Re: Heat generation and drill wear during dental implant site preparation: systematic review

Publication date: Available online 7 October 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): Stephan Christian Möhlhenrich, Ali Modabber, Timm Steiner, David A. Mitchell, Frank Hölzle




http://ift.tt/2xqKIJg

Re: Heat generation and drill wear during dental implant site preparation

Publication date: Available online 7 October 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): M. Koopaie, S. Kolahdouz




http://ift.tt/2y74VIc

Chronic recurrent dislocation of the temporomandibular joint secondary to a complex facial tic disorder

Publication date: Available online 7 October 2017
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): K.E. French, M.H. Wilson, P.J. Revington




http://ift.tt/2xqOXot

William (Barry) Inabnet appointed Editor-in-Chief of VideoEndocrinology

Mary Ann Liebert, Inc., publishers and the American Thyroid Association (ATA) are pleased to announce that Dr. William B. Inabnet, III, Chairman of the Department of Surgery at Mount Sinai Beth Israel (New York) and The Eugene W. Friedman, MD, Professor of Surgery and the Surgical Director of the Diabetes, Obesity and Metabolism Institute at the Icahn School of Medicine at Mount Sinai has been appointed incoming Editor-in-Chief of VideoEndocrinology effective in 2018. Dr. Inabnet is also the inaugural Director of Endocrine Surgery Quality for the Mount Sinai Health System.

Gerard M. Doherty, MD, Surgeon-in-Chief, Brigham and Women's Hospital, Harvard University, has provided strong leadership for VideoEndocrinology since its inception in 2014. We are very grateful for his invaluable work and guidance in founding the first broad-based videojournal in endocrinology. Dr. Doherty will be stepping down from his role at the end of 2017.

"Dr. Inabnet was selected as Editor-in-Chief by an ATA search committee from a pool of very strong candidates because of his experience with audiovisual production and presentation, his vision, and his prominent position in the field of Endocrine Surgery. The interest of this outstanding field of candidates in the position speaks to the importance of VideoEndocrinology, especially to surgeons performing thyroid, parathyroid, and adrenal procedures," says, John C. Morris, III, MD, President of the ATA, and Professor of Medicine, Mayo Clinic, Rochester, MN. "With Barry's leadership we look forward to continued growth and stature of this groundbreaking videojournal, continuing the trajectory established by its inaugural Editor-in-Chief, Dr. Gerard Doherty."

Dr. Inabnet attended the University of North Carolina at Chapel Hill where he received his undergraduate and medical school education. He completed his residency in general surgery at Rush Medical College and Rush-Presbyterian-St Luke's Medical Center in Chicago. Dr. Inabnet then completed a fellowship in endocrine surgery at Cochin Hospital in Paris, where he trained under Professor Yves Chapuis, a world leader in the field of endocrine surgery and targeted parathyroidectomy.

An international authority in the field of minimally invasive endocrine surgery, Dr. Inabnet has pioneered new techniques in minimal access endocrine neck surgery as well as adrenal and pancreatic surgery. In 1998, he helped perform the first endoscopic thyroid resection in the United States (2nd in the world), and has since helped advance the field of video-endoscopic neck surgery. Dr. Inabnet was among the first surgeons in the United States to introduce remote access thyroid surgery and is one of the few surgeons in the world who performs transaxillary, bilateral axillo-breast approach (BABA), and transoral endoscopic thyroid surgery.

Dr. Inabnet is also a leader in the field of minimally invasive metabolic surgery with an interest in disorders of the endocrine system in obese patients, especially type 2 diabetes and malignancy.  Dr. Inabnet has participated in national and international clinical trials evaluating the role of gastrointestinal surgery in treating diabetes. He holds numerous leadership positions in the American Association of Endocrine Surgeons, American Association of Metabolic and Bariatric Surgery, the American College of Surgeons, and the American Thyroid Association.

Dr. Inabnet has authored more than 180 peer-reviewed articles and book chapters, and five textbooks. He lectures throughout the world and was inducted into the Southern Surgical Association, the American Surgical Association, the French National Academy of Surgery, and the French Academy of Medicine.

"I am truly delighted that Dr. Barry Inabnet has agreed to be at the helm of VideoEndocrinology, which fills a unique niche among the many endocrinology-focused publications," says Peter A. Kopp, MD, Editor-in-Chief of the flagship journal Thyroid and Professor of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago. "His broad surgical expertise combined with extensive experience in the production of audiovisual materials and a dynamic vision make him ideally suited for this position. I also wish to thank Dr. Gerard Doherty for serving as the inaugural Editor-in-Chief of VideoEndocrinology and for establishing it as an important element of the Thyroid Journal Program."

Mary Ann Liebert, Inc., publishers and the American Thyroid Association look forward to the strong continuing commitment of our editorial board, reviewers, and authors.

About the ATA
The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization for over 1,700 clinicians and researchers from 43 countries around the world, representing a broad diversity of medical disciplines. It also serves the public, patients and their family through education and awareness efforts.

Celebrating its 94th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, Thyroid, Clinical Thyroidology, VideoEndocrinology and Clinical Thyroidology for the Public; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs; and the development of guidelines for clinical management of thyroid disease.

More information about ATA is found here.

The post William (Barry) Inabnet appointed Editor-in-Chief of VideoEndocrinology appeared first on American Thyroid Association.

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Radical espontânea

Radical espontânea

http://ift.tt/2y7Zbxe

Response to the letter to the editor regarding “The outcomes of overlay myringoplasty: Endoscopic versus microscopic approach”

We would like to thank Prof. Zheng-Cai Lou [1] for his interest in our study entitled "The outcomes of overlay myringoplasty: Endoscopic versus microscopic approach" [2] and we appreciate the useful comments. His main concerns will be discussed below.

http://ift.tt/2z4F5Tj

Short-term reasons for withdrawal and adverse events associated with apremilast therapy for psoriasis in real-world practice compared to clinical trials: a multicenter retrospective study

http://ift.tt/2y8fPgt

Focal Atrichia: A Diagnostic Clue in Female Pattern Hair Loss

Focal atrichia is a common clinical finding in female pattern hair loss whose specificity and histologic findings need further clarification.

http://ift.tt/2ywNqSB

QTc prolongation during phenol-croton oil peels

http://ift.tt/2ywO6HP

The Frisbee Maneuver: A Novel Method to Abort Acute Attacks of Raynaud’s Phenomenon

http://ift.tt/2kurd1s

Alternating histopathological pattern in blaschkoid dermatoses with epidermal changes: A retrospective series of 61 cases

http://ift.tt/2kwj3We

Re: Heat generation and drill wear during dental implant site preparation

We studied with interest the paper "Heat generation and drill wear during dental implant site preparation: systematic review" by Möhlhenrich et al, which provides valuable data about drilling bone. They describe "drill material" as "zirconium coated with steel", whereas because of the mechanical and thermal stresses at the interface of the drill and the bone, the material's resistance to wear must be a coating for the drill.1

http://ift.tt/2ywH4mq

Re: Heat generation and drill wear during dental implant site preparation: systematic review

We thank you for your interest in our study as well as your valuable comments. You are of course right that "zirconium coated with steel" does not make sense and, furthermore, that the material of the drills used by Harder et al.1 was zirconium oxide and not zirconium. We apologise for any inconvenience caused.

http://ift.tt/2xqkEhm

Chronic recurrent dislocation of the temporomandibular joint secondary to a complex facial tic disorder

We report the case of a 14-year-old boy who presented to the emergency department with bilateral dislocation of the temporomandibular joint (TMJ) of unusual aetiology. He had recently developed a repetitive action that involved thrusting the jaw forwards, which involved maximal mouth opening. This had preceded the dislocation of the TMJ two hours previously.

http://ift.tt/2yxaSir

Anatomy of the vasculature of the lower leg and harvest of a fibular flap: a systematic review

The fibular free flap (FFF) is based on the peroneal artery, which has a consistent anatomy and makes a minimal contribution to the pedal circulation. However, certain anatomical variations in the vasculature of the leg might leave the peroneal artery with a major role in the perfusion of the foot, and to raise a FFF could lead to ischaemic complications. Our aim was to review the implications of anatomical variants on planning and harvest of a FFF. We systematically reviewed all relevant publications, and included 28 cases that described a dominant peroneal artery and FFF.

