Dermatological and environmental toxicological impact of the sunscreen ingredient oxybenzone/benzophenone-3

Summary

Oxybenzone (Benzophenone-3) is an emerging human and environmental contaminant used in sunscreens and personal care products to help minimize the damaging effects of ultraviolet radiation. The Center for Disease Control fourth national report on human exposure to environmental chemicals demonstrated that approximately 97% of the people tested have oxybenzone present in their urine, and independent scientists have reported various concentrations in waterways and fish worldwide. Oxybenzone can also react with chlorine, producing hazardous by-products that can concentrate in swimming pools and wastewater treatment plants. Moreover, adverse reactions could very well be increased by the closed loop of ingesting fish contaminated with oxybenzone and/or washing the ingredient off our bodies and having it return in drinking water as treatment plants do not effectively remove the chemical as part of their processing protocols. In humans, oxybenzone has been reported to produce contact and photocontact allergy reactions, implemented as a possible endocrine disruptor and has been linked to Hirschsprung's disease. Environmentally, oxybenzone has been shown to produce a variety of toxic reactions in coral and fish ranging from reef bleaching to mortality. Lastly, with the rise in skin cancer rates and the availability of more effective sunscreen actives such as micronized zinc oxide and titanium dioxide, serious doubts about the relative prevention benefit of personal care products containing oxybenzone must be raised and compared with the potential negative health and environmental effects caused by the accumulation of this and other chemicals in the ecosystem.

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Process of tight junction recovery in the injured vocal fold epithelium: Morphological and paracellular permeability analysis

Objectives/Hypothesis

The vocal fold epithelium that includes tight junction (TJ)-based barrier function protects underlying connective tissues from external insults. TJs play an important role to control paracellular permeability of not only solutes but also ions, and preserve the vocal fold homeostasis. However, the distribution of TJs and paracellular diffusion barrier across the entire vocal fold epithelium are still unknown. The aim of this study was to identify the distribution of TJs in the vocal fold epithelium and to characterize the recovery process of TJ-based paracellular diffusion barrier in a rat model of vocal fold injury.

Study Design

Animal experiments with controls.

Methods

Normal and vocal fold–injured rats were used. Larynges were harvested for immunohistochemical examination of TJ proteins. For functional analysis, a tracer permeability assay was performed using EZ-Link Sulfo-NHS-LC-Biotin.

Results

TJ proteins occludin and zonula occludens 1 signals were localized to the junctional regions of the most luminal cell layers of the vocal fold epithelium. The injured region had been recovered with epithelium at 5 days postinjury, but the paracellular diffusion barrier assays revealed that biotinylation reagents diffused into the lamina propria at 5 days postinjury, and were blocked at the epithelium at 14 and 28 days postinjury.

Conclusions

It was strongly suggested that TJs in the vocal fold epithelium exist at the junctional regions of the first layer of stratified squamous epithelium. TJ-based paracellular diffusion barrier following vocal fold injury is recovered by 14 days postinjury, and this period corresponds with the time course of structural changes in the regenerating epithelium layer.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2xCV4Xp

MRSA chronic bacterial laryngitis: A growing problem

Objectives

Chronic bacterial infection of the larynx is characterized by long-standing hoarseness and exudative laryngitis. Prolonged antibiotic therapy is required to clear the infection, and methicillin-resistant staphylococcus aureus (MRSA) may be the responsible pathogen. The objective of this study was to describe the presentation, comorbidities, treatment response, and underlying etiology— including the incidence of MRSA—in our patient population with chronic bacterial laryngitis.

Methods

A review of patients with a diagnosis of chronic bacterial laryngitis from 2012 to 2016 was performed. Diagnosis of chronic bacterial laryngitis was based on clinical history and findings on flexible laryngoscopy. In selected cases, the diagnosis of bacterial laryngitis was confirmed by operative biopsy. Information regarding clinical presentation and course was collected.

Results

Twenty-eight patients were included in the study. Twenty-three were treated empirically with Amoxicillin-clavulonic acid for a minimum of 21 days. Twelve of the 23 (52%) had recurrence or nonresolution of infection. Seven of the 12 nonresponders (58%) were found to have MRSA by laryngeal tissue culture. Five patients were treated initially with Sulfamethoxazole and trimethoprim, and all resolved the infection without the need for further treatment. There was a nonstatistically significant increase in smoking and reflux in the MRSA population compared to the non-MRSA group.

Conclusion

MRSA infection was documented in 30% of patients overall with chronic bacterial laryngitis. Based on the results of the study, a treatment algorithm for management of this unusual patient population is suggested.

Level of Evidence

4. Laryngoscope, 2017

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Selective recurrent laryngeal nerve stimulation using a penetrating electrode array in the feline model

Objectives/Hypothesis

Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses.

Study Design

Acute experiments in cats.

Methods

The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement.

Results

Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments.

Conclusions

We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management.

Level of Evidence

NA Laryngoscope, 2017

http://ift.tt/2xCUWqT

Upper airway stimulation therapy and prior airway surgery for obstructive sleep apnea

Objective

To determine if patients with prior airway surgery for obstructive sleep apnea (OSA) had increased benefit following implantation with hypoglossal nerve stimulator.

Study Design

Retrospective chart review at a single institution tertiary academic care center.

Methods

Following implantation with hypoglossal nerve stimulator device, the outcomes of patients who underwent prior airway surgery for OSA were compared with those who did not. Primary outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS) as measured by polysomnography. Secondary outcome measures included Epworth Sleepiness Scale.

Results

Forty-seven patients underwent implantation with hypoglossal nerve stimulator. Of these, 30 patients had undergone prior airway surgery for OSA, whereas 16 did not. Mean preoperative AHI and NOS were 39.3 ± 2.8 and 78% ± 1.8% for all patients, 39.4 ± 3.7 and 79% ± 14% for patients with prior airway surgery, and 39.1 ± 4.0 and 77% ± 2.6% for patients without prior surgery. Mean postoperative AHI and NOS were 3.9 ± 1.2 and 91% ± 0.4% for all patients, 4.2 ± 1.7 and 91% ± 0.5% for patients with prior surgery, and 3.4 ± 1.5 and 93% ± 0.6% for patients without prior surgery (P = 0.756 and 0.053, respectively).

Conclusion

Overall, patients had significant improvement following implantation with hypoglossal nerve stimulator. Prior airway surgery had no statistically significant effect on postoperative AHI or NOS.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2A2IMta

Oropharyngeal squamous cell carcinoma incidence and mortality trends in the United States, 1973–2013

Objective

To analyze oropharyngeal squamous cell carcinoma incidence and mortality trends in the United States for the years 1973 through 2013.

Study Design

Cross-sectional study using a large population-based cancer database.

Methods

Data on incidence and mortality rates were extracted from the Surveillance, Epidemiology, and End Results (SEER) 9 Database. Annual percentage change in rates was calculated using Joinpoint regression analysis (National Cancer Institute, Bethesda, MD).

Results

Incidence rates increased (annual percent change [APC]; 1.52, 95% confidence interval [CI] 0.17 to 2.88) from 1973 to 1983, remained stable (APC −0.52, 95% CI −1.30 to 0.26) from 1983 to 1997, and increased (APC 1.32, 95% CI 0.83 to 1.81) from 1997 to 2013. Overall, incidence rates increased for males (APC 0.73, 95% CI 0.22 to 1.25) but not females (APC −0.77, 95% CI −0.68 to 0.82). Incidence rates increased in the white population (APC 0.79, 95% CI 0.33 to 1.25) but decreased in the black population (APC −0.72, 95% CI −1.41 to −0.02). The incidence rates increased for tongue-base tumors (APC 1.17, 95% CI 0.42 to 1.92) and tonsil tumors (APC 0.47, 95% CI 1.10 to 4.96) but decreased for other sites. Incidence-based mortality decreased (APC −0.78, 95% CI −1.13 to −0.42) from 1993 to 2013.

Conclusion

Oropharyngeal squamous cell carcinoma incidence rates increased in a nonlinear fashion from 1973 to 2013, whereas mortality rates declined. This, along with variation in trends by demographic and tumor factors, suggest that human papilloma virus is the main driver of the recent rise in incidence.

Level of Evidence

2b. Laryngoscope, 2017

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A matched comparison of human papillomavirus–induced squamous cancer of unknown primary with early oropharynx cancer

Objectives/Hypothesis

Patients with human papillomavirus (HPV)–induced cancer of unknown primary (CUP) are generally excluded from clinical trials, despite surgical series reporting detection rates of occult oropharynx primaries of >80%. We performed a matched-pair analysis to compare outcomes between T0N1-3M0 HPV+ CUP and T1-2N1-3M0 HPV+ oropharynx known primary (OPX).

Study Design

Retrospective cohort study at a single institution.

Methods

Patients with early T stage, node positive HPV+ OPX or CUP treated with curative intent between 1998 and 2016 were identified. For a subgroup of CUP patients with an unknown HPV status, we imputed HPV status and included patients with a >80% probability of being HPV+. Cohorts were matched based on patient demographics using a nearest neighbor propensity technique. After matching, patients were grouped according to either a favorable or unfavorable risk stratification designations per current NRG Oncology clinical trial enrollment criteria. Disease-free survival (DFS) and overall survival (OS) were calculated using Kaplan-Meier analysis.

Results

Of 298 patients with T1-2N1-3 OPX, 48 were matched to 48 HPV+ CUP patients (32 with confirmed and 16 imputed HPV status). Median follow-up for CUP (34.1 months) and OPX (27.8 months) patients were similar (P = .23).There were no significant differences between the CUP and OPX groups for 3-year DFS (89% vs. 85%, P = .44), and 3-year OS (91% vs. 91%, P = .11), respectively.

Conclusions

Patients with T0N+M0 HPV-induced CUP have similar survival outcomes to matched patients with T1-2N+M0 HPV+ OPX. These patients can reasonably be included in clinical trials investigating the role of treatment deintensification and risk stratified similar to patients with early-stage known primary OPX cancer.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2A32LaU

Feasibility of preservation of chorda tympani nerve during noninflammatory ear surgery: A systematic review

Objective

The objective of our systematic review is to investigate the postoperative gustatory function of the chorda tympani nerve following noninflammatory ear surgery for which the chorda tympani is at risk for iatrogenic injury (stretching, handling, or sacrificing).

Data Sources

PubMed and EMBASE.

Review Methods

A PubMed and EMBASE databases search was conducted on November 15, 2016. Study inclusion criteria included: 1) ear surgery performed for noninflammatory ear diseases, and 2) gustatory function of the chorda tympani reported as an outcome. The quality of eligible studies was assessed using the risk of bias assessment tool for nonrandomized studies. Study characteristics and outcome data of the included studies were extracted.

Results

In total 1,094 articles were retrieved. Fourteen studies encompassing 1,062 operated ears were included after quality assessment. Stapedectomy was the most frequent surgical procedure performed in 398 ears. The follow-up time varied between 6 weeks and 99 months. Patients with a preserved chorda tympani were less symptomatic (24% was symptomatic) compared to patients with a stretched (53% was symptomatic) or sacrificed chorda tympani (47% was symptomatic). The recovery rate varied from 61% to 79%. The results of the electrogustometry and strip test showed a discrepancy with the subjective complaints of the patients.

Conclusion

Patients with a stretched chorda tympani were slightly more symptomatic compared to patients with a sacrificed chorda tympani. Therefore, in cases for which the chorda tympani greatly hinders a proper view of the surgical field, sacrificing the nerve could be considered to maximize surgical performance and have a satisfactory postoperative result. Laryngoscope, 2017

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Utility of intraoperative imaging in cochlear implantation: A systematic review

Background

Many institutions routinely perform intraoperative imaging during cochlear implant (CI) surgery to determine accurate electrode placement. Different modalities exist; however, there remains some controversy regarding the usefulness of intraoperative imaging.

Objective

Systematically review the utility of intraoperative imaging in CI surgery and implications for management.

Methods

PubMed, EMBASE, Medline, CINAHL, and Cochrane library were searched from inception to April 2017. Studies analyzing the use of intraoperative imaging during CI surgery were included. Outcome measures included unsatisfactory placement and change in management. Two independent evaluators reviewed each abstract and article.

Results

Two hundred and sixty-seven articles were identified. Of those, 17 met inclusion criteria. There were no randomized controlled trials. Intraoperative X-rays were performed in 917 CIs in eight studies. Placement was unsatisfactory on radiograph in 19 implants (3.5%), and management was changed in 18 of 19 (94.7%). Intraoperative computed tomography (CT) was performed in 69 CIs in seven studies. Placement was unsatisfactory on CT in two implants (3.0%), and management was changed in both (100%). Intraoperative real-time fluoroscopy was performed in 20 CIs in two studies to help guide correct placement. Twenty-two of these patients had abnormal cochleas. Fifteen out of 17 studies concluded that intraoperative imaging is useful, especially with challenging anatomy or when the surgeon questions placement.

Conclusion

Intraoperative imaging detects unsatisfactory placement of electrodes during CI surgery at a low, but not negligible, rate. The current literature is not conclusive regarding the utility of routine imaging, but it appears to be most useful with abnormal cochlear anatomy or when the surgeon questions placement.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2A23fyj

A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

BACKGROUND: The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS). METHODS: Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR 160 mm Hg or minimum SBP 100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P 160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR 100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P

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Impact of Anesthetic Regimen on Remote Ischemic Preconditioning in the Rat Heart In Vivo

Remote ischemic preconditioning (RIPC) seems to be a promising cardioprotective strategy with contradictive clinical data suggesting the anesthetic regimen influencing the favorable impact of RIPC. This study aimed to investigate whether cardio protection by RIPC is abolished by anesthetic regimens. Male Wistar rats were randomized to 6 groups. Anesthesia was either maintained by pentobarbital (Pento) alone or a combination of sevoflurane (Sevo) and remifentanil or propofol (Prop) and remifentanil in combination with and without RIPC. RIPC reduced infarct size in Pento- and Sevo-anesthetized rats (Pento-RIPC: 30% ± 9% versus Pento-control [Con]: 65% ± 6%, P

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Healthcare Simulation Education: Evidence, Theory and Practice, 1st ed.

No abstract available

http://ift.tt/2iNF4zm

The Local, Global Perspective

No abstract available

http://ift.tt/2zkKTeB

A Left Ventricle to Left Atrial Appendage Fistula After Mitral Valve Replacement

No abstract available

http://ift.tt/2iMt3dz

Pressure Waveform Analysis

Monitoring cardiac output is of special interest for detecting early hemodynamic impairment and for guiding its treatment. Among the techniques that are available to monitor cardiac output, pressure waveform analysis estimates cardiac output from the shape of the arterial pressure curve. It is based on the general principle that the amplitude of the systolic part of the arterial curve is proportional to cardiac output and arterial compliance. Such an estimation of cardiac output has the advantage of being continuous and in real time. With "calibrated" devices, the initial estimation of cardiac output by pressure waveform analysis is calibrated by measurements of cardiac output made by transpulmonary thermal or lithium dilution. Later, at each time transpulmonary dilution is performed, the estimation by pressure waveform analysis, which may drift over time, is calibrated again. By contrast, uncalibrated devices do not use any independent measurement of cardiac output. Unlike calibrated devices, they can be plugged to any arterial catheter. Nevertheless, uncalibrated devices are not reliable in cases of significant short-term changes in arterial resistance, as for instance in patients undergoing liver surgery or those with vasodilatory shock receiving vasopressors. Perioperative hemodynamic monitoring is recommended for high-risk surgical patients since it reduces the number of complications in these patients. The pressure waveform analysis monitoring, especially with uncalibrated devices, is suitable for this purpose. In the intensive care setting, hemodynamic monitoring is recommended for patients with acute circulatory failure, who do not respond to initial therapy. Since these patients often experience large changes in arterial resistance, either spontaneously or due to vasoactive drugs, calibrated devices are more suitable in this context. Not only are they more reliable than uncalibrated devices but also they provide a comprehensive hemodynamic assessment through measurements of a variety of transpulmonary thermodilution-related variables. In this review, we summarize the characteristics of the monitoring devices using the pressure waveform analysis and discuss the appropriate use of different devices in the perioperative and intensive care unit settings. Accepted for publication August 30, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Jean-Louis Teboul, MD, PhD, Service de réanimation médicale, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, 78 rue du Général Leclerc, Le Kremlin-Bicêtre F-94270, France. Address e-mail to jean-louis.teboul@aphp.fr. © 2017 International Anesthesia Research Society

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Anaesthesia for the Elderly Patient, 2nd ed.

No abstract available

http://ift.tt/2iNbWZa

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial

BACKGROUND: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery. METHODS: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale. RESULTS: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15–60]; P = .007), followed by the HD group to the LD group (30 [15–45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [−15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0–60]; P = .034, 60 [0–93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15–60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0–0], LD: 0 [0–0], NE: 0 [0–3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups. CONCLUSIONS: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced. Accepted for publication August 30, 2017. Funding: Funding for this study was procured though the Icahn School of Medicine at Mount Sinai. Clinical Trial # (ClinicalTrials.gov): NCT02369510. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Daniel Katz, MD, Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, KCC 8th Floor Box 1010, New York, NY 10029. Address e-mail to Daniel.Katz@MountSinai.org. © 2017 International Anesthesia Research Society

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Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect

No abstract available

http://ift.tt/2iNJpCO

The pathogenesis of cutaneous squamous cell carcinoma in organ transplant recipients

Summary

The pathogenesis of keratinocyte carcinoma following organ transplantation is multifactorial, and recent evidence suggests a complex and often synergistic interplay between the carcinogenic effects of ultraviolet radiation, compromised immune surveillance, direct pro- and anticarcinogenic effects of drugs, oncogenic viruses (in particular, beta-genus human papillomaviruses) and host genetic susceptibility factors. We present an overview of those factors for which there is currently the most convincing evidence and highlight important gaps in our knowledge. In particular, a clear understanding of the interdependence and relative contributions of these co-factors is currently lacking, yet has important implications for rational development of clinically relevant biomarkers and targeted strategies for treatment and prevention of post-transplant keratinocyte cancers.

http://ift.tt/2z0OnAb

Research gaps in the management and prevention of cutaneous squamous cell carcinoma in organ transplant recipients

Summary

Although tremendous progress has been made in recent years in skin cancer care for organ transplant recipients, significant gaps remain in data-driven clinical guidelines, particularly for the treatment and prevention of cutaneous squamous cell carcinoma (cSCC), the most common malignancy among this population. In this review, we aim to summarize current knowledge around the management of cSCC and highlight the most significant gaps in knowledge that continue to pose challenges in the delivery of skin cancer care for organ transplant recipients. We suggest future directions for research that will bridge existing gaps and establish evidence-driven guidelines for primary prevention, screening and treatment of cSCC in this high-risk patient population.

http://ift.tt/2iMl549

Odontogenic sinusitis: developments in diagnosis, microbiology, and treatment.

Purpose of review: Odontogenic causes of sinusitis are frequently missed; clinicians often overlook odontogenic disease whenever examining individuals with symptomatic rhinosinusitis. Conventional treatments for chronic rhinosinusitis (CRS) will often fail in odontogenic sinusitis. There have been several recent developments in the understanding of mechanisms, diagnosis, and treatment of odontogenic sinusitis, and clinicians should be aware of these advances to best treat this patient population. Recent findings: The majority of odontogenic disease is caused by periodontitis and iatrogenesis. Notably, dental pain or dental hypersensitivity is very commonly absent in odontogenic sinusitis, and symptoms are very similar to those seen in CRS overall. Unilaterality of nasal obstruction and foul nasal drainage are most suggestive of odontogenic sinusitis, but computed tomography is the gold standard for diagnosis. Conventional panoramic radiographs are very poorly suited to rule out odontogenic sinusitis, and cannot be relied on to identify disease. There does not appear to be an optimal sequence of treatment for odontogenic sinusitis; the dental source should be addressed and ESS is frequently also necessary to alleviate symptoms. Summary: Odontogenic sinusitis has distinct pathophysiology, diagnostic considerations, microbiology, and treatment strategies whenever compared with chronic rhinosinusitis. Clinicians who can accurately identify odontogenic sources can increase efficacy of medical and surgical treatments and improve patient outcomes. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Delayed complications from expanded endonasal surgery for intracranial tumors.

Purpose of review: Delayed complications after endoscopic endonasal approaches to the skull base, defined as complications greater than 1 month postoperatively, are uncommon. These complications are divided into categories including sinonasal, neuroanatomic, endocrine and vascular. This review highlights the most up-to-date advancements and reviews the management of delayed complications for skull base patients. Recent findings: Over the last 10 years, the field of endoscopic endonasal skull base surgery has expanded with new data highlighting the long-term patient outcomes. The majority of patients experience increased quality of life (QOL) after these interventions. However, delayed complications including alterations to sinonasal function, delayed encephaloceles from the bony skull base defect and resulting endocrinopathies can significantly impact patient's QOL. Awareness of these complications and their current management is valuable for endoscopic surgeons. Summary: Endonasal approaches to the skull base are safe and well tolerated in properly selected patients. This article highlights the delayed complications that require recognition and management by skull base surgeons to ensure the best possible care for patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2zjQZw2

Review and update on postoperative opioid use after nasal and sinus surgery.

Purpose of review: We examine the current literature on pain management after sinus and nasal surgery. The goal after surgery is to provide effective pain management without having too many 'leftovers', as leftover medications are an important source of opioids that are fueling the current prescription narcotic epidemic in the United States. There are more than 250 000 sinus operations and 260 000 septoplasties performed annually, and surgeons commonly prescribe a narcotic pain medication for postoperative pain management. Recent findings: The literature suggests that an evidence-based approach may lead surgeons to prescribe significantly less narcotic pain medication for these procedures without affecting pain management. Summary: An evidence-based approach to pain management can result in unchanged pain control and a significant positive impact on the narcotic abuse epidemic. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2zlKQiA

Acute Hematogenous Osteomyelitis in a Five-Month-Old Male with Rickets

Osteomyelitis is defined as an infection of the bone, bone marrow, and the surrounding soft tissues. Most cases of acute hematogenous osteomyelitis in children are caused by Gram-positive bacteria, principally Staphylococcus aureus. We present a case where a 5-month-old male had an acute onset of decreased movement of his left leg and increased irritability and was subsequently diagnosed with rickets and hematogenous osteomyelitis with bacteremia. The case explores a possible association between hematogenous osteomyelitis and rickets.

http://ift.tt/2xCAF53

Ecthyma Gangrenosum in the Eyelid.

No abstract available

http://ift.tt/2gYSV5k

The Effect of Unilateral Concha Bullosa on Olfactory Bulb Volume: an Assessment by Magnetic Resonance Imaging.

Background: In this study, the authors compared the right and left olfactory bulb volumes by magnetic resonance image findings of patients with unilateral concha bullosa (CB). Methods: The cranial magnetic resonance imaging studies of 24 patients having unilateral CB were reviewed. There were 10 males and 14 females ranging in age from 29 to 51 years (mean age, 29 +/- 15.2 years). The volumes of both olfactory bulbs (contralateral and ipsilateral to the concha bullosa side) were calculated by using the computer program. Results: The average values for olfactory bulb volumes were 46.57 +/- 8.03 mm3 in the CB side of the nasal cavity and 54.80 +/- 10.031 mm3 in the normal side of the nasal cavity. We found a statistically significant difference in olfactory bulb volume between the contralateral and ipsilateral to the concha bullosa side of the patients (t = -3.08 and P

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Effect of Irrigation Time of Antiseptic Solutions on Bone Cell Viability and Growth Factor Release.

Antiseptic solutions are commonly utilized to treat local infection in the oral and maxillofacial region. However, surrounding vital bone is also exposed to antiseptic agents during irrigation and may have a potential negative impact on bone survival. The aim of the present study was therefore to investigate the effect of rinsing time with various antiseptic solutions on bone cell viability, as well as their subsequent release of growth factors important for bone regeneration. The bone samples collected from porcine mandible were rinsed in the following commonly utilized antiseptic solutions; povidone-iodine (0.5%), chlorhexidine digluconate (CHX, 0.2%), hydrogen peroxide (1%), and sodium hypochlorite (0.25%) for 1, 5, 10, 20, 30, or 60 minutes and assessed for cell viability and release of growth factors including vascular endothelial growth factor, transforming growth factor beta 1, bone morphogenetic protein 2, receptor activator of nuclear factor kappa-B ligand, and interleukin-1 beta by enzyme-linked immunosorbent assay. It was found in all the tested groups that the long exposure of any of the tested antiseptic solutions drastically promoted higher cell death. Sodium hypochlorite demonstrated the significantly highest cell death and at all time points. Interestingly, bone cell viability was highest in the CHX group post short-term rinsing of 1, 5, or 10 minutes when compared with the other 4 tested groups. A similar trend was also observed in subsequent growth factor release. The present study demonstrated that of the 4 tested antiseptic solutions, short-term CHX rinsing (ideally within 1 minute) favored bone cell viability and growth factor release. Clinical protocols should be adapted accordingly. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2gWVSUf

Maxillary Osteomyelitis Caused by Kocuria Species in a Patient Who Is on Long-Term Uncontrolled Use of Methylprednisolone.

Uncontrolled use of medicines bring with it serious health problems. Long-term and uncontrolled use of steroids, without the supervision of a healthcare professional, may cause unexpected infections due to immunosuppression. The authors present a patient with maxillary osteomyelitis caused by Kocuria species in a 41-year-old male who has been receiving methylprednisolone without control for 1.5 years. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2yZRAC8

Rhino Physiognomy: a Myth or Science?.

Face reading has been practised since time immemorial by different cultures. Different personality traits have been attributed to different characters of face. It is argued that everyone uses face reading in their daily life when they choose one person to another. One would not prefer to sit beside a tidy, handsome, well-dressed man if he had narrow mean eyes. People tend to artificially change the features of their face to gain acceptance in interviews. Most of these preferences are arbitrary and are born out of the authors' preconceived cultural and social influences. But is there a science behind these observations. The proponents of face reading argue that this is based on clearly stated rules and observation. Nose is an important part of the face. According to face reading the shape and size of nose determines the aggressiveness of the person. The present study tries to scientifically test this statement. (C) 2017 by Mutaz B. Habal, MD.

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Comparison of Postoperative Outcomes Between Monitored Anesthesia Care and General Anesthesia in Closed Reduction of Nasal Fracture.

Fracture of nasal bone is among the most common facial bone fractures. Reduction of nasal bone fracture is able to be performed under local or general anesthesia. The aim of this study is to compare monitored anesthetic care (MAC) and general anesthesia (GA) based on intraoperative vital signs, and the adverse effects after closed reduction of nasal bone fractures. The authors performed a retrospective study of 45 patients who underwent a closed reduction of nasal bone fracture between January 1, 2016 and December 31, 2016. Patients are divided into an MAC group (n = 17) or GA group (n = 28). A sore throat, postoperative pain scores, nausea, vomiting, hospital stay, operation time, and the result of surgery are compared between the groups. All the patients have interviewed their satisfaction of aesthetic and functional outcome. The operation time and hospital stay were lower in the MAC group. There is no difference in a sore throat, postoperative pain score, and the result of surgery significantly. In the MAC and GA groups, there was no statistically significant difference in the postoperative cosmetic and functional satisfaction scores. Closed reduction of nasal bone fracture using MAC is as safe and efficient as GA. However, MAC anesthesia may not be feasible if airway discomfort due to bleeding is expected, or fracture is severe and multiple manipulations are required. Therefore, MAC is considered to be a good alternative when patients undergoing short-term or small operations do not prefer general anesthesia. (C) 2017 by Mutaz B. Habal, MD.

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Perioperative Blood Loss and Transfusion in Craniosynostosis Surgery.

Craniosynostosis has an incidence of 1 in 2000 to 2500 live births and may be corrected through several methods including total calvarial remodeling and frontal orbital advancement remodeling. Blood loss during craniosynostosis surgery can be substantial, ranging from 20% to 500% of total circulating volume with a high associated risk of transfusion-related adverse events. The authors performed a retrospective analysis of all patients undergoing surgery for craniosynostosis at a tertiary pediatric craniofacial center with a focus on blood loss and subsequent transfusion. The authors reviewed 40 patients with craniosynostosis >16 years at a single-center. Data on perioperative blood loss and transfusion were obtained, including pre-, intra-, and postoperative hemoglobin, hematocrit, and use of tranexamic acid. The authors calculated estimated percentage of circulating red cell volume lost and transfused. The majority of patients had sagittal synostosis and underwent total calvarial remodeling (n = 20); the rest underwent frontal orbital advancement remodeling (n = 19) or lambdoid correction (n = 1). The average estimated volume red cell loss was 77% of circulating volume and 90% of patients received blood transfusion with an average 88.3% transfusion of circulating red cell volume. Longer operative time, younger age, and lower weight predisposed to >50% blood volume transfusion (P = 0.032, 50% blood volume transfusion. (C) 2017 by Mutaz B. Habal, MD.

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Role of Swallowing Function of Tracheotomised Patients in Major Head and Neck Cancer Surgery.

Introduction: Tracheotomy is a frequent procedure in extended head and neck cancer surgery and known to be a risk factor for prolonged hospitalization. The authors hypothesized that the clinical course and delayed decannulation of patients are not only influenced by airway narrowing, but also by a compromised postoperative swallowing function. Material and Methods: The investigators implemented a retrospective cohort study. The sample was composed of a tertiary care center patients who underwent major head and neck cancer surgery, each receiving a tracheostomy. Data collected include general clinical data as well as endoscopical evaluation of swallowing function and aspiration rate. Descriptive and bivariate statistics were computed and the P value was set at.05. Results: The sample was composed of 96 patients with an average age of 64.2 and sex ratio of 1.4:1 (m:f). There was a strong statistically significant relation between swallowing function and timing of decannulation (P

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A Review of Randomized Controlled Trials in Cleft and Craniofacial Surgery.

This study presents a systematic review of randomized controlled trials (RCTs) in cleft and craniofacial surgery. All studies reporting on RCTs in cleft and craniofacial surgery were identified on PubMed using the search terms "cleft," "velopharyngeal insufficiency," "velopharyngeal dysfunction," "nasoalveolar molding," "gingivoperiosteoplasty," "Pierre Robin sequence," "craniofacial," "craniosynostosis," "craniofacial microsomia," "hemifacial microsomia," "hypertelorism," "Le Fort," "monobloc," "distraction osteogenesis," "Treacher Collins," and "Goldenhar." Studies were excluded if they were not randomized, did not focus primarily on topics related to cleft or craniofacial surgery, included repeat publications of data, or were unavailable in English. Studies were evaluated on demographic and bibliometric data, study size, specific area of focus, and findings reported. Four hundred forty-seven unique studies were identified. One hundred eighty-three papers met inclusion criteria (115 cleft lip and palate, 65 craniofacial, and 3 spanning both disciplines). Sixty-six (36%) were dedicated to topics related to surgical techniques. There were no studies comparing current cleft lip or soft palate repair techniques and no studies on cleft rhinoplasty. The most frequently reported surgical topic was cleft palate. There were several studies on orthognathic techniques which compared distraction osteogenesis to traditional advancement. Most craniofacial operations, such as cranial vault remodeling and frontofacial advancement/distraction, were not represented. Several standard operations in cleft and craniofacial surgery are not supported by Level I evidence from randomized controlled trials. Our community should consider methods by which more RCTs can be performed, or redefine the acceptable standards of evidence to guide our clinical decisions. (C) 2017 by Mutaz B. Habal, MD.

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Revisiting the Skin Lines on the Forehead and Glabellar Area.

This paper attempted to revisit the skin lines in forehead and glabellar area. Using PubMed, Scopus, and Google, papers describing skin tension lines of face were searched. Papers with illustrations or pictures of the facial lines were selected and reviewed. The studies of the skin lines in the forehead and glabellar area were analyzed. Langer used the term "cleavage of the cutis, anatomical lines." Over the forehead, he found a border zone of horizontal folds that were interrupted many times by the ascending folds coming from the flabella area. Cox used the terms "cleavage lines of the skin" and "lines of increased tension." In the glabellar area, cleavage lines were vertical and extended to the forehead. Rubin used the term "skin line." In the midline area over the nose, the skin wrinkled vertically. