Head and Neck Medicine by Alexandros G.Sfakianakis: 09/27/17

Τετάρτη 27 Σεπτεμβρίου 2017

Stent-assisted coiling of a ruptured vertebrobasilar junction aneurysm via direct vertebral artery puncture

A 78-year-old patient was admitted with subarachnoid hemorrhage caused by rupture of a broad-based vertebrobasilar junction aneurysm. Direct endovascular access to the vertebrobasilar circulation was not possible due to chronic occlusion of the proximal dominant left vertebral artery (VA), hypoplastic right VA and posterior communicating arteries. The distal cervical left VA was reconstituted by muscular branches of the ascending cervical artery. Therefore, endovascular access was gained by direct percutaneous VA puncture guided by a roadmap-controlled anterior approach at the level of C5 proximally to the main reconstituting collateral feeders. Successful endovascular treatment of the aneurysm was performed by stent-assisted coiling. Closure of the puncture site at the cervical VA level was achieved by occluding the proximal part of the VA with coils. The post-interventional clinical course was uneventful; early post-interventional CT showed no evidence of cervical hematoma.

http://ift.tt/2wmahLY

Intrapartum assessment of fetal well-being

1A012A043J02

http://ift.tt/2k2Dfi4

Earliest depiction of vitiligo in “Venus at a Mirror” (1615) by Peter Paul Rubens (1577–1640)

Summary

The 1615 painting of Venus at a Mirror by Peter Paul Rubens is considered a powerful example of the Flemish Baroque movement. Recently it has been identified that the Venus character in the image has a goitre, however on studying the image further, I note dermato-pathology in another of the painting's main characters; the dark-skinned female typically described as the Venus' maidservant who clearly demonstrates patches of skin pigment loss on her face and neck with a concurrent streak of white hair. Together these suggest the underlying diagnosis of vitiligo. There is also a goitre in this individual suggesting thyroid disease. This new finding may offer additional insight into the historical epidemiology of disease in northern Europe but also offers further understanding of the method, origin, and pathological associations of this prominent painting from a genius artist.

http://ift.tt/2xH02F6

Brain functional connectivity differentiates dexmedetomidine from propofol and natural sleep

Abstract

Background.

We used functional connectivity measures from brain resting state functional magnetic resonance imaging to identify human neural correlates of sedation with dexmedetomidine or propofol and their similarities with natural sleep.

Methods.

Connectivity within the resting state networks that are proposed to sustain consciousness generation was compared between deep non-rapid-eye-movement (N3) sleep, dexmedetomidine sedation, and propofol sedation in volunteers who became unresponsive to verbal command. A newly acquired dexmedetomidine dataset was compared with our previously published propofol and N3 sleep datasets.

Results.

In all three unresponsive states (dexmedetomidine sedation, propofol sedation, and N3 sleep), within-network functional connectivity, including thalamic functional connectivity in the higher-order (default mode, executive control, and salience) networks, was significantly reduced as compared with the wake state. Thalamic functional connectivity was not reduced for unresponsive states within lower-order (auditory, sensorimotor, and visual) networks. Voxel-wise statistical comparisons between the different unresponsive states revealed that thalamic functional connectivity with the medial prefrontal/anterior cingulate cortex and with the mesopontine area was reduced least during dexmedetomidine-induced unresponsiveness and most during propofol-induced unresponsiveness. The reduction seen during N3 sleep was intermediate between those of dexmedetomidine and propofol.

Conclusions.

Thalamic connectivity with key nodes of arousal and saliency detection networks was relatively preserved during N3 sleep and dexmedetomidine-induced unresponsiveness as compared to propofol. These network effects may explain the rapid recovery of oriented responsiveness to external stimulation seen under dexmedetomidine sedation.

Trial registry number.

Committee number: 'Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège' (707); EudraCT number: 2012-003562-40; internal reference: 20121/135; accepted on August 31, 2012; Chair: Prof G. Rorive. As it was considered a phase I clinical trial, this protocol does not appear on the EudraCT public website.

http://ift.tt/2yuexJP

Does length of intubation prior to tracheostomy affect intensive care unit length of stay?

Publication date: Available online 27 September 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Shaun R. Young, Gary F. Bouloux, Sebastian D. Perez, Shelly Abramowicz
PurposeThe purpose of this study was to determine if length of intubation prior to tracheotomy (LIT) affects length of stay in intensive care unit (ICU).Materials and MethodsThis was a retrospective case series of patients who had open tracheotomies at Grady Memorial Hospital by the Oral and Maxillofacial Surgery (OMS) service. Medical records were reviewed to document patient demographics, etiology for ventilator dependence, and complications. The primary predictor variable was LIT and primary outcome variable was length of stay in ICU after tracheotomy. Statistical analysis was performed (significance p<.05).ResultsThere were 115 subjects (mean age 54 years old) included in the study. Majority received tracheotomies due to prolonged mechanical ventilation secondary to a medical comorbidity. Intraoperative complications were cardiac arrest and difficulty accessing trachea. Postoperative complications were bleeding. Postoperatively, majority of patients were discharged from the ICU or weaned off mechanical ventilation within 5 days. The correlation between LIT and ICU stay was not statistically significant but the trend was positive.ConclusionThe results of this study indicate that patients undergoing an earlier tracheotomy were more likely to have an earlier discharge from the ICU.

http://ift.tt/2hB9iov

A historical perspective with current opinion on the management of atrophic mandibular fractures

Publication date: Available online 27 September 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Jaime Castro-Núñez, Larry L. Cunningham, Joseph E. Van Sickels
The management of atrophic mandibular fractures has been a challenge for maxillofacial surgeons for decades. During the past 70 years, various techniques for treating edentulous mandibular fractures have been advocated. These techniques have been praised, critized, abandoned, improved, and used in combination with other methods. Although some of the principles of management outlined before the end of World War II are still valid in today's technological era, other concepts did not survive the test of time. The aim of this paper is to examine the evolution of treatment modalities for the management of atrophic mandibular fractures that have been employed over the years. Debates and discussions generated by this topic are included. Current techniques and treatment philosophies with thoughts for future therapies are provided.

http://ift.tt/2xDuVJ4

Announcements

Dear Colleagues,

http://ift.tt/2fTbMuV

EACMFS Prizes and Awards

The Council of EACMFS wishes to ensure that all members of the Association are aware of the current awards and prizes that are available. These are designed to provide educational support and also to allow the opportunity for trainees and those who have recently achieved specialist status to visit units outside their own departments.

http://ift.tt/2xN4brk

Editorial Board

http://ift.tt/2fTbiVM

Procaine and Local Anesthetic Toxicity: A Collaboration Between the Clinical and Basic Sciences.

In 1924, the Therapeutic Research Committee of the American Medical Association appointed a special committee to investigate deaths following the administration of local anesthetics. The Committee for the Study of Toxic Effects of Local Anesthetics found procaine, although a safer clinical alternative to cocaine, was capable of causing death when large doses were injected into tissues and advised that it should be used with caution. This article describes a collaboration beginning in 1928 between Dr John Lundy of the Mayo Clinic and Dr Robert Isenberger of the University of Kansas, which arose from a controversy surrounding systemic adverse reactions to procaine. Isenberger then traveled to the Mayo Clinic to conduct research on various procaine local and spinal anesthesia doses and sodium amytal's protective effect against procaine-induced toxicity. Lundy and Isenberger's work would add to the ongoing discovery of systemic reactions to local anesthetics. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

http://ift.tt/2wm2GNy

Impact of Regional Anesthesia on Recurrence, Metastasis, and Immune Response in Breast Cancer Surgery: A Systematic Review of the Literature.

