic and non-eosinophilic CRSwNP, and hence can be used to predetermine postoperative management before surgery.

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Effect of combination of fractional CO 2 laser and narrow-band ultraviolet B versus narrow-band ultraviolet B in the treatment of non-segmental vitiligo

Abstract

The present study was designed to evaluate the effect of combining fractional CO₂ laser with narrow-band ultraviolet B (NB-UVB) versus NB-UVB in the treatment of non-segmental vitiligo. The study included 20 patients with non-segmental stable vitiligo. They were divided into two groups. Group I received a single session of fractional CO₂ laser therapy on the right side of the body followed by NB-UVB phototherapy twice per week for 8 weeks. Group II received a second session of fractional CO₂ laser therapy after 4 weeks from starting treatment with NB-UVB. The vitiligo lesions were assessed before treatment and after 8 weeks of treatment by VASI. At the end of the study period, the vitiligo area score index (VASI) in group I decreased insignificantly on both the right (−2.6%) and left (−16.4%) sides. In group II, VASI increased insignificantly on the right (+14.4%) and left (+2.5%) sides. Using Adobe Photoshop CS6 extended program to measure the area of vitiligo lesions, group I showed a decrease of −1.02 and −6.12% in the mean area percentage change of vitiligo lesions on the right and left sides, respectively. In group II the change was +9.84 and +9.13% on the right and left sides, respectively. In conclusion, combining fractional CO₂ laser with NB-UVB for the treatment of non-segmental vitiligo did not show any significant advantage over treatment with NB-UVB alone. Further study of this combination for longer durations in the treatment of vitiligo is recommended.

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Alcohol intake and risk of nonmelanoma skin cancer: a systematic review and dose–response meta-analysis

Summary

Nonmelanoma skin cancer (NMSC) comprises mainly basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). The association between alcohol intake and NMSC has been inconclusive; therefore the objective of this study is to quantify the relationship between alcohol intake and NMSC using meta-analyses. A systematic literature search of PubMed and Embase was performed on 30 October 2016. Eligible articles were case–control or cohort studies that examined alcohol intake and risk of BCC or cSCC and reported relative risks (RRs) with 95% confidence intervals (CIs). Of the 307 articles identified, 13 case–control and cohort studies were included in the systematic review, including 95 241 NMSC cases (91 942 BCC and 3299 cSCC cases). A random-effects model was used to obtain summary RRs and 95% CIs for dose–response meta-analyses. For every 10-gram increase in ethanol intake per day, a positive association was found for both BCC (summary RR of 1·07; 95% CI 1·04–1·09) and cSCC (summary RR of 1·11; 95% CI 1·06–1·16). While there was evidence suggesting a nonlinear association for BCC, it may be due to the sparse data at higher alcohol intake levels. This meta-analysis found evidence that alcohol drinking is positively associated with both BCC and cSCC risk in a dose-dependent manner. These results should be interpreted with caution due to potential residual confounding. Nonetheless, because alcohol drinking is a prevalent and modifiable behaviour, it could serve as an important public health target to reduce the global health burden of NMSC.

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Computed Tomography Score an Excellent Marker: Differentiates Eosinophilic and Non-eosinophilic Variants of Chronic Rhinosinusitis with Nasal Polyp

Abstract

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Morbidity and Functional Outcomes following Free Jejunal Flap Reconstruction for Head and Neck Cancer

Aim: To evaluate the morbidity and fundamental functional outcomes (swallow and speech) after free jejunal flap (FJF) reconstruction following total pharyngolaryngo-esophagectomy (PLE) in China. Methods: 18 patients with FJF reconstruction after total PLE were retrospectively reviewed. Scheduled barium swallow test was performed 7-10 days postoperatively. Rehabilitation of swallowing and speech for patients was assessed by the Performance Status Scale for Head and Neck Cancer Patients. Results: 8 patients died of tumor recurrence and 2 patients died of other reasons (cerebrovascular disease and respiratory disease, respectively). The 1-year, 2-year, and 3-year survival rates were 70.5, 49.4, and 33.8%, respectively. 83.3% of all patients could tolerate soft chewable foods, such as cooked vegetables, fish, hamburger, and small pieces of meat. 2 patients with early stenosis at upper anastomotic sites were with good swallowing function; while 2 patients with early stenosis at lower anastomotic sites were found to have difficulty in oral diet. 2 (11.1%) patients with larynx-preserving pharyngo-esophagectomy showed no compromise in speech. Only 2 (11.1%) patients underwent primary tracheoesophageal puncture for inserting an indwelling voice prosthesis for speech, and both patients achieved functional tracheoesophageal speech. The remaining 14 (77.8%) patients with total PLE did not resume functional speech. Conclusion: Postoperative barium swallow examination is helpful to predict long-term anastomotic stenosis. Good functional swallow rehabilitation is achieved following FJF reconstruction after total PLE or a larynx-preserving procedure. However, the speech outcomes are not satisfactory. It raises the demand of enhancement of functional recovery so that quality of life can be improved for these patients in China.
ORL 2017;79:212-221

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ADAM10 and Notch1 on murine dendritic cells control the development of type 2 immunity and IgE production

Abstract

Background

Allergy and allergic asthma are significant health burdens in developed countries and are increasing in prevalence. Dendritic cells (DCs) initiate immune responses to common aeroallergens and ADAM10 has been demonstrated to be important for the development of adaptive responses. This study's objective was to understand the role of ADAM10 on DCs in the development of allergic and anaphylactic responses.

Methods

In this study we used mouse models of allergic airway inflammation (house dust mice and Alternaria alternata) and OVA-induced models of active anaphylaxis to determine the DC-specific function of ADAM10 and Notch signaling. To examine T_H1 and T_H17 immunity infection with Anaplasma phagocytophilum and Citrobacter rodentium were used.

Results

Mice, which have ADAM10 deleted from DCs, have dramatic reductions in IgE production and do not develop significant T_H2 immune responses. Further, ADAM10^DC^-/- mice are resistant to IgE-mediated anaphylaxis. This response is selective for T_H2 immunity as T_H1 and T_H17 immunity are largely unaffected. Notch1, a known ADAM10 substrate, when knocked out of DCs (Notch1^DC^-/-) demonstrated a similar reduction in anaphylaxis and IgE. Without ADAM10 and Notch1 signaling, DCs were unable to make cytokines that stimulate T_H2 cells and cytokines. Anaphylaxis and allergic lung inflammation were restored in ADAM10^DC^-/- with the overexpression of the Notch1-intracellular domain, confirming the role of Notch signaling.

Conclusions

Targeting ADAM10 and Notch1 on DCs represent a novel strategy for modulating T_H2 immune responses and IgE production.

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Glandular odontogenic cyst: an updated analysis of 169 cases reported in the literature

Abstract

Objective

To integrate the available data published on glandular odontogenic cyst (GOC) into a comprehensive analysis of its clinical/radiologic and histopathological features.

Methods

An electronic search was undertaken in May/2017. Eligibility criteria included publications having enough clinical/radiological/histological information to confirm the diagnosis.

Results

58 publications (169 GOCs) were included. The lesion was slightly more prevalent in men than in women. There was a high prevalence in the fifty/sixth decades of life, in the anterior regions, and in mandibles. Lesions were commonly associated with bone expansion (73%) and unilocular radiological appearance (61.5%). GOC was found to be associated with tooth displacement or an unerupted tooth (30.9%), cortical bone perforation (26%), presence of clinical symptoms (24.3%), root resorption (13.9%). Microscopic parameters most commonly observed in GOCs - in at least 95% of the lesions: presence of hobnail cells, intraepithelial microcysts, epithelial lining with variable thickness. The presence of apocrine snouting was the microscopic parameter less often found (40.4%).

Conclusions

Although the recurrence rate of GOCs is not as high as previously believed, it is a relevant phenomenon (21.6%). Adjunctive procedures after enucleation should be considered. None of the clinical/radiologic and histopathological features evaluated had a statistically significant effect on the recurrence rate.

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Idiopathic sudden sensorineural hearing loss and Ménière syndrome: The role of cerebral venous drainage

Abstract

Aim

to evaluate the influence of cerebral venous drainage on the pathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL) and Ménière syndrome (MD).

Methods

we enrolled 59 consecutive patients (32 males, mean age 53.05+15.37 years): 40 ISSHL and 19 MD. All underwent physical examination, biochemical evaluation (glycemic and lipid profile, viral serology, C reactive protein, etc), audiometric (tonal, vocal, vestibular evoked myogenic potentials and auditory brainstem response test) and impedentiometric examination. The pure tone average (PTA) was calculated for the following frequencies: 250, 500, 1000, 2000, 3000, 4000, 8000. An echo-color Doppler evaluation of the venous cerebral veins, internal jugular (IJV) and vertebral veins (VV) at supine and 90° position was performed.

Results

no morphological alterations were found both in patients and controls. There were no signs of stenosis, blocked flow, membranes, etc. We found lower minimum, mean and maximum velocities in distal IJVs (p=0.019; p=0.013; p=0.022; respectively) and left VVs (p=0.027; p=0.008; p=0.001; respectively) in supine (0°) position in both MD and ISSHL patients as compared to controls. The same was for orthostatic position (90°). We found negative correlations between the velocities in extracranial veins and PTA values: therefore, the worst the audiometric performance of the subjects, the lower the velocities in the venous cerebral drainage.

Conclusions

ISSHL and MD patients showed altered venous flow in IJVs and VVs as compared to controls, independently from posture. This different behavior of venous tone control can influence the ear performance and may have a role in the pathogenesis of both diseases.

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Lichen amyloidosis involving the scalp

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Measurement Error of a Simplified Protocol for Quantitative Sensory Tests in Chronic Pain Patients.

Background and Objectives: Large-scale application of Quantitative Sensory Tests (QST) is impaired by lacking standardized testing protocols. One unclear methodological aspect is the number of records needed to minimize measurement error. Traditionally, measurements are repeated 3 to 5 times, and their mean value is considered. When transferring QST to a clinical setting, reducing the number of records would be desirable to meet the time constraints encountered in a routine clinical environment and to reduce the testing burden to chronic pain patients. However, there might be a trade-off between measurement error and number of records. We determined the measurement error of a single versus the mean of 3 records of pressure pain detection threshold (PPDT), electrical pain detection threshold (EPDT), and nociceptive withdrawal reflex threshold (NWRT) in 429 chronic pain patients recruited in a routine clinical setting. Methods: We calculated intraclass correlation coefficients and performed a Bland-Altman analysis. Results: Intraclass correlation coefficients were all clearly greater than 0.75, and Bland-Altman analysis showed minute systematic errors with small point estimates and narrow 95% confidence intervals. Reducing the number of records from traditionally 3 to only 1 did not lead to relevant measurement error in PPDT, EPDT, or NWRT. Conclusions: This study contributes to a standardized QST protocol, and based on the minimal measurement error of 1 single record of PPDT, EPDT, and NWRT, we submit to reduce the testing burden. This would allow saving time, resources, and patient discomfort. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Desmoplastic small round cell tumor: evaluation of reverse transcription-polymerase chain reaction and fluorescence in situ hybridization as ancillary molecular diagnostic techniques

Abstract

Desmoplastic small round cell tumor (DSRCT) is a rare, biologically aggressive soft tissue neoplasm of uncertain differentiation, most often arising in the abdominal and pelvic cavities of adolescents and young adults with a striking male predominance. Histologically, it is characterized by islands of uniform small round cells in prominent desmoplastic stroma, and it has a polyimmunophenotypic profile, typically expressing WT1 and cytokeratin, desmin, and neural/neuroendocrine differentiation markers to varying degrees. Tumors at other sites and with variant morphology are more rarely described. DSRCT is associated with a recurrent t(11;22)(p13;q12) translocation, leading to the characteristic EWSR1-WT1 gene fusion. Fluorescence in situ hybridization (FISH), to detect EWSR1 rearrangement, and reverse transcription-polymerase chain reaction (RT-PCR) to assess for EWSR1-WT1 fusion transcripts are routine diagnostic ancillary tools. We present a large institutional comparative series of FISH and RT-PCR for DSRCT diagnosis. Twenty-six specimens (from 25 patients) histologically diagnosed as DSRCT were assessed for EWSR1 rearrangement and EWSR1-WT1 fusion transcripts. Of these 26 specimens, 24 yielded positive results with either FISH or RT-PCR or both. FISH was performed in 23 samples, with EWSR1 rearrangement seen in 21 (91.3%). RT-PCR was performed in 18 samples, of which 13 (72.2%) harbored EWSR1-WT1 fusion transcripts. The sensitivity of FISH in detecting DSRCT was 91.3%, and that of RT-PCR was 92.8% following omission of four technical failures. Therefore, both methods are comparable in terms of sensitivity. FISH is more sensitive if technical failures for RT-PCR are taken into account, and RT-PCR is more specific in confirming DSRCT. Both methods complement each other by confirming cases that the other method may not. In isolation, FISH is a relatively non-specific diagnostic adjunct due to the number of different neoplasms that can harbor EWSR1 rearrangement, such as Ewing sarcoma. However, in cases with appropriate morphology and a typical pattern of immunostaining, FISH is confirmatory of the diagnosis.

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Pediatric primary Sjögren syndrome presenting with bilateral ranulas: A case report and systematic review of the literature

Publication date: October 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 101
Author(s): Casey Means, Mark A. Aldape, Ericka King
ContextPrimary Sjögren syndrome is uncommon in children, and the standard clinical criteria used in diagnosis of adult Sjögren syndrome will miss many children with the disease. Floor of mouth ranulas have not been described in Sjögren syndrome.ObjectiveThis study aims to describe a novel presentation of juvenile primary Sjögren syndrome, and to present a comprehensive systematic review of the literature regarding the presentation and diagnosis of Sjögren syndrome in children.Data sourcesOvid MEDLINE.Study selectionA MEDLINE literature search was performed using the following search terms: primary, Sjögren, disease, and children. Results were limited to human subjects and articles written in English between 1981 and 2014. Applicable articles were reviewed and qualitatively summarized.Data extractionPreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRIMA).ResultsInitial MEDLINE search yielded 146 articles, 80 of which were excluded as not clinically pertaining to Sjögren syndrome. An additional 25 were excluded due to lack of pediatric-specific data. Systematic review of the literature revealed no reports of ranula in association with Sjögren syndrome. 6 papers were manually included from review of reference lists of included articles. Our review indicated that recurrent parotitis is the most commonly reported presenting symptom in children, followed by ocular and oral symptoms, musculoskeletal, and renal symptoms. Compared to adults, children are less likely to present with dry eyes and mouth.LimitationsAll studies were retrospective chart reviews, case series or case reports.ConclusionThis is the first report of a child presenting with floor of mouth ranulas in association with Sjögren syndrome. While recurrent parotitis is the most common presentation in children, other salivary gland and extra-salivary manifestations may be seen, and the clinician must maintain a high index of suspicion for underlying Sjögren syndrome.

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Endocrine problems in the critically ill 2: endocrine emergencies

Key points

Most endocrine emergencies are triggered by a secondary insult, which should be sought and managed appropriately.
Clinical features may be non-specific, mimicking other disease processes. Maintain a high index of suspicion.
Derangement of thyroid/adrenal function is common in the critically ill; correction of these derangements in the absence of underlying adrenal or thyroid disease is not required.
Confirmation of diagnosis should not delay treatment in suspected acute adrenal insufficiency.
Vitamin D deficiency is associated with increased all-cause mortality, yet there is no current evidence to support its routine replacement in critical illness.

Endocrine emergencies account for approximately 1.3% of UK critical care admissions. Although relatively uncommon, many of these emergencies are potentially life-threatening. Most endocrine crises are triggered by a secondary insult, commonly infection, and clinical features are often vague and potentially attributable to other causes, such as the precipitating illness. Consequently, the underlying endocrine disorder may easily be overlooked. This article will outline the presentation, investigation, and acute management of adult endocrine emergencies. Diabetic emergencies and glycaemic control in critical illness are discussed in the accompanying article, 'Endocrine problems in the critically ill 1: diabetes and glycaemic control'.¹

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Αρχειοθήκη ιστολογίου

Τετάρτη 26 Ιουλίου 2017

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