http://ift.tt/2xqzGDY

Immediate reactions to iodinated contrast media

Immediate hypersensitivity reactions (IHRs) to iodinated contrast media (ICMs) remain a common clinical concern. Positive skin test and basophil activation test results suggest a specific IgE-mediated mechanism in some cases. Skin test and controlled challenge test (CCT) are useful to manage these patients.

http://ift.tt/2y7yA3G

Small percentage of anaphylactic reactions treated with epinephrine during food challenges in Dutch children

Severe allergic reactions, including anaphylaxis, occur during oral food challenges (OFCs) and the first-line treatment of anaphylaxis is epinephrine.

http://ift.tt/2z6ZeZ1

Successful perinatal management of hereditary angioedema with normal C1 esterase inhibitor and factor XII mutation using C1 esterase inhibitor therapy

Hereditary angioedema (HAE) is a rare, autosomal dominant condition that consists of a deficiency or dysfunction of C1 esterase inhibitor (C1-INH). Various triggers can lead to self-limiting or life-threatening airway edema.1 Owing to its nonhistaminergic pathophysiologic features, HAE subtypes do not respond to epinephrine, corticosteroids, or antihistamine. Supplementation of C1-INH is an accepted and common treatment for HAE attacks and HAE prophylaxis.

http://ift.tt/2y7GolG

The burden of atopic dermatitis in US adults: Health care resource utilization data from the 2013 National Health and Wellness Survey

There is a lack of data on the burden of atopic dermatitis (AD) in adults relative to the general population.

http://ift.tt/2xqhWIQ

Chronic spontaneous urticaria and the extrinsic coagulation system

Publication date: Available online 6 October 2017
Source:Allergology International
Author(s): Yuhki Yanase, Shunsuke Takahagi, Michihiro Hide
Chronic spontaneous urticaria (CSU) is a common skin disorder characterized by daily or almost daily recurring skin edema and flare with itch. Recently, the activation of the blood coagulation cascade has been suggested to be involved in CSU, but the trigger of the coagulation cascade remains unclear. In this article, we review recent understanding of the relationship between the pathogenesis of CSU and extrinsic coagulation reactions. In CSU, vascular endothelial cells and eosinophils may play a role as TF-expressing cells for activating the extrinsic coagulation pathway. Moreover, the expression of TF on endothelial cells is synergistically enhanced by the activation of Toll-like receptors and histamine H1 receptors. The activated coagulation factors may induce plasma extravasation followed by degranulation of skin mast cells and edema formation recognized as wheal in CSU. Molecules involved in this cascade could be a target for new and more effective treatments of urticaria.



http://ift.tt/2xZ1GCT

RNA-seq analysis of Lgr6+ stem cells and identification of an Lgr6 isoform

Abstract

We studied Lgr6⁺ stem cells in experimental UV carcinogenesis in hairless mice. For further characterisation through RNA-seq, these stem cells were isolated by FACS from transgenic hairless mice bearing an EGFP-Ires-CreERT2 reporter cassette inserted into exon-1 of the Lgr6 gene (purity confirmed by human ERT2 expression). Between Lgr6/EGFP⁺ and Lgr6/EGFP^– basal cells (Tg/wt) 682 RNAs were differentially expressed, indicating stemness and expression of cancer-related pathways in Lgr6/EGFP⁺ cells. We discovered that suspected 'Lgr6 null' mice (Tg/Tg) expressed RNA of an Lgr6 isoform (delta-Lgr6, lacking 74 N-terminal aa) which could be functional and explain the lack of a phenotype.

This article is protected by copyright. All rights reserved.

http://ift.tt/2xpEzgB

Diagnostic flaws in oral lichen planus and related lesions

Publication date: Available online 6 October 2017
Source:Oral Oncology
Author(s): A. Thirumal Raj, Shankargouda Patil




http://ift.tt/2gjhWEF

Sensitivity of aspiration as a safety test before injection of soft tissue fillers

Summary

Background

Embolism due to accidental intra-arterial injection of a soft tissue filler (STF) can lead to serious complications. Physicians practice aspiration as a safety test before injection to rule out intra-arterial placement of the needle tip. The value of aspiration as a safety test is evaluated in this study, which also considered the rheological properties of different STFs and their needle dimensions.

Methods

Aspiration with eleven different needle sizes and 24 different STFs was performed using Ringer's lactate (RL) colored with blue skin marking ink and secondly an empty saline bag containing anticoagulated blood, both pressurized to 150 mm Hg to mimic arterial blood pressure. Time between the start of aspiration and liquid in the needle hub was recorded.

Results

A total of 340 individual aspiration tests with different STFs and needles were performed, of which 112 yielded true-positive results within 1-s and 128 yielded false-negative results after 10 s. Positive results between one and ten seconds were seen in 101 aspiration tests.

Conclusions

True-positive results were seen in 33% of the tests performed with STFs within 1 s of aspiration. Aspiration test results are influenced by needle diameter, needle length, and rheological properties of STFs. Additional safety measures are necessary to further reduce risk of inadvertent intravascular injection of STFs.

http://ift.tt/2xpWvHU

Efficacy and safety of a novel, soluble microneedle patch for the improvement of facial wrinkle

Summary

Background

Various kinds of functional cosmetics are on the market, although there are a variety of opinions concerning the actual effect. Transdermal microneedle patch has been introduced as a newly developed device for drug delivery through the skin.

Objective

This study was conducted to verify the face skin improvement effect and safety of a novel cosmetic microneedle patch.

Methods

A total of 84 Korean females finished this prospective clinical trial. The subjects were divided into 3 groups: (1) soluble hyaluronic acid (HA) microneedle patch alone, (2) soluble HA microneedle patch plus adenosine wrinkle cream, and (3) adenosine wrinkle cream alone. The treatments were applied to the crow's feet and nasolabial fold wrinkle for 12 weeks. The test areas were measured before treatment and at 4, 8, and 12 weeks after use of the test product. At the completion of the testing period of the trial, the global assessment of efficacy and product preferences were surveyed from the subjects.

Results

Combination treatment with wrinkle cream and microneedle patch significantly improved Merz scale for crow's feet and nasolabial folds, compared to the sole application of wrinkle cream or patch. Measurement on the crow's feet showed an overall improvement in all 3 groups, yielding no significant differences among the groups. No serious adverse effects were observed during the follow-up period.

Conclusion

Combination application of a soluble microneedle patch and wrinkle cream was an effective treatment in improving facial wrinkles, thus enhancing skin rejuvenation.

http://ift.tt/2ywarVQ

CRD and beyond: multivariable regression models to predict severity of hazelnut allergy

Abstract

Background

Component-resolved diagnosis (CRD) has revealed significant associations between IgE against individual allergens and severity of hazelnut allergy. Less attention has been given to combining them with clinical factors in predicting severity.

Aim

To analyze associations between severity and sensitization patterns, patient characteristics and clinical history, and to develop models to improve predictive accuracy.

Methods

Patients reporting hazelnut allergy (n=423) from 12 European cities were tested for IgE against individual hazelnut allergens. Symptoms (reported and during DBPCFC) were categorized in mild, moderate and severe. Multiple regression models to predict severity were generated from clinical factors and sensitization patterns (CRD- and extract-based). Odds ratios (OR) and areas under receiver operating characteristic (ROC) curves (AUC) were used to evaluate their predictive value.

Results

Cor a 9 and 14 were positively (OR 10.5 and 10.1 respectively), and Cor a 1 negatively (OR 0.14) associated with severe symptoms during DBPCFC, with AUCs of 0.70-073. Combining Cor a 1 and 9 improved this to 0.76. A model using a combination of atopic dermatitis (risk), pollen allergy (protection), IgE against Cor a 14 (risk) and walnut (risk), increased the AUC to 0.91. At 92% sensitivity, the specificity was 76.3% and the positive and negative predictive values 62.2% and 95.7%, respectively. For reported symptoms, associations and generated models proved to be almost identical but weaker.

Conclusion

A model combining CRD with clinical background and extract-based serology is superior to CRD alone in assessing the risk of severe reactions to hazelnut, particular in ruling out severe reactions.

This article is protected by copyright. All rights reserved.

http://ift.tt/2gkaVDA

Complete kinetic follow-up of symptoms and complement parameters during a hereditary angioedema attack

Abstract

We studied the kinetics of C1-inhibitor (C1-INH) and other complement parameters in a self-limited edematous attack (EA) in a patient with hereditary angioedema due to C1-INH deficiency to better understand the pathomechanism of the evolution, course, and complete resolution of EAs. C1-INH concentration and functional activity (C1-INH_c+f), C1(q,r,s), C3, C4, C3a, C4a, C5a and SC5b-9 levels were measured in blood samples obtained during the 96-hour observation period. The highest C1-INH_c+f, C4, and C1(q,r,s) levels were measured at baseline, and their continuous decrease was observed during the entire observation period. C4 depletion started at prodromal phase and C4 was lowest after the maximum severity peak. Compared to baseline, C4a level was four times higher 7 hours before the onset of the attack. C1-INH did not increase after resolution of the attack suggesting that factors other than C1-INH may be important in this process. C4a may be a useful biomarker for the prediction of EAs.

This article is protected by copyright. All rights reserved.

http://ift.tt/2ywDfxd

Concept, Importance and Practice of Lateral Tucking in Tympanoplasty

Abstract

The current study aims at observing the technique and results of doing lateral tucking during tympanoplasty surgery. It is intended to provide additional support to the graft and prevent displacement as well. 98 cases included in the study and the graft uptake rate of 97.96% noted. Average pre operative air bone gap (ABG) was 31.12 db and average post operative ABG observed to be 14.01 db. Gain of 17.11 ± 7 db achieved by the procedure. Lateral tucking is a concept that requires to be inculcated in routine tympanoplasty surgeries, especially where canal skin incisions are used. It is easy to practice and the results are good and complications are minimal.

http://ift.tt/2fTlkWa

Concept, Importance and Practice of Lateral Tucking in Tympanoplasty

Abstract

The current study aims at observing the technique and results of doing lateral tucking during tympanoplasty surgery. It is intended to provide additional support to the graft and prevent displacement as well. 98 cases included in the study and the graft uptake rate of 97.96% noted. Average pre operative air bone gap (ABG) was 31.12 db and average post operative ABG observed to be 14.01 db. Gain of 17.11 ± 7 db achieved by the procedure. Lateral tucking is a concept that requires to be inculcated in routine tympanoplasty surgeries, especially where canal skin incisions are used. It is easy to practice and the results are good and complications are minimal.

http://ift.tt/2fTlkWa

Prevalence of Goitre in Raichur District (Karnataka): A Descriptive Study

Abstract

This prevalence study was exclusively for the goitre detection in individuals who has no prior awareness of thyroid disorder and also those patients giving history of signs and symptoms of such conditions. Subjects underwent investigations for (T3, T4, TSH and FNAC) to analyze status and type of Goitre. Of the first 30 cases, only 8 cases were investigated and later on personal  interest  for confirmation of goitre disorder prevalence additional 70 cases were assessed of which 51 cases were investigated. On basis of investigation and epidemiology, we concluded that probably soil and water sources contain less iodine. Sample shown are comparatively less, but in our area number of goitre  cases are more and it needs further extensive survey.

http://ift.tt/2ghSDD4

Uncovering the diagnostic dermoscopic features of flat melanomas located on the lower limbs

Abstract

Lower limbs represent the second most common site of all melanomas and the first one in females (1,2). Few studies have explored the diagnostic clues helping in the early diagnosis for melanoma on lower limbs (3).

This article is protected by copyright. All rights reserved.

http://ift.tt/2y6lDqA

Development of an international core outcome set for peripheral vascular malformations (OVAMA project)

Summary

Background

An important limitation in vascular malformation research is the heterogeneity in outcome measures used for the evaluation of treatment outcome.

Objective

The Outcome measures for VAscular MAlformations (OVAMA) project aimed to reach international consensus on a core outcome set (COS) for clinical research on peripheral vascular malformations: lymphatic (LM), venous (VM) and arteriovenous malformations (AVM). In this consensus study, we determined what domains should constitute the COS.

Methods

Thirty-six possibly relevant outcome domains were proposed to an international group of physicians, patients and the parents of patients. In a 3-round e-Delphi process using online surveys, participants repeatedly rated the importance of these domains on a 5-point Likert scale. Participants could also propose other relevant domains. This process was performed for LM, VM and AVM separately. Consensus was pre-defined as 80% agreement on the importance of a domain amongst both the physician group and the patient/parent group. Outcomes were then reevaluated in an online consensus meeting.

Results

167 physicians and 134 patients and parents of patients with LM (n=50), VM (n=71) and AVM (n=29) participated in the study. After three rounds and a consensus meeting, consensus was reached for all three types of vascular malformations on the core domains of radiological assessment, physician-reported location-specific signs, patient-reported severity of symptoms, pain, quality of life, satisfaction and adverse events. Vascular malformation type-specific signs and symptoms were included for LM, VM and AVM, separately.

Conclusion

It is recommended to measure at least these core outcome domains in therapeutic-efficacy studies on peripheral vascular malformations.

This article is protected by copyright. All rights reserved.

http://ift.tt/2y2QaEg

Prevalence of Goitre in Raichur District (Karnataka): A Descriptive Study

Abstract

This prevalence study was exclusively for the goitre detection in individuals who has no prior awareness of thyroid disorder and also those patients giving history of signs and symptoms of such conditions. Subjects underwent investigations for (T3, T4, TSH and FNAC) to analyze status and type of Goitre. Of the first 30 cases, only 8 cases were investigated and later on personal  interest  for confirmation of goitre disorder prevalence additional 70 cases were assessed of which 51 cases were investigated. On basis of investigation and epidemiology, we concluded that probably soil and water sources contain less iodine. Sample shown are comparatively less, but in our area number of goitre  cases are more and it needs further extensive survey.

http://ift.tt/2ghSDD4

Tumor-infiltrating immune cells as potential biomarkers predicting response to treatment and survival in patients with metastatic melanoma receiving ipilimumab therapy

Abstract

Monoclonal antibodies targeting immune checkpoints are gaining ground in the treatment of melanoma and other cancers, and considerable effort is made to identify biomarkers predicting the efficacy of these therapies. Our retrospective study was performed on surgical tissue samples (52 lymph nodes and 34 cutaneous/subcutaneous metastases) from 30 patients with metastatic melanoma treated with ipilimumab. Using a panel of 11 antibodies against different immune cell types, intratumoral immune cell densities were determined and evaluated in relation to response to ipilimumab treatment and disease outcome. For most markers studied, median immune cell densities were at least two times higher in lymph node metastases compared to skin/subcutaneous ones; therefore, the prognostic and predictive associations of immune cell infiltration were evaluated separately in the two groups of metastases as well as in all samples as a whole. Higher prevalence of several immune cell types was seen in lymph node metastases of the responders compared to non-responders, particularly FOXP3⁺ cells and CD8⁺ T lymphocytes. In subcutaneous or cutaneous metastases, on the other hand, significant difference could be observed only in the case of CD16 and CD68. Associations of labeled cell densities with survival were also found for most cell types studied in nodal metastases, and for CD16⁺ and CD68⁺ cells in skin/s.c. metastatic cases. Our results corroborate the previous findings suggesting an association between an immunologically active tumor microenvironment and response to ipilimumab treatment, and propose new potential biomarkers for predicting treatment efficacy and disease outcome.

http://ift.tt/2ghTgfU

Clinicopathological Significance of Tumor Lymphatic Vessel Density in Head and Neck Squamous Cell Carcinoma

Abstract

Various studies have demonstrated that the lymphatic system is the additional route for solid tumor metastasis. Lymph nodes metastasis in Head and neck squamous cell carcinoma (HNSCC) is a major prognostic indicator for disease progression and a guide for therapeutic strategies. We conducted a study to compare intratumoral (IT) and peritumoral (PT) lymphatic vessel density (LVD) in HNSCC using lymphatic marker D2-40 and its correlation with lymph node metastasis, histological grading and other clinicopathological parameters. Fifty specimen of HNSCC with modified radical neck dissection tissue were included in the study group. Tissue from tumor, peritumoral tissue, tumor margin and all the lymph nodes were processed for paraffin wax blocks and histopathological diagnosis. Immunohistochemical profile of lymphatic vessels in intratumoral and peritumoral tissue was assessed by subjecting one section each from the tumor and peritumoral tissue to D2-40 immunostain. To determine LVD, four fields with the highest LVD (hot spots) were identified. The mean values were calculated by taking an average of all the measurements. The comparison of LVD between peritumoral and intratumoral area revealed significantly higher PT-LVD (P = 0.001). No significant association was seen between LVD, IT-LVD and PT-LVD and different age groups, gender, site of tumor, risk factors, size of tumor, tumor inflammation, pushing/infiltrating margin and stage of tumors. Significantly higher LVD, IT-LVD and PT-LVD was seen in association with lymph node metastasis. Both high intratumoral and peritumoral LVD were found significantly associated with the presence of lymph node metastasis, however lymphatic vessels were found to be significantly more numerous and larger in peritumoral areas as compared to intratumoral lymphatics. The specificity of D2-40 as a lymphatic endothelial marker was also confirmed. The results of our study support the possibility of using the determination of tumor lymphangiogenesis to identify patients of HNSCC who are at risk of developing the lymph node metastasis.

http://ift.tt/2gfUh85

Flexible Laryngoscopy in Management of Congenital Stridor

Abstract

The incidence of congenital stridor is on rise due to improved neonate and infant survival rate. The gold standard investigation for evaluation of stridor is rigid laryngotracheobronchoscopy, but this is invasive and requires general anesthesia. Flexible fibreoptic laryngoscopy, a relatively simple and less invasive procedure can be done under topical anaesthesia for evaluation of stridor. In this study, we have presented our experience of flexible laryngoscopy in children with congenital stridor, their results and management. Laryngomalacia was the commonest cause of stridor accounting for 80% of cases. 15% (6) patients required tracheostomy for relieving airway obstruction and 22.5% (9) patients required a definitive surgical procedure for correcting the cause. Flexible laryngoscopy is safe and gives a comprehensive analysis of airway including its dynamic functions. We also recommend flexible laryngoscopy as a frontline investigation for evaluation of stridor.

http://ift.tt/2xYXBfx

Tolerance of Chemoradiation in Advanced Head and Neck Cancers: Comparison Between Inpatients and Outpatients

Abstract

Concurrent chemoradiation (CCRT) is the mainstay of treatment for majority of locally advanced head and neck carcinomas (LAHNC). Addition of chemotherapy to radiotherapy increases the probability of local control and improved disease-free survival but at the cost of acute and delayed toxicities. A retrospective observational study. To compare the tolerance of CCRT and its toxicity profile amongst two groups, first arm (Arm A) being outdoor patients and the second group (Arm B) was hospitalized patients of LAHNC in an oncology centre of a tertiary care hospital. A total of 100 patients were enrolled, 50 in each arm. Overall, the most common site was oropharynx, followed by larynx and hypopharynx. 38 patients in Arm A received full 6 cycles of weekly chemotherapy with Inj Cisplatin infusion. 39 of the hospitalized patients completed 6 cycles of weekly Cisplatin, 04 patients also received 3 weekly Cisplatin. Average duration of treatment was 49.18 days in arm A and 50.92 days in arm B. Incidence of Grade II onwards dysphagia was 48 and 45 (96 and 90%) in Arm A and Arm B respectively; Chi Square value—0.6 (Yate's corrected); P value—0.43. Grade III oral mucositis was seen in 14% patients in Arm A and 34% patients in Arm B. 3 patients (6%) in Arm A and 14 patients (28%) in Arm B has Grade II and III hematological toxicities and nephrological toxicities. Aspiration pneumonia was seen in 2 patients (4%) in Arm A and in 4 patients (8%) in Arm B, Chi Square value—0.2 (Yate's corrected) P value—0.67. The incidence of febrile neutropenia was 3 and 10 in Arms A and B (6 and 20%) respectively. The tolerance of CCRT in hospitalized patients is marginally better, with relatively few associated complications as compared to outdoor setting. Every institute should promulgate its own guidelines regarding hospitalization of such patients.

http://ift.tt/2ktqptC

The Correlation of Allergic Rhinitis with ABO Phenotype

Abstract

The aim of study the correlation of ABO phenotypes in patients of allergic rhinitis and controls and to compare our study with the previous studies to analyse the association of above. 100 patients with symptoms of allergic rhinitis and 100 controls individual were selected from same geographical region and paired by gender and age were enrolled in the study. Detailed history, examination and relevant radiological and hematological investigations were done. ABO phenotypes were identified in red blood cells using hemagglutination technique. This clinic-based observational study was conducted among the patients presenting with signs and symptoms of allergic rhinitis. Maximum no. of cases were seen in ABO phenotype O (52%), followed by A, B and AB (33, 12 and 3% respectively) and it was found to be statistically significant (p = 0.001). Also more number of male patients were found in B and O blood group which was statistically significant (OR 5.33, p = 0.017 and OR 3.63, p = 0.006 respectively). Controls showed marginalized difference in distribution among the basis of different ABO phenotypes. The O blood group phenotype of ABO histo-blood group system is associated with AR. This study contributes to the better understanding of the pathophysiology and clinical variability of this disease and may help to improve strategies towards its prevention and diagnosis. Additionally, ABO histo-blood group phenotyping, an inexpensive and easy to perform assay could be used to identify individuals at risk of developing allergic rhinitis.

http://ift.tt/2xjfO5r

Intratympanic Injection of Steroid for Treatment of Tinnitus

Abstract

Tinnitus has become one of the most challenging tasks faced by the medical field. It has a moderately negative impact on patient's quality of life. Different methods had been developed in medical science for managing tinnitus but none of these offered a permanent cure. In our study we used a simple procedure of intratympanic injection of dexamethasone in managing our tinnitus patients. Total number of patients involved in this study were 40, 26 females and 14 males with age spanned from 15 to 65 years. Out of 40 patients, 22 of them complained of tinnitus only while the other 18 of them complained of tinnitus with impaired hearing which was confirmed further by pure tone audiometry. Injection was given under otologic microscopic vision through posteroinferior quadrant of tympanic membrane in weekly interval. After receiving several number of injections, 24 patients (60%) reported complete disappearance of tinnitus, 10 of them (25%) still had residual tinnitus but comparatively less severe and 6 (15%) of them reported no improvement.

http://ift.tt/2yeuwQu

Bacterial Biofilms in Chronic Rhinosinusitis and Their Implications for Clinical Management

Abstract

To study the microbiological profile in patients with chronic rhino-sinusitis. To correlate disease severity with the presence of biofilms and host risk factors. To assess outcome of Sinus Surgery 2 weeks post operatively in terms of presence of bacteria and their ability to form biofilm. Prospective study. 50 cases of chronic rhino-sinusitis requiring Functional Endoscopic Sinus Surgery admitted in SDM Hospital, Dharwad, Karnataka were studied using intra-operative mucosal samples for microbiological analysis. The organisms isolated were tested for biofilm forming ability using three in vitro tests. Severity of disease was assessed using SNOT 22 scoring system. Of 50 cases studied, 66% showed presence of chronic rhino-sinusitis with polyposis and had higher SNOT scores compared to those without polyps. Bacterial isolates were obtained from only 17 samples. Staphylococcus species was isolated from 16 samples and Klebsiella pneumoniae from one. 11 Staph spp. isolates showed biofilm forming ability in vitro. Postoperative events in 3 cases yielded biofilm-forming Staphylococcus. Staphylococcus was the most dominant organism isolated and 11 isolates were biofilm formers. Thus the detection of biofilm forming organisms can be considered as a negative prognostic indicator and should forewarn the surgeon about the risk of recurrence.

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Cochlear Implantation in Children with Anomalous Cochleovestibular Anatomy: Our Experience

Abstract

To report operative findings, postoperative course, and postimplantation performance in patients with cochlear malformations who underwent cochlear implantation. Seventeen patients with malformations which included enlarged vestibular aqueduct (n = 6), Mondini's dysplasia (n = 5) common cavity deformity (n = 3) and incomplete partition type 2 (n = 3) underwent cochlear implantation with Nucleus 22 straight array device at our center. Operative findings described facial nerve anatomy and cerebrospinal fluid leak. Standard tests of speech perception were used to evaluate the postoperative performance for each subject. Operative findings included cerebrospinal fluid leak (thirteen patients) all of which were repaired successfully with graft. None had abnormal facial nerve anatomy. No surgical complications occurred. All the patients except two with common cavity had complete insertion. Electrode thresholds and discomfort levels were variable for several months after implantation. All patients demonstrated improved performance after implantation. Patients with enlarged vestibular aqueduct fared better than patients with other inner ear malformations. Cochlear implantation can be a successful method of rehabilitation in patients with congenital deafness who have cochlear malformations.

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Evaluation of Serum Selenium and Erythrocyte Glutathione Peroxidase Levels in Patients with Recurrent Tonsillitis

Abstract

The aim of this study is to investigate serum selenium (Se) and glutathione peroxidase (GSH-Px) levels in patients with recurrent tonsillitis. The study included 53 patients with recurrent tonsillitis and 51 healthy children. The measurement of serum Se levels were done in graphite furnace atomic absorption spectrophotometer using Zeeman background correction. Erythrocyte GSH-Px levels were indirectly measured by using the spectrophotometry. The ages of children in both groups ranged between 3 and 13 years, with a mean age of 7.60 years for patient group and 7.22 years for control group. Mean serum Se levels in patient and control groups were 60.4 and 78.7 µg/dL respectively. Mean erythrocyte GSH-Px levels in patient and control groups were 7.0 and 23.1 U/g hb, respectively. The mean blood Se and GSH-Px levels in patients with recurrent tonsillitis were significantly (P < 0.001) lower than control group. In our study, we found that serum Se and erythrocyte GSH-Px levels of cases with recurrent tonsillitis were significantly lower than healthy controls. The decline in serum Se and erythrocyte GSH-Px enzyme levels may predispose a chronic disease state but this issue needs further investigation.

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Tonsillectomy-Comparative Study of Various Techniques and Changing Trend

Abstract

Tonsillectomy is a major surgical procedure in terms of volume in the general otolaryngological practice. It is a 3000-year-old surgical operation, referred in Hindu medicine. There has been a conceptual change in the indications and surgical technique in the last 40 years. A comparative study between the various methods of tonsillectomy was done. The study was carried out in the single institutional set up by the same surgeon but using different techniques. The study aimed at comparing the intra-operative factors (blood loss, time taken for surgery), postoperative results (pain, bleeding, dehydration, time taken for complete healing), and other complications like vomiting and hospitalization time between different groups of surgical methods. This study was done in 2500 patients undergoing tonsillectomy with or without adenoid removal in a period of 35 years (1979–2013). The majority of the patients (approximately 41%) in the first half of this period underwent cold steel tonsillectomy whereas 39% underwent microdebrider assisted tonsillectomy. Microdebrider assisted tonsil surgery was done as day care procedure in 90%. In 21% of the patients, other methods viz coblation, radio frequency and laser were used. Microdebrider intracapsular tonsillectomy is associated with lower mortality and morbidity as compared to cold steel, coblation, electrodissection, laser and radio frequency.

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Safety of shortened infusion times for combined ipilimumab and nivolumab

Abstract

Background

Combined ipilimumab and nivolumab induces encouraging response rates in patients with unresectable or metastatic melanoma. However, the approved protocol for dual checkpoint inhibition (3 mg/kg ipilimumab over 90 min and 1 mg/kg nivolumab over 60 min) is time-intensive and several trials have shown that both single agents can be safely administered at faster infusion rates.

Aim

To investigate whether combined checkpoint inhibition with 3 mg/kg ipilimumab and 1 mg/kg nivolumab can be safely administered over 30 min per agent.

Patients and methods

We reviewed the rate of infusion-related reactions (IRRs) in the first 12 months of our single-institution experience using shortened infusion times for combined checkpoint inhibition with ipilimumab and nivolumab.

Results

Between May 24, 2016 and June 10, 2017, a total of 46 melanoma patients received 100 shortened cycles of combined 3 mg/kg ipilimumab and 1 mg/kg nivolumab. One patient (2.2%; 1/46) had a questionable reaction after administration of 1 mg/kg nivolumab over 30 min, but none of the other patients had a bona fide IRR.

Conclusions

Shortened infusion times for combined ipilimumab and nivolumab treatment are safe, thereby facilitating a more efficient use of outpatient facilities and enhancing patient's convenience.

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Ascending cholangitis: rare presentation of a ruptured right-sided renal angiomyolipoma

Abstract

We report the case of a 46-year-old female who presented to the Emergency Department with acute, painful obstructive jaundice, with evidence of secondary ascending cholangitis. Surprisingly, imaging revealed the clinical picture to be caused not by hepatobiliary pathology, but by external compression of the biliary tree from a ruptured renal angiomyolipoma (AML) of the right kidney. The patient remained haemodynamically stable and conservative management saw resolution of biliary obstruction. We believe this to be the first report of a renal AML presenting in this way. This report highlights the diverse spectrum of presentations of renal angiomyolipomas.

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Intussusception as a complication of bariatric surgery in pregnant patients: report of one case and revision of the literature

Abstract

Occlusive complications after a laparoscopic Roux-in Y gastric bypass (LRYGB), appear mainly as fibrous membranes of wounds, internal hernias or intussusception. Intussusception after a bariatric surgery occurs in 0.1–0.3% of the cases. We present a case of intussusception in a pregnant patient after a LRYGB.

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Longstanding unilateral dislocation of the temporomandibular joint in a 6-year-old girl

Abstract

Unilateral longstanding dislocation of the temporomandibular joint (TMJ) is rare in children. These patients may demonstrate some function in opening and closing of the mouth due to the formation of a pseudo-joint in the dislocated position. In this report we describe a case of longstanding unilateral dislocation of the TMJ in a 6-year-old girl, highlighting the diagnostic difficulty and management of the condition.

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Retention of molars after root-resective therapy: a retrospective evaluation of up to 30 years

Abstract

Objectives

Long-term retention of teeth and especially molars in function is the ultimate goal of periodontal therapy. Root-resective therapy is a treatment option for molars with advanced furcation involvement, which has been questioned because of the heterogenous success rates published in literature. This study aimed to evaluate long-term results of root-resective treatment over a period of up to 30 years.

Methods

In this retrospective cohort, 90 root-resected molars in 69 patients were examined for 4–30 years (14.7 ± 6.8 years). The complete treatment sequence was performed by one of the authors in a general dental practice.

Results

Overall cumulative survival rate was 90.6% after 10 years, but then decreased considerably. Molars after root resection had a median survival time of 20 years. The incidence of endodontic complications leading to tooth extraction was only 26.7%, 50% were lost due to periodontal problems, and 16.7% because of caries. Mandibular molars had a significantly lower relative risk of loss than molars in the maxilla (HR 0.31, 95% CI 0.1–0.91, p = 0.033). Mandibular molars showed a survival probability of almost 80% even 20 years after root resection.

Conclusion

Root-resective therapy is a predictable treatment option, when care is administered at each phase of therapy.

Clinical relevance

This study provides important information about what is possible in daily practice under the outlines of public health care, when care is administered at each phase of resective therapy.

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Mastocytosis in Children

Abstract

Purpose of Review

In this review, we examine the current understanding of the pathogenesis, clinical presentations, diagnostic tools, and treatment options of pediatric mastocytosis as well as the natural history of the disease.

Recent Findings

We discuss the emerging concept of mast cell activation syndrome.

Summary

Mastocytosis in children presents most commonly as isolated cutaneous lesions and is a relatively rare occurrence with excellent prognosis and spontaneous regression often occurring by adolescence. Systemic mastocytosis with organ system involvement is a more serious condition and is likely to persist into adulthood.

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Electron Microscopy of Dural and Arachnoid Disruptions After Subarachnoid Block.

Background: It has been customary to attribute postdural puncture headache (PDPH) incidence and severity to size and nature of the dural hole produced during major neuraxial blockade or diagnostic dural puncture. Needle orientation in relation to the direction of dural fibers was thought to be of importance because of the propensity for horizontal bevel placement to cause cutting rather than splitting of the dural fibers. Methods: In vitro punctures of stringently quality-controlled human dural sac specimens were obtained with 27-gauge (27G) Whitacre needle (n = 33), with 29G Quincke used parallel to the spinal axis (n = 30), and with 29G Quincke in perpendicular approach (n = 40). The samples were studied with a scanning electron microscope, and the perimeter, appearance, and area (%) of the lesion were calculated. Results: When using small 27G to 29G needles, neither needle tip characteristics nor needle orientation had a substantial bearing on the damage to dural fibers in the dural lesion. Of ultimate importance was the characteristic and size of the hole in the arachnoid. Arachnoid layer lesions produced by different types of spinal needles were not markedly different. Conclusions: Accepted theories of the etiology of PDPH need to be revised. This article marks the first time that arachnoid layer damage has been quantified. Dural fibers tend to have sufficient "memory" to close back the hole created by a spinal needle, whereas arachnoid has diminished capacity to do so. The pathogenesis of PDPH and its resolution algorithm are a far more complex process that involves many more "stages" of development than hitherto imagined. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Dose-Response Curves for Intrathecal Bupivacaine, Levobupivacaine, and Ropivacaine Given for Labor Analgesia in Nulliparous Women.

Background and Objectives: Bupivacaine, levobupivacaine, and ropivacaine are often given intrathecally for labor analgesia, but limited data are available for their dose-response properties in this context. The objective of this study was to describe the dose-response curves of these local anesthetics when given intrathecally for labor analgesia, to determine values for D50 (dose producing a 50% response) and to compare the calculated values of D50 for levobupivacaine and ropivacaine with those for bupivacaine. Methods: With ethics approval and written consent, we randomized 270 nulliparous laboring patients requesting neuraxial analgesia at 5-cm cervical dilation or less to receive a single dose of intrathecal local anesthetic without opioid as part of a combined spinal-epidural technique. Patients received either bupivacaine, levobupivacaine, or ropivacaine at a dose of 0.625, 1.0, 1.5, 2.5, 4.0, or 6.25 mg (n = 15 per group). Visual analog scale pain scores were measured for 15 minutes, after which further analgesia and management were at the clinician's discretion. The primary end point was percentage reduction of pain score at 15 minutes. Logistic sigmoidal dose-response curves were fitted to the data using nonlinear regression, and D50 values were calculated for each drug. Results: Data were analyzed from 270 patients. Patient characteristics were similar between groups. The calculated D50 and 95% confidence interval values were as follows: bupivacaine, 1.56 mg (1.25-1.94 mg); ropivacaine, 1.95 mg (1.57-2.43 mg); and levobupivacaine, 2.20 mg (1.76-2.73 mg). Conclusions: The results of this study support previous work showing that intrathecal levobupivacaine and ropivacaine are less potent than bupivacaine. Clinical Trial Registration: Chinese Clinical Trial Registry (identifier: ChiCTR-TRC-09000773) and Centre of Clinical Trials Clinical Registry of the Chinese University of Hong Kong (identifier: CUHK_CCT00245). Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Determination of ED50 and ED95 of 0.5% Ropivacaine in Adductor Canal Block to Produce Quadriceps Weakness: A Dose-Finding Study.

Background and Objectives: Adductor canal block (ACB) is popular for knee analgesia because of its favorable effect on quadriceps strength. The aim of this study was to find the minimum volume of local anesthetic, which can be injected into the ACB that would result in quadriceps weakness. Methods: This nonrandomized study used an up-and-down sequential allocation design. Twenty-six patients scheduled to undergo arthroscopic knee surgery received an ultrasound-guided ACB preoperatively. The initial volume of ropivacaine 0.5% injected was 30 mL, which was subsequently increased or decreased by 2 mL, depending on whether the previous subject had a 30% reduction in quadriceps function. The minimum effective volume in 50% of patients was determined using Dixon-Massey up-and-down method. The effective volume in 95% of patients was then calculated using probit transformation. Results: The ED50 (minimum effective anesthetic volume in 50% of the subjects) needed for a 30% decrease in quadriceps power was 46.5 mL (95% confidence interval, 45.01-50.43 mL), and estimated ED95 (minimum effective anesthetic volume in 95% of the subjects) was 50.32 mL (95% confidence interval, 48.66-67.26 mL). The local anesthetic volume injected correlated with degree of quadriceps weakness at 20 minutes postblock (P

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Diagnostic flaws in oral lichen planus and related lesions

There has been a constant debate as to the exact prevalence and malignant potential of oral lichen planus (OLP). The present ambiguity is due to the existence of lesions which have a clinicopathological resemblance to OLP [1]. Our research team had conducted a retrospective study on OLP and related lesions like oral epithelial dysplasia (OED), OLP, OLP with dysplasia and oral lichenoid lesions (OLL), and have commented on the possible existence of "oral lichenoid dysplasia" (OLD) which is a primary epithelial dysplasia with secondary lichenoid features as opposed to "OLP with dysplasia" which is a lichen planus with secondary dysplastic features [2].

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Analgesia Nociception Index Monitoring During Supratentorial Craniotomy.

Background: Objective monitoring of pain during and after surgery has been elusive. Recently, Analgesia Nociception Index (ANI) monitor based on the high frequency component of heart rate variability has been launched into clinical practice. We monitored analgesia during craniotomy using ANI monitor and compared it with cardiovascular parameters and response entropy (RE) of entropy monitor. Materials and Methods: In 21 patients undergoing a craniotomy for a supratentorial lesion, we monitored ANI, heart rate (HR), mean arterial pressure (MAP), state entropy, and RE throughout the surgery. Also, ANI, hemodynamic variables and spectral entropy values were noted at the times of maximal stimulation, such as induction, intubation, head pin fixation, skin incision, craniotomy, durotomy, and skin closure. We also compared ANI with RE during administration of bolus doses of fentanyl. Results: There was an inverse correlation between ANI values and the hemodynamic changes. When the HR and MAP increased, ANI decreased suggesting a good correlation between hemodynamics and ANI values during the times of maximal stimulation. State entropy and RE did not change significantly in response to bolus doses of fentanyl administered during the course of surgery, while ANI increased significantly. Conclusion: In neurosurgical patients undergoing elective supratentorial craniotomy, ANI measures response to noxious stimuli with at least as much reliability as hemodynamic variables and changes in ANI parallel the changes in HR and MAP. ANI is superior to RE for measurement of response to noxious stimuli. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

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Hemodynamic Instability and Cardiovascular Events After Traumatic Brain Injury Predict Outcome After Artifact Removal With Deep Belief Network Analysis.

Background: Hemodynamic instability and cardiovascular events heavily affect the prognosis of traumatic brain injury. Physiological signals are monitored to detect these events. However, the signals are often riddled with faulty readings, which jeopardize the reliability of the clinical parameters obtained from the signals. A machine-learning model for the elimination of artifactual events shows promising results for improving signal quality. However, the actual impact of the improvements on the performance of the clinical parameters after the elimination of the artifacts is not well studied. Materials and Methods: The arterial blood pressure of 99 subjects with traumatic brain injury was continuously measured for 5 consecutive days, beginning on the day of admission. The machine-learning deep belief network was constructed to automatically identify and remove false incidences of hypotension, hypertension, bradycardia, tachycardia, and alterations in cerebral perfusion pressure (CPP). Results: The prevalences of hypotension and tachycardia were significantly reduced by 47.5% and 13.1%, respectively, after suppressing false incidents (P=0.01). Hypotension was particularly effective at predicting outcome favorability and mortality after artifact elimination (P=0.015 and 0.027, respectively). In addition, increased CPP was also statistically significant in predicting outcomes (P=0.02). Conclusions: The prevalence of false incidents due to signal artifacts can be significantly reduced using machine-learning. Some clinical events, such as hypotension and alterations in CPP, gain particularly high predictive capacity for patient outcomes after artifacts are eliminated from physiological signals. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

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Red Cell Distribution Width After Subarachnoid Hemorrhage.

Background: High red cell distribution width (RDW) values have been associated with increased hospital mortality in critically ill patients, but few data are available for subarachnoid hemorrhage (SAH). Methods: We analyzed an institutional database of adult (>18 y) patients admitted to the Department of Intensive Care after nontraumatic SAH between January 2011 and May 2016. RDW (normal value, 10.9% to 13.4%) was obtained daily from admission for a maximum of 7 days, from routine blood analysis. We recorded the occurrence of delayed cerebral ischemia (DCI), and neurological outcome (assessed using the Glasgow Outcome Scale [GOS]) at 3 months. Results: A total of 270 patients were included (median age 54 y-121/270 male [45%]), of whom 96 (36%) developed DCI and 109 (40%) had an unfavorable neurological outcome (GOS, 1 to 3). The median RDW on admission was 13.8 [13.3 to 14.5]% and the highest value during the intensive care unit (ICU) stay 14.2 [13.6 to 14.8]%. The RDW was high (>13.4%) in 177 patients (66%) on admission and in 217 (80%) at any time during the ICU stay. Patients with a high RDW on admission were more likely to have an unfavorable neurological outcome. In multivariable regression analysis, older age, a high WFNS grade on admission, presence of DCI or intracranial hypertension, previous neurological disease, vasopressor therapy and a high RDW (OR, 1.1618 [95% CI, 1.213-2.158]; P=0.001) during the ICU stay were independent predictors of unfavorable neurological outcome. Conclusions: High RDW values were more likely to result in an unfavorable outcome after SAH. This information could help in the stratification of SAH patients already on ICU admission. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

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Recurrent chylothorax: a clinical mystery

Chylothorax is an unusual cause of pleural effusion, typically caused by trauma or malignancy. Waldenstrom's macroglobulinaemia (WM) is a clinicopathological entity demonstrating lymphoplasmacytic lymphoma in the bone marrow with an IgM monoclonal gammopathy in the blood. Recurrent chylous effusions are often resistant to conservative treatment and may require surgical intervention. We present a unique case of a 50-year-old woman with recurrent chylothorax secondary to WM that completely resolved with ibrutinib therapy. To our knowledge, this is the eighth such case reported in literature and the first case of successful resolution of chylothorax with monoclonal antibody therapy.

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Enterobius vermicularis (pinworm) infestation in a child presenting with symptoms of acute appendicitis: a wriggly tale!

Acute appendicitis is the most common surgical emergency worldwide. However, it can still present a challenging diagnosis especially in the young, elderly and those individuals of reproductive age, thus encompassing a wide spectrum of varied clinical presentations. Parasitic infections of the appendix are a rare cause of acute appendicitis. However, they must be considered in children presenting with abdominal pain. We report a case of Enterobius vermicularis infestation mimicking the features of acute appendicitis in a 10-year-old girl. This case is a cautionary reminder of the importance of considering E. vermicularis infestation in children presenting with abdominal pain, but who do not have a significantly raised white cell count or high Alvarado scores. A history of anal pruritus is the most characteristic symptom, but the parasites can cause severe abdominal pain mimicking appendicitis. Prompt recognition and a high clinical index of suspicion are required to prevent an unnecessary appendicectomy. Caution is advised when performing a laparoscopic appendectomy, as in our case, to prevent contamination of the peritoneum. This infestation is easily treatable with mebendazole.

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Sclerokeratouveitis and lens dislocation in a patient with genital ulcer: was the great imitator imitated?

Uveitis is the most common ocular manifestation of syphilis, while scleritis is rare. A case of nodular scleritis, peripheral keratitis and uveitis in a patient with genital ulcer is presented in this report. This patient had a clinical profile suggestive of syphilis, though the serology was negative for treponemal antibodies. Other possible differential diagnosis imitating syphilis are discussed.

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Unusual case of immune-related colitis

The cancer immunotherapy field has had many promising developments in recent years. Checkpoint inhibitors are good examples of that. This new class of medications comes with a new constellation of side effects that require early recognition and management. Here we present a patient with metastatic adenocarcinoma on pembrolizumab who was admitted to the hospital for colitis. This was found to be an immune-related adverse event from pembrolizumab. We discuss our work-up and approach to the diagnosis, then highlight important treatment pearls for internal medicine physicians who are increasingly taking care of such patients.

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Solar retinopathy: the yellow dot and the rising sun

Description

A 62-year-old Indian male presented with complaints of minimally blurred vision in both eyes since 3–4 months. He was a known case of essential hypertension. On ocular examination, best corrected visual acuity was 20/40 in both eyes with a +4D spherical correction. Anterior segment evaluation revealed immature senile cataract with normal intraocular pressures. On fundus examination, a discrete yellow dot was noted at the fovea of both eyes (right > left), along with features of early hypertensive retinopathy (figure 1). He was diagnosed to have outer lamellar macular hole in both eyes. Spectral-domain optical coherence tomography (OCT) revealed hyporeflective space in outer retina at the foveal centre of both eyes (right > left) (figure 2). A diagnosis of solar retinopathy was considered and on leading questions, he gave a history of performing religious rituals involving direct gazing into the rising sun soon after dawn for 5–10 min...

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Erythema ab igne in an individual with diabetes and gastroparesis

Description

Prolonged abdominal heat application in an individual with diabetes and gastroparesis leads to the development of erythema ab igne. Practitioners should be aware of the various ways that erythema ab igne can present.1

Erythema ab igne is due to prolonged heat exposure (43–47°C) which causes damage to superficial vascular plexus leading to vasodilation, erythema and haemosiderin deposition which clinically appears as hyperpigmentation.2

A 28-year-old man with type 1 diabetes and gastroparesis had presented with vomiting and abdominal pain. Abdominal examination revealed a erythematous, reticulated, macular and non blanchable pigmentation, (figure 1). The patient used to apply hot water bottles for abdominal pain relief.

Figure 1

Erythema ab igne in an individual with diabetes and gastroparesis.

Erythema ab igne can be associated with epidermal atrophy and scaling.1 The lesions may become keratotic and bullous (rare) with a...

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Primary dural diffuse large B cell lymphoma mimicking parafalcine meningioma

A 58-year-old immunocompetent woman presented with complaints of recent onset recurrent generalised tonic-clonic seizures and left hemiparesis. On MRI a dural-based heterogeneously enhancing mass was seen along the falx cerebri mimicking parafalcine meningioma, causing brain parenchymal compression and vasogenic oedema in the right frontal and parietal lobes. The tumour was completely excised and on subsequent investigation it was diagnosed as diffuse large B cell type primary dural lymphoma. Chemotherapy with CHOP (cyclophosphamide, hydroxyl doxorubicin, vincristine and prednisone) regimen was started; however, the patient later died from episodes of acute pulmonary thromboembolism, aspiration pneumonia and septic shock.

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Small bowel obstruction due to a jejunal enterolith: an unusual complication of jejunal diverticulitis

A 91-year-old woman presented with symptoms of acute bowel obstruction supported by clinical findings. A CT of the abdomen was performed which demonstrated jejunal diverticulosis with a single inflamed, wide necked diverticulum. A large enterolith was found to be impacted in the jejunum just distal to the area of inflammation resulting in small bowel obstruction. The patient underwent emergency laparotomy, which confirmed the CT findings. Small bowel resection was performed. The patient had an uneventful postoperative recovery.

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A rare case of localised pigmented villonodular synovitis in the knee of a 24-year-old female soccer player: diagnosis, management and summary of tenosynovial giant cell tumours

Localised pigmented villonodular synovitis (PVNS) of the knee is a rare diagnosis, with clinical signs and symptoms mimicking meniscal damage or other common knee injuries.

We report the case of a 24-year-old female soccer player, seeking treatment after 7 months of persisting knee pain. Additionally, we present an overview of tenosynovial giant cell tumours.

On examination, the patient was found to have tenderness in the medial joint space of the knee. MRI revealed a heterogeneous formation in the central part of the knee. The formation was completely enucleated arthroscopically, histological analyses confirmed the diagnosis of localised PVNS. The patient was subsequently free of symptoms with no signs of recurrence on MRI and had resumed soccer practice at the 1-year follow-up appointment.

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Does quality of life outweigh the cardiovascular risks of stimulant medication in a child with ADHD and hypertrophic cardiomyopathy?

A 10-year-old girl with attention-deficit hyperactivity disorder (ADHD) is diagnosed with hypertrophic cardiomyopathy. The stimulant medications used to control her ADHD pose possibly fatal risks to her cardiovascular health, so stimulant medication is stopped. Due to very poor quality of life off of medication, alternative therapies are used without improvement. The patient's caretakers decide that the benefits of stimulant medication outweigh the risks to the patient. The healthcare team clears the patient to be put back on stimulant medication with a signed waiver of liability by her caretakers.

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In the setting of paediatric osteomyelitis do not be afraid to CAST an eye

The case commences with an innocuous right ankle injury (lateral malleolus), for which the patient, a 9-year-old boy, was placed in a temporary cast at his local hospital. Three days following this incident, the patient was diagnosed with new-onset type 1 diabetes mellitus. He was admitted to his local hospital with severe diabetic ketoacidosis appropriately treated and subsequently discharged c.1 week later clinically well. Approximately 1 week later, again he presented for a third time with a significant serosanguinous discharge from the site of the initial injury permeating through the temporary cast in place for c.2 weeks by that time. On removal of the cast, a severely invasive infection of bone and soft tissue was noted, and the patient was urgently transferred to our unit at the tertiary general hospital for further management. He underwent a series of orthopaedic and plastic surgery procedures with an eventual satisfactory outcome.

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Asymmetric glaucoma in pseudoplateau iris syndrome

A 39-year-old Caucasian man with bilateral narrow angles, a plateau-like iris configuration on gonioscopy and elevated intraocular pressure (IOP) presented with significant asymmetric glaucoma, left eye affected more than right. Initial management with topical medical therapy, laser iridoplasty and peripheral iridotomy in the left eye was ineffective in lowering the IOP or opening the anterior chamber angle. Ultrasound biomicroscopy demonstrated bilateral ciliary body cysts. The patient ultimately required surgical management, consisting of cataract extraction and endoscopic cyclophotocoagulation of ciliary body cysts in the left eye and trabeculectomy in the right eye, for persistent IOP control to prevent further optic nerve damage and subsequent visual field loss.

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Imaging of foreign bodies: a radiological conundrum

A 24-year-old woman escaped a fire by jumping from the first floor of her house onto a temporary greenhouse. She was brought into the emergency department and later treated surgically. Three years after the initial episode a tender lump in her right thigh was found during regular follow-up for her acute myeloid leukaemia, for which she was in remission. This was treated as a suspicious mass due to her haematological history and further imaging was organised. This was later identified as a piece of the greenhouse that she had landed on 7 years previously. It is a common occurrence for foreign bodies to be missed on initial examination. Fortunately the patient recovered well from her physical wounds and, more importantly, remains humorous when reflecting on her almost 7-year long battle with a piece of plastic.

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Safe usage of anakinra and dexamethasone to treat refractory hemophagocytic lymphohistiocytosis secondary to acute disseminated histoplasmosis in a patient with HIV/AIDS

Hemophagocytic lymphohistiocytosis (HLH) is a serious life-threatening disease if not recognised early. In patients with HIV/AIDS, this association has been reported following acute opportunistic infections, including histoplasmosis. However, optimal treatment is not known. We describe a male aged 46 years with AIDS who developed HLH following acute disseminated histoplasmosis. Presenting symptoms included fever, hepatosplenomegaly and pancytopenia. Bone marrow biopsy confirmed HLH. Initially, he was refractory to the treatment with amphotericin B, antiretroviral therapy and intravenous immunoglobulin (IVIG). Anakinra, an interleukin-1 receptor antagonist, and dexamethasone were initiated. He improved clinically, did not exhibit any harmful effects and ultimately was discharged from the hospital. This, we believe, is the first reported treatment of HLH with anakinra in a patient with AIDS and acute disseminated histoplasmosis.

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Bilateral intracranial calcifications with bilateral facial cutaneous naevus: Sturge Weber syndrome

Sturge Weber syndrome also known as mother spot disease belongs to a group of disorders called phakomatoses (neurocutaneous syndromes involving the central nervous and cutaneous systems). It is a congenital disorder of the vasculature of the meninges, brain, face and eyes. Clinically, it usually presents with seizures and other neurological complications, including mental retardation, contralateral hemiparesis and glaucoma. Its incidence is estimated at one case in 20 000–50 000 persons with equal frequency in boys and girls. We present a case of 18-months-old boy was brought by parents with history of seizures since birth resulting in fall 1 day back. Physical examination showed bilateral port-wine stain on face. CT head examination revealed bilateral intracranial calcification. This is a highly unusual presentation of Sturge Weber syndrome.

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Bilateral large subconjunctival haemorrhages unmasking immune thrombocytopenic purpura during retinopathy of prematurity screening

Although thrombocytopenia is known to be associated with pathogenesis of retinopathy of prematurity (ROP), immune thrombocytopenic purpura (ITP) is rare in infancy and not reported to occur with ROP. A preterm infant with aggressive posterior ROP developed bilateral massive subconjunctival haemorrhage after scleral indentation during screening. On evaluation, the infant was found to have severe ITP. Following intravenous transfusion of platelets and immunoglobulin, platelet counts improved and subconjunctival haemorrhage resolved over time. This case highlights the unusual presentation of ITP and also discusses the association of thrombocytopenia with ROP. Ophthalmologists should get prompt haematological work-up of such occurrences.

http://ift.tt/2xYFuch

Why in the age of CT scans and MRIs is a brain tumour mistaken for a psychiatric illness?

The first author of this paper operated on two patients with brain tumour, who had been undergoing long-term treatment for depression. In the age of CT scans and MRIs, why are there still cases in which a brain neoplasia is mistaken for a psychiatric condition with consequent serious delays in diagnosis? In this article, we have highlighted what in our experience are three noticeable obstacles in achieving the right diagnosis.

http://ift.tt/2fZ9vBO

Oxaliplatin-induced posterior reversible encephalopathy syndrome (PRES)

Posterior reversible encephalopathy syndrome (PRES), first introduced in 1996, is a neurotoxic state characterised by seizures, headache, vision change, paresis, nausea and altered mental status. Risk factors include hypertension, eclampsia/pre-eclampsia, infection/sepsis and cancer chemotherapy. Although exposure to toxic agents is a common occurrence in patients who develop PRES, oxaliplatin has rarely been associated with it, with only 10 cases reported worldwide. We present the case of an oxaliplatin-induced PRES in a 23-year-old male patient who was started on oxaliplatin/capecitabine as adjuvant chemotherapy for anal canal adenocarcinoma. The patient developed symptoms of headache, slurred speech and left-sided facial weakness on the ninth day after the first dose of oxaliplatin that lasted for 6–8 hours. The patient experienced another episode next day with similar symptoms that lasted for 8 hours. Oxaliplatin was withheld and the patient was discharged on capecitabine only. The patient had no new episodes since discharge on follow-up.

http://ift.tt/2xZ3c8f

Management of extensive external apical root resorption leading to root perforation

Resorption is both a physiological and pathological process which results in loss of hard tissues of the tooth, i.e , cementum and dentine and the surrounding bone. External resorption is much more common than internal resorption and can occur when tooth is luxated or avulsed. If remained unchecked, resorption can eventually lead to loss of the tooth. Timely management of the affected tooth can slow down the resorptive lesion and increase the prognosis of the survival of the tooth. This case report describes the surgical management of extensive external root resorption leading to perforation of apical one-third of the root area which was managed through root canal along with periapical surgery and bone grafting. A 6-month follow-up showed arrest of the resorptive defect and progressive healing as evident on the cone-beam computed tomography.

http://ift.tt/2fYPSKa

Aspiration of Nasopore nasal packing

We present a case of postoperative Nasopore aspiration in an otherwise fit and well 11-year-old. An endoscopic adenoidectomy had been performed without incident and Nasopore packing placed into each nasal cavity. Immediately after extubation, there was marked hypoxia, tachypnoea and high clinical suspicion of pack aspiration. The patient returned to theatre for emergency rigid bronchoscopy and retrieval of nasal packing.

http://ift.tt/2y04f7C

Angiogenesis in the Transplanted Donor Graft after Living-Donor Liver Transplantation.

Background: There is no direct evidence for the role of angiogenesis in liver regeneration in humans. This study aimed to determine whether angiogenesis is involved in the regeneration of transplanted donor grafts in human living-donor liver transplantation (LDLT) and to examine the impact of donor graft volume on angiogenesis. Methods: Clinical data and liver tissue characteristics were analyzed in 4 patients who received adult-to-adult LDLT with dual left lobe grafts from 2 living donors. Liver tissues from transplanted donor grafts were obtained and immunohistochemically examined at 3-4 weeks after transplantation using the endothelial marker Ki67+ and CD31+. Results: All recipients showed recovery of normal liver function and a significant increase in the volume of engrafted left lobes after transplantation. Immunohistochemistry showed a remarkable increase in Ki67+ single hepatocyte proliferation, implying the role of hepatocytes in liver reconstitution, and a high density of blood vessels and proliferative endothelium, suggesting in vivo angiogenesis. Furthermore, we found that Ki67+ nuclei in CD31+ sinusoidal endothelial cells were higher in recipients with smaller donor grafts than in those with larger donor grafts. Conclusions: Our results suggested that angiogenesis is involved in the regeneration of transplanted liver in humans in inverse proportion to the donor graft volume. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2xYxtnB