Background and Objectives: The perioperative period is critical in the long-term prognosis of breast cancer patients. The use of regional anesthesia, such as paravertebral block (PVB), could be associated with improvements in long-term survival after breast cancer surgery by modulating the inflammatory and immune response associated with the surgical trauma, reducing opioid and general anesthetic consumption, and promoting cancer cells death by a direct effect of local anesthetics. Methods: A systematic literature search was conducted for studies of patients who received PVB for breast cancer surgery. The Jadad score and Ottawa-Newcastle scale were used to assess the methodological quality of randomized controlled trial and observational retrospective studies, respectively. Only high-quality studies were considered for meta-analysis. The selected studies were divided into 3 groups to determine the impact of PVB on (a) recurrence and survival, (b) humoral response, and (c) cellular immune response. Results: We identified 467 relevant studies; 121 of them underwent title and abstract review, 107 were excluded, and 15 studies were selected for full text reading and quality assessment. A meta-analysis was not conducted because of low-quality studies and lack of uniform definition among primary outcomes. Thus, a systematic review of the current evidence was performed. Conclusions: Our study indicates that there are no data to support or refute the use of PVB for reduction of cancer recurrence or improvement in cancer-related survival. However, PVB use is associated with lower levels of inflammation and a better immune response in comparison with general anesthesia and opioid-based analgesia. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

http://ift.tt/2xDAdUL

The role of the ugly duckling sign in patient education

The ABCDE (with A standing for asymmetry, B for border irregularity, C for color variegation, D for diameter larger than 6 mm, and E for evolution) rule for melanoma (MM) recognition is widely taught in the general population. The ugly duckling (UD) sign is an alternate MM recognition strategy that is not generally taught.

http://ift.tt/2yafuet

Cultural competence for the 21st century dermatologist practicing in the United States

Significant health disparities exist among under-represented minorities in the Unites States, which can partially be accounted for by the quality of patient-physician interaction. A distinguishing factor of this interaction is the ability of the provider to demonstrate cultural competence, or address the social, cultural, and community influences on healthcare behaviors and incorporate these elements into patient care. However, this practice has yet to be universally implemented in our healthcare system.

http://ift.tt/2fzCziL

Gefitinib for patients with incurable cutaneous squamous cell carcinoma: A single-arm phase II clinical trial

Preclinical data demonstrate a key role for the epidermal growth factor receptor (EGFR) in the carcinogenesis of cutaneous squamous cell carcinomas (CSCCs). There are, however, limited data on the efficacy of EGFR inhibitors in incurable, recurrent, and/or metastatic CSCC.

http://ift.tt/2fAtIgM

Recurrent scarring papulovesicular lesions on sun-exposed skin in a 22-year-old man

A 22-year-old white man has been followed in the Clinical Center at the National Institutes of Health (NIH) for recurrent outbreaks of scarring herpetiform lesions on sun-exposed areas. The patient and/or parents signed consent forms and were followed under NIH protocols that were approved by the institutional review boards of the National Human Genome Research Institute, National Institute of Allergy and Infectious Diseases, and National Cancer Institute.

http://ift.tt/2y9e4Rw

Cardiovascular comorbidities of pediatric psoriasis among hospitalized children in the United States

Psoriasis has been shown to be associated with cardiovascular disease in adults. Little is known about cardiovascular risk in pediatric psoriasis.

http://ift.tt/2yaAmCm

Racial and ethnic differences in health care utilization for childhood eczema: An analysis of the 2001-2013 Medical Expenditure Panel Surveys

Eczema is a common chronic inflammatory disease of the skin. Studies suggest differences in disease prevalence and severity by race/ethnicity. Our knowledge of health care utilization for eczema among different racial/ethnic groups remains limited.

http://ift.tt/2fAcpwH

Comparison of snoring sounds between natural and drug-induced sleep recorded using a smartphone

Snoring is an important clinical feature of obstructive sleep apnea (OSA), and recent studies suggest that the acoustic quality of snoring sounds is markedly different in drug-induced sleep compared with natural sleep. However, considering differences in sound recording methods and analysis parameters, further studies are required. This study explored whether acoustic analysis of drug-induced sleep is useful as a screening test that reflects the characteristics of natural sleep in snoring patients.

http://ift.tt/2wXZJSK

The Role of Allergy in Chronic Rhinosinusitis

The role of allergy in chronic rhinosinusitis (CRS) has long been debated and remains controversial. The 2 diseases frequently co-occur; however, direct causality has never been proved. The literature is largely mixed as to the manner and degree by which allergy contributes to CRS and this is in large part due to heterogeneity in the definitions of allergy and of CRS. In this review, the potential role of allergy in the disease processes of CRS without polyps, CRS with polyps, and allergic fungal rhinosinusitis is discussed.

http://ift.tt/2xLojtY

Advances in Food Allergy

Food allergy has been increasing in prevalence for the last few decades, and numerous studies have evaluated ways of improving the allergy practitioner's ability to accurately diagnose patients who are truly food allergic, rather than sensitive but able to tolerate food. Once diagnosed, the current standard treatment is food elimination and avoidance, but other potential treatment options like oral immunotherapy, sublingual immunotherapy, and epicutaneous immunotherapy are becoming promising alternatives. Due the health care costs and potential for life-threatening adverse reactions, much attention has been given to the prevention of food allergies, resulting a shift in recent guideline recommendations.

http://ift.tt/2yJf7Eq

Efficacy and Safety of Subcutaneous and Sublingual Immunotherapy for Allergic Rhinoconjunctivitis and Asthma

Allergic rhinitis is often associated with asthma and has significant impacts on health care costs and productivity in the United States. Although allergen avoidance and pharmacotherapy are effective, allergen-specific immunotherapy is the only treatment that may lead to improved allergy symptoms even after treatment is discontinued. Subcutaneous immunotherapy has been the mainstay of allergen-specific immunotherapy in the United States for decades, but sublingual immunotherapy has recently become available. This review discusses the use of subcutaneous immunotherapy and sublingual immunotherapy in the treatment of allergic rhinitis and asthma and reviews the current evidence regarding the safety and efficacy of both formulations.

http://ift.tt/2xMejku

Immunotherapy

Polysensitization, sensitization to more than one allergen, is a common feature of patients with allergic rhinitis, and may be a risk factor for subsequent development of allergic diseases, especially allergic asthma. However, a polysensitized patient does not necessarily have polyallergy, a documented, causal relationship between exposure to 2 or more specific, sensitizing allergens and the subsequent occurrence of relevant clinical symptoms of allergy. Allergen immunotherapy treatment strategy for the polysensitized patient in Europe is to treat the single or 2 most clinically relevant allergen(s), whereas patients in the United States are usually treated for all potential clinically relevant allergens.

http://ift.tt/2yHCcHP

Contemporary Pharmacotherapy for Allergic Rhinitis and Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are chronic conditions causing nasal inflammation. CRS is increasingly recognized as a chronic inflammatory process rather than a chronic infection. Although the primary initiating factors in CRS remain unclear, AR is driven by IgE-mediated hypersensitivity to environmental allergens. Understanding the underlying inflammatory pathways and disease endotypes are driving innovation toward novel pharmacotherapies targeting critical mediators implicated in CRS and AR, including IL-4, IL-13, IL-5, IgE, and epithelial initiators IL-33 and TSLP. Extensive investigations are needed to determine the role, timing, predictive prognostic factors and long-term safety and efficacy of these agents.

http://ift.tt/2xLFLPb

Staging of squamous cell carcinoma of the tongue: extrinsic lingual muscles and the 8th editions of the American Joint Committee on Cancer/Union for International Cancer Control staging manuals

Our aim was to find out first whether the extrinsic muscles of the tongue are histologically identifiable, and secondly to what degree the use of the new criteria in the 8th editions of the American Joint Committee on Cancer(AJCC)/Union for International Cancer Control (UICC) manuals (which have recognised the importance of depth of invasion of tumour, rather than invasion of the extrinsic muscles of the tongue and extranodal extension), will alter staging of lingual squamous cell carcinoma (SCC).

http://ift.tt/2k4ixyy

Recurrent synovial chondromatosis of the temporomandibular joint: report of two cases

Synovial chondromatosis is the most common tumour-like lesion that is found in the temporomandibular joint (TMJ). Although it is benign and self-limiting, it can recur. We retrospectively reviewed 274 cases that were treated in our department from 2001-16 and found two recurrences, the radiological, surgical, histopathological, and follow-up results of which we report here. The reasons for their recurrence were analysed and elucidated.

http://ift.tt/2ytnYtc

Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of dentoalveolar surgery after treatment with antiresorptive or antiangiogenic agents.1 Patients are diagnosed with MRONJ if they have or have had: current or previous treatment with antiresorptive or antiangiogenic agents, exposed bone or bone that can be probed through an intraoral or extraoral fistula that has persisted for more than eight weeks, and no history of radiation to the jaws or metastatic disease to the jaws.

http://ift.tt/2k4iqmC

Comparison of Emla cream and lidocaine injection for local anaesthetic before radiofrequency reduction of the inferior turbinates

We compared the effectiveness of local anaesthetic with Emla cream with that of an injection of lidocaine for radiofrequency reduction of the inferior turbinates. We studied 98 consecutive patients with hypertrophied inferior turbinates, 46 of whom were given Emla cream and 52 lidocaine injection. The procedure began five minutes after the injection of lidocaine and 10minutes after the Emla cream had been applied. Patients were asked to indicate on a visual analogue scale (VAS) the degree of perioperative pain, anxiety, sensation of choking, and discomfort on swallowing that they felt after the procedure.

http://ift.tt/2yuhcDs

Multidisciplinary team approach in the oral rehabilitation of patients with cleidocranial dysplasia to achieve a functional aesthetic outcome

Cleidocranial dysplasia is a hereditary congenital disorder that results in delayed ossification of midline structures, and is caused by mutations in the RunX2 (runt-related transcription factor 2) gene located on the short arm of chromosome 6. Successful treatment depends on multidisciplinary assessment and a comprehensive staged treatment plan. We present a case series of 12 patients who were managed with a specifically tailored combination of surgery, orthodontics, and prosthodontics to provide a functional dentition and restore their smile and facial contour.

http://ift.tt/2k4adyI

Beneficial effect of botulinum toxin A on secondary ischaemic injury of skin flaps in rats

Botulinum toxin A (BTX-A) protects against primary ischaemia of skin flaps, but its effect on secondary ischaemia is unknown. We induced secondary arterial or venous ischaemia in skin flaps of 32 Wistar rats, and tested the effectiveness of BTX injected subcutaneously 12hours before the flap was raised. The animals were divided into two groups of 16 (arterial or venous). Eight animals in each group were then treated with saline 1ml (control), and eight with BTX-A 5 IU (treatment). Ischaemia and necrosis were assessed after five days.

http://ift.tt/2yuh3jo

The Effect of Manufacturing Techniques on Custom-Made Titanium Cranioplasty Plates: A Pilot Study

This study investigated the effect of varying techniques on the surface characteristics of pressed titanium cranioplasty plates, commonly manufactured in laboratory practice. The aim was to highlight the variety of techniques currently used, assess these methods of manufacture and produce manufacturing recommendations.

http://ift.tt/2y9IW47

Editorial Board

Publication date: October 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 134, Issue 5

http://ift.tt/2wVrLmF

Publication date: October 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 134, Issue 5

http://ift.tt/2xD2Hhp

The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial.

BACKGROUND: Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. METHODS: This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 [micro]g, and morphine 150 [micro]g. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. RESULTS: One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. CONCLUSIONS: We were unable to demonstrate a beneficial effect of phenylephrine on umbilical artery pH compared with ephedrine. Our findings suggest that phenylephrine may not have a clinically important advantage compared with ephedrine with regard to improved neonatal acid-base status when used to prevent spinal anesthesia-induced hypotension in women with preeclampsia undergoing cesarean delivery. (C) 2017 International Anesthesia Research Society

http://ift.tt/2fyn1vO

In Response.

No abstract available

http://ift.tt/2wlnLaR

Understanding the Significance of Aerosolized Vasodilator Use in Pulmonary Hypertension: What Is Numerically, Statistically, and Clinically Meaningful?.

No abstract available

http://ift.tt/2fAeZmi

Mechanisms Supporting Astrocyte-Mediated Neuroprotection.

No abstract available

http://ift.tt/2wkJfEI

The Effect of Zinc Lozenge on Postoperative Sore Throat: A Prospective Randomized, Double-Blinded, Placebo-Controlled Study.

BACKGROUND: Postoperative sore throat (POST) is commonly seen after endotracheal intubation, and oral zinc prevents oral mucositis associated with chemotherapy. This study is designed to evaluate the effects of administration of zinc lozenges on POST. METHODS: Seventy-nine patients undergoing low- or moderate-risk surgery with endotracheal intubation were randomly assigned into 2 groups: Control group received placebo and zinc group received 40-mg zinc lozenges 30 minutes preoperatively. Patients were assessed for incidence and severity (4-point scale, 0-3) of POST at 0, 2, 4, and 24 hours postoperatively. The primary outcome was incidence of POST at 4 hours after surgery. The secondary outcomes were the incidence of POST at 0, 2, and 24 hours and the severity of POST. RESULTS: At 4 hours, there was a significantly lower incidence of POST in the zinc group, 7%, than the control group, 29% (P = .046). The incidence of POST at 0 hour was 0% in zinc group and 24% in control group (P = .004). The highest incidence of POST occurred at the second hour after surgery, with the rate of 10% in the zinc group and 34% in the control group (P = .0495). The incidence of POST at 24 hours was 13% in zinc group and 24% in control group (not significant). The severity of POST was significantly lower in the zinc group for mild (P = .003) and moderate (P = .004) POST. CONCLUSIONS: The administration of a single dose of 40-mg zinc lozenge 30 minutes preoperatively is effective to reduce both incidence of POST in the first 4 hours and severity of mild and moderate POST in the immediate postoperative period. (C) 2017 International Anesthesia Research Society

http://ift.tt/2fAKgFr

How Safe Are Various Systemic Therapies for Pediatric Psoriasis?

Reuters Health Information

http://ift.tt/2fzdbty

The sex-shift in single disease and multimorbid asthma and rhinitis during puberty

Abstract

Background

Cross-sectional studies suggested that allergy prevalence in childhood is higher in boys compared to girls, but it remains unclear if this inequality changes after puberty. We examined the sex-specific prevalence of asthma and rhinitis as single and as multimorbid diseases before and after puberty-onset in longitudinal cohort data.

Methods

In six European population-based birth cohort studies we assessed the outcomes current rhinitis, current asthma, current allergic multimorbidity (i.e. concurrent asthma and rhinitis), puberty status, and allergic sensitization by specific serum antibodies (immunoglobulin E) against aero-allergens. With generalized estimating equations we analysed the effects of sex, age, puberty (yes/no), and possible confounders on the prevalence of asthma and rhinitis, and allergic multimorbidity in each cohort separately and performed individual participant data meta-analysis.

Findings

We included data from 19,013 participants from birth to age 14-20 years. Current rhinitis only affected girls less often than boys before and after puberty onset: adjusted odds ratio for females vs. males 0.79 (95%-confidence interval 0.73-0.86) and 0.86 (0.79-0.94) respectively (sex-puberty interaction p= 0.089).

Similarly, for current asthma only, females were less often affected than boys both before and after puberty-onset: 0.71, 0.63-0.81 and 0.81, 0.64-1.02, respectively (sex-puberty interaction p=0.327).

The prevalence of allergic multimorbidity showed the strongest sex-effect before puberty onset (female-male-OR 0.55, 0.46-0.64) and a considerable shift towards a sex-balanced prevalence after puberty onset (0.89, 0.74-1.04); sex-puberty interaction: p<0.001.

Interpretation

The male predominance in prevalence before puberty and the 'sex-shift' towards females after puberty-onset was strongest in multimorbid patients who had asthma and rhinitis concurrently.

The median follow-up was 35.9 months. The 3-year OS of the IMRT, 3D conformal RT, and total groups was 81.6%, 57.2%, and 66.6%, respectively. Pulmonary toxicity was not observed with IMRT. Six of 62 cases (9.6%) with nodal involvement developed upper cervical node recurrence outside the prophylactic region. Ten patients in the IMRT group were salvaged, and 60% survived without recurrence; 20% of the 3D conformal RT group was salvaged.

Conclusion

The IMRT group was comparable with 3D conformal RT group, with a better salvage rate. We recommend extended cervical irradiation for nodal involvement.

http://ift.tt/2y8L0cJ

Prior Authorizations for Diagnostic Skin Biopsies

This Viewpoint outlines how managed care policies on prior authorization for diagnostic skin biopsies are affecting costs, access to care, and quality of care for patients.

http://ift.tt/2wW3vRl

Nonhealing Leg Ulcer in a Middle-aged Indian Man

A middle-aged Indian man with multiple, ill-defined, hypopigmented, asymptomatic lesions on his face and scalp presents with a painful foot ulcer having well-defined margins and a yellowish slough that remained unhealed after 1 year. Treatment with rifampicin, dapsone, and clofazimine after an earlier diagnosis of multibacillary leprosy failed. What is your diagnosis?

http://ift.tt/2yHmnkx

Thyroid Function in Children With Alopecia Areata

This study characterizes thyroid function in children with alopecia areata to establish guidelines for thyroid dysfunction screening.

http://ift.tt/2wVoxzt

Descriptive Error in the Text

In the Original Investigation titled "Prevalence of Pubic Hair Grooming–Related Injuries and Identification of High-Risk Individuals in the United States," published online August 16, 2017, there was a descriptive error in the text. The term vagina was used rather than the more accurate labia majora in 4 instances. This article has been corrected online.

http://ift.tt/2yGGtLu

Use of a Physician Extender and Dermatology Appointment Wait Times

This cross-sectional analysis of responses to a telephone algorithm finds that dermatology appointment wait times have doubled over the past decade and appointment wait time may have an influence on dermatology office management.

http://ift.tt/2wWQQxs

Chronic Urticaria in Children

Six years ago, we reviewed what was then known about chronic urticaria (CU) in children. We came to the conclusion that many important and interesting questions were unanswered. These included, but were not limited to, how common chronic spontaneous urticaria (CSU) and inducible urticaria are in children, the clinical presentation, underlying causes, impact on everyday life of CU in children, and the natural course of pediatric CU. We also suggested strategies to address and answer these questions and encouraged further studies to do so.

http://ift.tt/2yHdabS

Sclerotherapy for Reticular Veins in the Lower Limbs

This randomized clinical trial compares sclerotherapy of reticular veins of the lower limb with 2% polidocanol diluted in 70% hypertonic glucose vs hypertonic glucose alone.

http://ift.tt/2wVFutU

Factors Associated With Chronic Urticaria in Children

This cohort study examined the resolution rate of chronic urticaria in children and whether there are biomarkers that can predict resolution.

http://ift.tt/2yHcMtW

Airway pathology in severe asthma is related to airflow obstruction but not symptom control

Abstract

Background

Patients with asthma present structural and inflammatory alterations that are believed to play a role in disease severity. However, airway remodeling and inflammation have not been extensively investigated in relation to both symptom control and airflow obstruction in severe asthmatics. We aimed to investigate several inflammatory and structural pathological features in bronchial biopsies of severe asthmatics that could be related to symptom control and airflow obstruction after standardized treatment.

Methods

50 severe asthmatics received prednisone 40 mg/day for 2 weeks and maintenance therapy with budesonide/formoterol 400/12 μg twice daily + budesonide/formoterol 200/6 μg as needed for 12 weeks. Endobronchial biopsies were performed at the end of 12 weeks. We performed extensive immunopathological analyses of airway tissue inflammation and remodeling features in patients stratified by asthma symptom control and by airflow obstruction.

Results

Airway tissue inflammation and remodeling were not associated with symptom control. Asthmatics with persistent airflow obstruction had greater airway smooth muscle (Asm) area with decreased periostin and transforming growth factor beta positive cells within Asm bundles, in addition to lower numbers of chymase positive mast cells in the submucosa compared to patients with non-persistent obstruction.

Conclusions

Symptom control in severe asthmatics was not associated with airway tissue inflammation and remodeling, although persistent airflow obstruction in these patients was associated with bronchial inflammation and airway structural changes.

http://ift.tt/2hz9KjH

The roadmap for Allergology in Europe: the subspecialty of Allergology as ‘stop-over’ on the way to a full specialty. An EAACI position statement

Abstract

The vision of EAACI and the UEMS Section and Board (S&B) on allergology is to promote and to establish a full specialty of allergology in all European countries. In many European countries a full specialty does not exist. In those countries organ-based (sub)specialists or paediatricians and internists with an expertise in allergology may deliver allergy care. There are no generally accepted requirements for the training of subspecialists available. To fill the gap between the need and availability of experienced and accredited physicians who can deliver optimal care to the allergic patients the EAACI Specialty Committee proposes the minimal requirements for training and certification of subspecialists in allergology. This paper describes the required theoretical knowledge, skills, competences and training facilities (staff and institution). The subspecialist as described in this paper should ideally show the necessary competence in providing good quality care to patients in an environment lacking those full specialists in allergology or tertiary care paediatric subspecialists in allergy.

http://ift.tt/2hxRHhj

Iridociliary epithelial cyst

Description

A 26-year-old male patient presented for routine ocular evaluation; visual acuity was 20/20 in each eye with +0.75 dioptre sphere. Bilateral anterior segment examination showed a clear cornea and a normal central anterior chamber depth. In the right eye towards the periphery on temporal aspect, anterior surface of the iris showed irregular anterior elevation (figure 1A, red and yellow arrows) without any loss of its contour or endothelial touch. Lens was crystalline clear, and the pupil was reactive in absence of any posterior synechiae or anterior chamber cells; intraocular pressures were 16 and 14 mm Hg in right and left eye, respectively. Left eye anterior segment and retina in both the eyes were essentially within normal limits. Gonioscopy in both the eyes showed open angles without any identifiable pathology. Anterior segment optical coherence tomography (ASOCT) confirmed the anterior elevation of the iris at two sites (figure 1B,...

http://ift.tt/2yGQGaY

Spontaneous intramural small bowel hematoma in a patient with acute myeloid leukaemia receiving chemotherapy and nilotinib

Spontaneous intramural small bowel hematoma (SISBH) is a rare, acute abdominal condition, with increasing incidence in recent years. Excessive anticoagulation with vitamin K antagonists is the most common aetiology. We report the case of a large acute jejunal intramural hematoma in a patient with newly diagnosed acute myeloid leukaemia receiving chemotherapy and nilotinib. The patient presented with abdominal pain, haematochezia, acute anaemia and thrombocytopenia. CT of the abdomen and pelvis revealed SISBH. The patient was managed conservatively with supportive management and cessation of nilotinib therapy. The patient's symptoms improved, with subsequent CT imaging confirming resolution. This case highlights an uncommon cause of gastrointestinal bleed usually diagnosed only after radiological imaging. A correct diagnosis is important as SISBH usually responds to conservative measures, and may obviate the patient from unnecessary invasive investigations.

http://ift.tt/2wU81Ql

Ventricular tachycardia after initiation of fingolimod

Fingolimod, a sphingosine-1-phosphate receptor modulator, is used for the treatment of relapsing-remitting multiple sclerosis. It is well known to cause bradyarrhythmias. We present a 63-year-old woman who was admitted to the hospital with sustained monomorphic ventricular tachycardia 2 weeks after fingolimod initiation. Further evaluation showed that the patient's ventricular tachycardia was most likely secondary to her medication. Medical practitioners need to be aware of such possible life-threatening side effects while using fingolimod.

http://ift.tt/2yIBNF4

Unusual combination of bilateral ischaemic optic neuropathy following cardiac surgery

Ischaemic optic neuropathy is a rare but serious complication post cardiopulmonary bypass in cardiac surgery patients. It presents with visual loss either unilaterally or bilaterally, and it can be anterior or posterior in type depending on the segment of the optic nerve involved. In non-ocular surgery patients, the most common type is called non-arteritic ischaemic optic neuropathy. We report a case of bilateral non-arteritic ischaemic optic neuropathy following coronary artery bypass grafting and mitral valve surgeries and review the published literature for the aetiology, management and prognosis of this rare complication.

http://ift.tt/2wWahqt

Dementia with Lewy bodies presenting as probable epileptic seizure

We discuss the case of an 83-year-old man admitted to the hospital after losing control of his vehicle due to an unexplained episode of altered consciousness. This occurred on a background of multiple similar episodes associated with acute confusion, superimposed on a gradual cognitive decline spanning 6 years. Organic aetiologies for delirium were excluded and CT and MRI of the brain were negative for cerebrovascular accidents or other epileptogenic foci. Electroencephalogram (EEG) was negative for epileptiform activity. A diagnosis of seizure in the setting of dementia with Lewy bodies (DLB) was deemed probable. Subsequent brain single-photon emission computed tomography (SPECT) and flurodeoxy glucose-positron emission tomography (FDG-PET) studies supported the underlying diagnosis of DLB. Acute changes in consciousness or cognition are often related to strokes or seizures in the older person. As illustrated in this case, however, it is important to consider alternative comorbidities that may coexist.

http://ift.tt/2yHbxL9

Primary cutaneous Ewing sarcoma presenting as a chest wall lesion

A 10-year-old boy presents with a rare case of primary cutaneous Ewing sarcoma. The left-sided chest wall lesion was initially thought to be a benign haemangioma and treated with cryotherapy. Within 4 months, the lesion returned and post excision was found to be primary cutaneous Ewing sarcoma on histology. Few cases of primary cutaneous Ewing sarcoma exist in the literature, and although it is a rare differential for paediatric skin lesions, it is an important consideration due to the associated mortality risk in this young cohort.

http://ift.tt/2wWaeLj

Recurrent gastric metal bezoar: a rare cause of gastric outlet obstruction

A 52-year-old male patient with psychiatric medical history who presented to the emergency department five times during a period of 5 years due to gastric outlet obstruction manifested mainly by abdominal pain, vomiting and haematemesis after intentionally ingesting metals and which necessitate several surgical interventions. Lately, he presented with generalised peritonitis due to gastric perforation from metal bezoars. Chronic abdominal symptoms in patient having a psychiatric disorder can be due to foreign body ingestion. Treatment is often surgical and the whole digestive tract should be explored to avoid retained bezoars.

http://ift.tt/2yGRxIN

Traumatic elbow arthrotomy after motorcycle accident not evident on CT

An 84-year-old man sustained a motorcycle accident resulting in a left elbow laceration. Orthopaedics was consulted to rule out traumatic arthrotomy. Radiographs and CT of the left elbow showed no acute osseous abnormalities and no evidence of traumatic arthrotomy. The wound was irrigated, dressed and splinted. On follow-up, the patient reported that he had been given clindamycin on a return visit to the emergency department for increased drainage. On inspection, the patient's wound was found sutured and draining purulent fluid. The patient persistently had no pain on axial loading or range of motion since his injury and no evidence of intra-articular air on initial CT. However, given the mechanism of injury, irrigation and debridement (I&D) in the operating room was immediately performed revealing purulent joint fluid and a traumatic arthrotomy. I&D was carried out for the second time in the joint. After an extended hospital stay and antibiotics, the infection resolved.

http://ift.tt/2wWa3j7

Laparoscopic removal of migrated intrauterine device

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.

http://ift.tt/2yGzmmm

Gastric necrosis and perforation in a patient with Aspergers syndrome

Acute gastric necrosis is a very rare but potentially fatal condition which has been reported in patients with abnormal eating behaviours.We describe the case of a 24-year-old female with a background of Asperger's syndrome, who presented with abdominal pain and gross distension. She underwent an emergency exploratory laparotomy and was found to have a massively distended, necrotic stomach. A total gastrectomy was performed with interval reconstruction planned. This case reports the surgical management of a rarely seen condition and highlights the importance of recognising gastric necrosis and its causes, which include patients with abnormal eating behaviours, the majority of whom are young females. This is the first report highlighting gastric necrosis in a patient with Asperger's syndrome and coincides with a growing recognition of the association between eating disorders and the autistic spectrum. It is also a rare example of patient survival following total gastric necrosis with perforation.

http://ift.tt/2wVtd8s

Multimodality cardiac imaging of submitral left ventricular aneurysm with concurrent descending aorta mycotic aneurysm

We present a case of a 20-year-old Malay man with underlying tuberculous (TB) lymphadenitis who presented with shortness of breath and found to have submitral left ventricular aneurysm (SLVA). SLVA is well recognised but rare. Incidence of SLVA in Malay has never been documented. This is the first reported case of SLVA in Malays with concomitant thoracic aorta mycotic aneurysm. TB has been reported to be associated with SLVA. Treatment is either surgical or conservative. Imaging is required for diagnosis and preoperative assessment. Multimodality imaging include echocardiography (ECHO), cardiac CTangiography and the robust multiparametric cardiac MR (CMR). ECHO is the first line imaging and useful for initial detection of the aneurysm. CMR including the late gadolinium enhancement allows excellent visualisation of the LV aneurysm, tissue characterisation, cardiac function and detection of associated pathology as shown in this case.

http://ift.tt/2yGRGfh

Eosinophilic myocarditis: an often subtle and potentially under-recognised phenomenon

A 34-year-old woman presented to our service with chest pain, a troponin rise and dynamic ECG changes. Of note, she had complained of fatigue, feeling constitutionally unwell and a generalised rash in the days prior to her presentation. Her echocardiogram showed normal wall motion and preserved ejection fraction. Her eosinophil count, normal at presentation, rose to a peak of 12.21x10⁵/L. She was haemodynamically stable throughout with no evidence clinically of congestive cardiac failure. CT coronary angiogram showed no obstructive coronary artery disease. Cardiac MRI demonstrated areas of late gadolinium enhancement consistent with myocarditis. A diagnosis of eosinophilic myocarditis was made. No tissue biopsy was performed due to the patchy myocardial involvement and high potential for low-yield biopsy. Our patient was treated conservatively and has made an excellent recovery.

http://ift.tt/2wVi5c3

Iatrogenic displacement of high-speed bur during third molar removal

Surgical removal of impacted mandibular third molar is a routine procedure in oral surgery. Various iatrogenic complications related to the procedure has been discussed well in the literatures before. Some of these complications are related to the wrong usage of instruments and techniques. Here we discuss a rare complication on a 42-year-old male, related to the use of high-speed handpiece drill in mandibular third molar removal in a general dental office setting. He was referred when a high speed tungsten carbide bur was accidentally broken and displaced into the mandibular bone during surgical procedure. It is not common to use a high-speed handpiece in impacted third molar removal. This iatrogenic complication could have been totally avoided with the use of proper equipment and technique; therefore raising awareness regarding wrong usage of instrument is vital to avoid similar incidents in the future.

http://ift.tt/2yGitbv

Unilateral adrenal mass as the sole initial manifestation of differentiated thyroid cancer

Unilateral adrenal metastases without disseminated disease has rarely been reported in differentiated thyroid carcinoma (DTC). A 72-year-old female presented with vague abdominal discomfort and loss of appetite of 2 months duration. She had undergone left hemithyroidectomy for a benign thyroid nodule 18 years ago. A contrast CT of the abdomen showed a large left adrenal mass measuring 11x9 cm, suspicious of adrenocortical carcinoma. Hormonal evaluation was in keeping with a non-functional tumour. The patient underwent left adrenalectomy, histopathology of which revealed metastatic well-differentiated thyroid carcinoma. Ultrasound of thyroid done postoperatively showed a subcentimetric hypoechoic lesion with increased vascularity and microcalcifications in the right thyroid bed. Histopathology from a completion thyroidectomy specimen was consistent with follicular variant of papillary thyroid carcinoma. She was treated with high-dose radioiodine ablation therapy and has remained disease-free on follow-up for more than a year.

http://ift.tt/2wVF7iJ

Rare presentation of necrotising fasciitis and streptococcal toxic shock syndrome by group A streptococcus

Description

A 44-year-old healthy male presented to the emergency room with a 6-day history of right medial thigh pain and itching. Examination revealed mild erythema with superficial swelling, but no tenderness (figure 1A). Vital signs were stable. White cell count (WBC) was 11.2x10⁹/L with no other significant laboratory abnormality. During the next 6 hours, his erythema and swelling extended to involve the whole thigh with the patient getting septic (spiking 102°F, heart rate 110/min and blood pressure 118/79 mm Hg). WBC trended up to 23x10⁹/L and lactate 4.7 mmol/L. MRI was performed which showed possible myositis (figure 1B). Despite intravenous antibiotics (penicillin and vancomycin) and resuscitation, his clinical condition deteriorated rapidly. In the next 4 hours, patient was taken to the operative room for fasciotomy and exploration. Intraoperatively, patient was found to have fasciitis. Necrotic tissue was removed.

Figure 1

(A) Right medial thigh with mild erythema. (B) MRI of the lower...

http://ift.tt/2yGRxIL

A fatal case of malignant neurocysticercosis

Description

A 43-year-old Muslim woman presented with intermittent fever, lethargy, poor appetite and weight loss for a month and altered behaviour for a week. She had a holiday trip to the provincial town of Hat Yai in South Thailand 7 months prior where she had eaten pork-free street food. On admission, she was confused, lethargic and not obeying command. There was no motor deficit.

Septic workup for bacterial and fungal infections was negative. Cerebrospinal fluid analysis showed pleocytosis with a negative tuberculosis (TB)-PCR result. IgG serology for HIV, Toxoplasma gondii and Taenia solium was negative.

Initial CT brain showed white matter hypodensities at bilateral frontoparietal regions. Several small peripherally enhancing parenchymal lesions seen on contrast-enhanced CT. These lesions were well circumscribed with no calcification or soft-tissue component. No hydrocephalus was seen.

MRI brain later revealed multiple small rim-enhancing cystic lesions in the basal ganglia, grey–white matter junctions and subarachnoid spaces....

http://ift.tt/2wUjmQh

Nephrectomy for infected stag horn calculus confounded by the presence of squamous cell carcinoma

Squamous cell carcinoma of kidney is a rare tumour of the many tumours seen in the kidney. It is usually associated with chronic irritation by a foreign body, which is mostly a stag horn calculus. Diagnosis of carcinoma in the presence of stag horn calculus is bizarre as it is seen in only <1% of patients. After imaging in this patient, the lymph nodes were enlarged and showed necrosis, which favoured the diagnosis of tuberculosis in a country where it is endemic. The pathological examination after surgery has amazed us by the presence of squamous cell carcinoma with lymph nodes positive with metastasis to vertebrae as the patient has presented to us with all symptoms of infection like pain and fever, which never made us think about malignancy preoperatively.

http://ift.tt/2yGRvAD

A case of Potts puffy tumour from primary dental infection

Description

A 45-year-old man presented to the emergency department with a large midline swelling of his forehead (figures 1 and 2). He described 8 months of progressive symptoms starting with anosmia and left-sided nasal discharge. The lump on his head had appeared suddenly 2 weeks prior to presentation and continued to grow before becoming tender.

Figure 1

Initial clinical appearance of midline forehead lump measuring 8 cm x 8 cm.

Figure 2

Lateral view of initial clinical appearance.

Nasendoscopy confirmed extensive left-sided polyps and discharge. A CT scan demonstrated extensive opacification of the left maxillary, sphenoid and ethmoidal sinuses with an 11 mm midline defect in the anterior wall of the frontal sinus at the site of the external mass. The posterior wall was very thin but intact. There was no evidence of intracranial extension.

He was...

http://ift.tt/2wVkhAf

Daunorubicin conjugated with alpha-fetoprotein selectively eliminates myeloid-derived suppressor cells (MDSCs) and inhibits experimental tumor growth

Abstract

Failure of antitumor immunity in cancer was shown to be mediated by myeloid-derived suppressor cells (MDSCs), which are considered to be one of the key factors contributing to the development of malignant diseases. Therefore, the development of pharmacological approaches to effectively eliminate MDSCs in organisms carrying growing tumors is a promising pathway for potential treatment. For this purpose we propose alpha-fetoprotein (AFP) conjugated with a cytotoxic agent as a vector molecule, specifically recognizing MDSCs. The present study was aimed at examination of this suggestion using both in vitro and in vivo approaches. MDSCs, obtained from the spleen of Ehrlich carcinoma bearing mice, selectively bound AFP labeled with fluorescein isothiocyanate. AFP conjugated to daunorubicin (AFP-DR) and DR alone showed similar in vitro cytotoxicity against the granulocytic MDSC subpopulation. The monocytic MDSC subpopulation was resistant to treatment with DR, whereas it was completely depleted in the presence of AFP-DR. Treatment of mice bearing Ehrlich carcinoma with AFP-DR resulted in reduced numbers of splenic MDSCs, normalization of NK cell levels, and inhibition of tumor growth. The obtained results demonstrate that cytotoxic conjugates based on AFP are promising anticancer drugs, which, in addition to the direct effect on tumor cells expressing receptors to AFP, may contribute to elimination of MDSCs.

http://ift.tt/2ysu4tM

Invited Commentary: Mast Cell Activation

http://ift.tt/2wVRCGa

Checkpoint Inhibitors: Applications for Autoimmunity

Abstract

To limit excessive T cell-mediated inflammatory responses, the immune system has a milieu of inhibitory receptors, called immune checkpoints. Cancer cells have evolved to seize those inhibitory pathways and to prevent T cell-mediated killing of tumor cells. Therefore, immune checkpoint inhibitors (ICI) consisting of blocking antibodies against these receptors present an exciting avenue in the fight against cancer. The last decade has seen the implementation of ICI against a variety of cancer indications that have improved the overall anti-tumor responses and patient survival. However, inflammatory toxicities and autoimmunity are a significant adverse event of ICI therapies. In this review, we will discuss the biology of immune checkpoints, highlight research strategies that may help reduce the incidence of immune-related adverse events associated with ICI therapies, and also suggest investigational approaches to manipulate immune checkpoints to treat primary autoimmune disorders.

http://ift.tt/2xFkiXM

Patch testing with the European baseline series fragrance markers: A 2016 update

Summary

Background

Fragrance contact allergy is common and is currently screened for with the European baseline series fragrance markers: Fragrance Mix 1, Fragrance Mix 2, Myroxylon pereirae and hydroxyisohexyl 3-cyclohexene carboxaldehyde.

Objectives

To investigate the validity of patch testing with these fragrance markers in detecting fragrance allergy to 26 individual fragrance substances for which cosmetic ingredient labelling is mandatory in the European Union.

Methods

We conducted a retrospective review of the patch test records of all eczema patients who underwent testing with the European baseline series extended with the individual fragrance substances during the period 2015-2016.

Results

359 patients (17.2%) reacted to one or more allergens from the labelled fragrance substance series and/or a fragrance marker from the European baseline series. The allergens that were positive with the greatest frequencies were oxidised linalool (154; 7.4%, 95% CI 6.3%-8.6%), oxidised limonene (89; 4.3%, 95% CI 3.4%-5.2%) and Evernia furfuracea (44; 2.1%, 95% CI 1.5%-2.8%). Of the 319 patients who reacted to any of the labelled fragrance substances, only 130 (40.8%) also reacted to a baseline series fragrance marker. The sensitivity of our history-taking for fragrance allergy was 25.7%.

Conclusions

With the evolving trends in fragrance allergy patch testing with Fragrance Mix 1, Fragrance Mix 2, Myroxylon pereirae and hydroxyisohexyl 3-cyclohexene carboxaldehyde are no longer sufficient for screening for fragrance allergy.

http://ift.tt/2xKxCdY

Incidence of Hidradenitis Suppurativa among Tobacco Smokers: a population based retrospective analysis in the United States

Summary

Background

The relationship between tobacco use and hidradenitis suppurativa (HS) is controversial.

Objective

To determine incidence of HS among tobacco smokers.

Methods

Retrospective cohort analysis identifying incident HS cases among adult tobacco smokers and non-smokers sampled from a demographically heterogeneous population-based sample of over 50 million unique patients across all census regions.

Results

We identified 3,924,310 tobacco smokers, among whom were 7,860 patients newly diagnosed with HS. Tobacco smokers diagnosed with HS were most commonly aged 18-39 years (3795/7,860; 48.3%), women (5,640/7,860; 71.8%), Caucasian (5,200/7,860; 66.2%), and those with BMI ≥30 (5,690/7,860; 72.4%). Overall incidence of HS was 0.20% (7,860/3,924,310) among tobacco smokers and 0.11% (8,430/8,027,790) among non-smokers (p< 0.0001). Incidence was greatest among tobacco smokers who were aged 30-39 years (0.35%), women (0.28%), African Americans (0.46%), and those with BMI ≥30 (0.33%). Overall adjusted odds of developing HS was 1.90 [95% CI 1.84-1.96] among tobacco smokers, compared to non-smokers (p<0.0001). HS incidence among tobacco smokers remained increased within each demographic subgroup.

Conclusions

Incidence of HS appears to be doubled among tobacco smokers. These findings may support evidence-based counseling efforts on cessation of smoking for populations at risk for HS.

http://ift.tt/2fxKjSy

Toxic shock syndrome: A dermatological emergency

http://ift.tt/2xx1aM8

MYC protein expression is associated with poor prognosis in cutaneous diffuse large B-cell lymphoma

http://ift.tt/2fQUoqJ

Aryl hydrocarbon receptor (AhR) transcription is decreased in skin of vitiligo patients

Nontraumatic Intradiploic Epidermoid Cyst and Older Age: Association or Causality?.

Background: Intradiploic epidermoid cysts (IEC) are rare, benign lesions derived from ectodermal remnants during neural tube closure. Their origin is still debated or unknown. Objective: Analyzing of the patients with intradiploic epidermoid cysts operated in the authors' department. Methods: The patients with IEC who were operated in the authors' department between January 2014 and December 2015 were investigated from data file. Results: Six patients with IEC were found, reviewed the literature, and noted that these cysts usually occur in adults. There are only 3 young cases that occurred after head injury. Conclusion: It was shown that the nontraumatic IEC are more frequent in older ages. In youngs, it can generally be embryologic or rarely of mechanical origin following trauma. Cranial trauma may be important for developing of IEC. Trauma may lead to inclusion of epidermal cells into the diploe of the skull and may be a reason of intradiploic epidermoid cyst in older age. The effect of older age, and gender difference on occurrence should be investigated. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wk8CGz

Wide Linear Corticotomy and Anterior Segmental Osteotomy Under Local Anesthesia Combined Corticision for Correcting Severe Anterior Protrusion With Insufficient Alveolar Housing.

Backgrounds: This article presents an alternate surgical treatment method to correct a severe anterior protrusion in an adult patient with an extremely thin alveolus. To accomplish an effective and efficient anterior segmental retraction without periodontal complications, the authors performed, under local anesthesia, a wide linear corticotomy and corticision in the maxilla and an anterior segmental osteotomy in mandible. Methods: In the maxilla, a wide linear corticotomy was performed under local anesthesia. In the maxillary first premolar area, a wide section of cortical bone was removed. Retraction forces were applied buccolingually with the aid of temporary skeletal anchorage devices. Corticision was later performed to close residual extraction space. In the mandible, an anterior segmental osteotomy was performed and the first premolars were extracted under local anesthesia. Results: In the maxilla, a wide linear corticotomy facilitated a bony block movement with temporary skeletal anchorage devices, without complications. The remaining extraction space after the bony block movement was closed effectively, accelerated by corticision. In the mandible, anterior segmental retraction was facilitated by an anterior segmental osteotomy performed under local anesthesia. Corticision was later employed to accelerate individual tooth movements. Conclusions: A wide linear corticotomy and an anterior segmental osteotomy combined with corticision can be an effective and efficient alternative to conventional orthodontic treatment in the bialveolar protrusion patient with an extremely thin alveolar housing. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2fpRjgB

Dental Infection and Pregnancy: the Lack of Treatment by the Dental Professional Evolving to a Complex Maxillofacial Infection.

Infections of the maxillofacial complex caused by caries disease are common in dental practice. The professionals have to have technical knowledge to treat it at the onset of the condition and avoid the spread to deep anatomical spaces of face and neck, which can implicate in a risk of patients' life. In Brazil, current dental professionals usually denied oral surgical treatments in patients with some clinical conditions, not because of fear to resolve it but for lack of knowledge to treat it. An example of these conditionals is pregnancy. It is well known that during the pregnancy period, the patient can be treated in the correct period of gestation. Early diagnosis is crucial for effective therapy in serious infections. The treatment has to be crucial during pregnancy because of the potentially fatal situation that the disease can create to the pregnant woman and the fetus. The aim of this article is to demonstrate a case of dental caries in a pregnant patient, which was evaluated by other professionals and had the treatment denied, evolving to a serious maxillofacial infection. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wkr7uB

Head Shape Configuration Over The Centuries.

No abstract available

http://ift.tt/2fpQe8r

Lipoma on the Lower Lip.

Lipoma is a benign tumor of fat tissue, found frequently in subcutaneous tissues. However, oral manifestations are relatively rare. The present patient illustrates the successful treatment of a lipoma treated by complete excision of the lesion. A female patient, 75 years old, presenting lesion in the right oral vestibule where excisional biopsy was performed. The professional must diagnose this type of injury as soon as possible and treat it so that it does not take large proportions, which can result in esthetic and functional sequelae to the patient. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wj3dQd

Effect of Facial Parameters in Primary Acquired Nasolacrimal Duct Obstruction.

Purpose: In this study, the authors aimed to identify facial and nasal parameters, which may create an anatomic disposition toward obstruction in patients with primary acquired nasolacrimal duct obstruction. Materials and Methods: Forty-eight patients (14 males and 34 females) who presented to the ophthalmology outpatient clinic and were diagnosed with primary acquired nasolacrimal duct obstruction between January 2014 and January 2015 were included in the study. The control group comprised 59 patients (38 females and 21 males) without nasolacrimal duct obstruction. Measurements of nasal height, length, and depth, presence of a nasal hump, alar width and alar angle, distance between the maxillary bone nasal notches, and right and left distances between outer canthi and corners of the mouth were made using photographs of the patients. The presence of facial asymmetry was also assessed. Results: Facial asymmetry (P = 0.014) and nasal hump (P = 0.048) were more common in the patient group. The patient group had smaller nasal radix depth (P

http://ift.tt/2fpR8lr

Levator Palpebrae Superioris Muscle Direct Neurotization.

Direct muscle neurotization has been proved to be a feasible technique for facial reanimation microsurgical procedures. Direct muscle neurotization is performed by implanting the interposition nerve graft directly into the substance of the muscle. The authors present the case of a 36-year-old male patient with upper eyelid dysfunction secondary to facial trauma. The levator palpebrae superioris muscle was macroscopically unaffected; however, neurophysiological test proved a selective denervation of the CN III motor branch to the levator palpebrae superioris muscle. Direct muscle neurotization was performed by means of 2 separate nerve procedures. The authors have made follow-up for 3 months after surgery. The authors have noted development of upper eyelid movement meaning adequate function of the neurotized muscle. The authors believe that this procedure could be integrated into the surgical options to treat selective nerve injuries should the right patient is encountered. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wkj5C2

Mucosal Melanoma Originating From the Eustachian Tube.

A 77-year-old man was referred with a 4-month history of hearing impairment and ear fullness of the left ear. Otoscopic examination revealed an effusion in the left middle ear, and nasal endoscopic examination revealed a dark polypoid lesion at the opening of the left Eustachian tube. In addition to the lesion of the Eustachian tube, a dark mucosal lesion was seen at the posterior choana and the posterior end of the nasal septum. Endoscopic biopsy was done and pathologic result was consistent with malignant melanoma. Wide surgical excision with postoperative radiotherapy was performed; multiple metastases were detected 4 months after the treatment. Mucosal melanoma originating from nasopharynx was extremely rare, but careful examination of nasopharyngeal area should be considered when the patient presents with unilateral middle ear effusion, especially in older age. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2fpR6tP

Complex Subunit Repair of a Cheek, Nose, and Medial Canthal Defect: A Stepwise Approach.

A recent national survey suggests that up to one-third of facial reconstructive and plastic surgeons do not adhere to the classical principle of subunit reconstruction. While single-stage flaps and grafts may be easier and less time consuming, they can also lead to a poor cosmetic outcome. Here, the authors describe how the authors repaired a complex post-Mohs surgery facial defect involving multiple cosmetic subunits and how adherence to the subunit principle was essential to obtaining the most optimal functional and esthetic outcome. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wkj40W

Endoscopic Removal of Displaced Sagittal Intracapsular Condylar Fracture.

Fractures involving the mandibular condyle are among the most common fractures of facial bones and still generate great discussion concerning therapeutic issues. Several factors have influence on the decision of treatment management of these fractures. In some patients, even when there is displacement of fractured fragments, the choice for conservative treatment is made. However, the removal of the condyle fragment may be required. In the oral surgery scope, endoscopy is a procedure used in many areas, and can be helpful to improve the visualization of surgical sites with difficult access. The endoscopic surgery brings benefits to patient such as no scar or minimal scar, lower risk to nerve damage, and decreased of surgical trauma and bleeding. In addition, according to surgeon experience, the surgery may become more dynamic. The aim of this study is to present an endoscopic technique associated with a transoral approach to remove a displaced sagittal intracapsular condyle fragment. Furthermore, to expose the advantages and benefits of this technique as well as the satisfactory results achieved. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2fpR4lH

Bony Changes in a Unilateral Maxillary Sinus Fungal Ball.

Objectives: In the paranasal sinus fungal ball (SFB), changes that occur in the underlying bone have not been well described. Recently, bacterial coinfection has been reported in patients with paranasal SFB. We evaluated whether bone changes occur in patients with unilateral maxillary SFB, and also how bacteria in an SFB affect the bony wall of the sinus. Methods: A retrospective study of patients with a unilateral maxillary SFB undergoing endoscopic sinus surgery was conducted from July 2009 to December 2015. Preoperative computed tomography images of the patients were reviewed. Wall thickness (WT) and wall density (WD) of the diseased sinus were measured and compared to the normal sinus. Specimens of the sinus aspirates were obtained during surgery for aerobic and anaerobic cultures. Results: Forty-three patients were included (mean, 55.7 +/- 12.8 years). Thirty-one cultures (72.1%) were positive for bacteria. Thickening was evident in the anterior, lateral, and posterior walls of the diseased sinus. The average WT was 1.69 +/- 0.45 mm on the diseased sinus and 1.14 +/- 0.31 mm on the normal sinus (P

http://ift.tt/2wktwpi

Secondary Maxillary and Orbital Floor Reconstruction With a Free Scapular Flap Using Cutting and Fixation Guides Created by Computer-Aided Design/Computer-Aided Manufacturing.

Computer-aided design/computer-aided manufacturing (CAD/CAM) guides are now widely used in maxillofacial reconstruction. However, there are few reports of CAD/CAM guides being used for scapular flaps. The authors performed the secondary maxillary and orbital floor reconstruction using a free latissimus dorsi muscle, cutaneous tissue, and scapular flap designed using CAD/CAM techniques in a 72-year-old man who had undergone partial maxillectomy four years previously. The patient had diplopia, the vertical dystopia of eye position, and a large oral-nasal-cutaneous fistula. After the operation, the authors confirmed that the deviation between the postoperative and preoperative planning three-dimensional images was less than 2 mm. Because scapular guides require 3 cutting surfaces, the shape of the scapular guide is more complex than that of a conventional fibular guide. In orbital floor reconstruction, the use of a CAM technique such as that used to manufacture the authors' fixation guide is as necessary for accurate, safe, and easy reconstruction as is preoperative CAD planning. The production of a fixation guide as well as a cutting guide is particularly useful because it is difficult to determine the angle for reconstructing the orbital floor by freehand techniques. In this case, the orbital floor was reconstructed based on a mirror image of the healthy side to avoid overcompression of the orbital tissue. Although the patient's vertical dystopia of eye position was improved, diplopia was not improved because, for greater safety, the authors did not plan overcorrection of the orbital volume. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2fpR05r

The Elution Kinetics of BMP-2, BMP-4, and BMP-7 From a Commercial Human Demineralized Bone Matrix Putty.

Bone morphogenetic proteins (BMPs) are associated with bone extracellular matrix and impart osteoinductive properties to demineralized bone matrix (DBM) grafts. The first step of the osteoinductive process is BMP release from DBM in situ; however, this has not been characterized for human DBM. The authors investigated the release of BMPs 2, 4, and 7 from a clinical human DBM putty (Bonus II DBM, Biomet Inc, Warsaw, IN). The DBM was placed in Sorensen buffer and the BMP concentrations in the Sorensen buffer and guanidine extracts of the DBM were measured concurrently by enzymelinked immunosorbant assay for up to 7 days. The baseline DBM concentrations were BMP-2: 28.1 +/- 1.3 ng/g DBM, BMP-4: 0.577 +/- 0.056 ng/g DBM, and BMP-7: 92.9 +/- 7.5 ng/g DBM. Relative to baseline, the proportions released by 7 days were 11.1%, 3.9%, and 29.3%, respectively. The early (0-8 hour) and late (8-168 hours) elution rates were BMP-2: 0.16 +/- 0.24 and 0.0089 +/- 0.012 ng/(g DBM hr), and BMP-7: 1.29 +/- 2.1 and 0.086 +/- 0.039 ng/(g DBM hr), respectively. Little BMP-4 elution occurred over the first 24 hours, with the rate for the remaining interval being 0.00014 +/- 0.00021 ng/(g DBM hr). The apparent DBM BMP profiles were counterintuitive in that the concentrations increased from baseline for some, or all, of the 7 days instead of monotonically decreasing. Similar behavior has previously been reported in bovine studies. This provides further evidence that BMPs are associated with at least 2 compartments in DBM differing by their affinity for BMPs and that guanidine extraction of BMPs is not 100% efficient. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wjqh1d

Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes.

Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P

http://ift.tt/2fpQMeB

Bilateral Submental Flap: An Innovative Modification.

Early management of premalignant lesions like oral submucous fibrosis cannot be underestimated in context of prevention and control of oral malignancies. Soft tissue reconstruction of the oral cavity and face is a complex undertaking. Several flaps local and distant as well as microvascular are available, each with their pros and cons. Microvascular free flaps lay a considerable burden on resources, expertise, increased operating time, and logistics. Simple and technically reproducible alternatives are needed to tackle these issues, more so in developing countries like ours. Submental flap is based on a large branch of the facial artery and was initially described in 1993 by Martin et al as an excellent option in head and neck reconstruction. We describe innovative modification of the submental flap based on concept of bilateral presence of facial and submental vasculature and thus can be used for bilateral cheek reconstruction. We use pedicled bilateral submental flap (BSF) by dividing the oval skin paddle obliquely, maintaining needed length. The best use of the BSF is in reconstruction of cheek defect, after surgical release of grade IV oral submucous fibrosis, a debilitating affliction commonly affecting young productive adults and seen in Indian subcontinent. The technique was used successfully in 20cases with minor complications. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2wj42bR

Review of "Implementation Science: A Neglected Opportunity to Accelerate Improvements in the Safety and Quality of Surgical Care" by Hull L, Athanasiou T, Russ S in Ann Surg 265:1104-1112, 2016.

No abstract available

http://ift.tt/2fpQSCZ

Review of "Reporting of Randomized Controlled Trials With Statistically Nonsignificant Primary Outcomes Published in High-Impact Surgical Journals" by Arunachalam L, Hunter IA, Killeen S in Ann Surg 265: 1141-1145, 2017.

No abstract available

http://ift.tt/2wkiSyK

Dorsal Augmentation of Saddle Nose Deformity With Toothpick-Shaped Costal Cartilage Grafts in the Secondary Septorhinoplasty.

Saddle nose deformity is a challenging complication of septoplasty or septorhinoplasty, characterized by underprojected cartilaginous dorsum. Nasal dorsal augmentation is a significant part of reconstructive surgery of saddle nose deformities. In this study, the authors aimed to discuss the results of using toothpick-shaped costal cartilage grafts in nasal dorsal augmentation of saddle nose deformity. Twelve patients who underwent nasal dorsal augmentation due to moderate to severe saddle nose deformity secondary to the previous septoplasty or septorhinoplasty were retrospectively reviewed. Costal cartilage grafts prepared in the shape of toothpicks were used in all patients. Costal cartilage was used as toothpick-shaped free grafts in 12 patients (female: 7, male: 5) with a mean age of 42 (range: 24-56) for dorsal augmentation in the secondary septorhinoplasty. All patients had a history of previous surgery (septoplasty, n = 9; and septorhinoplasty, n = 3). All patients were operated under general anesthesia with open technique septorhinoplasty. The mean follow-up was 18 (range: 9-48) months. In only 1 of the 12 patients, a postoperative complication was observed including an infection of the tip area in the second postoperative week. None of the patients experienced donor site complications or major graft resorption. All patients were satisfied with functional and esthetic outcomes. No revision surgery was needed in any patient. Toothpick-shaped costal cartilage grafts are useful in nasal dorsal augmentation of moderate to severe saddle nose deformity. This technique offers smooth camouflage, satisfactory accordance with the recipient region, and shorter operation time. In addition, it avoids the side effects from wrapping techniques such as foreign body reaction or additional donor site morbidities. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2fqAmm5

Αρχειοθήκη ιστολογίου

Τετάρτη 27 Σεπτεμβρίου 2017

Summary

Abstract

Background

Methods

Findings

Interpretation

Abstract

Abstract

Abstract

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusions

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusion

Abstract

Background

Methods

Results

Conclusions

Abstract

Abstract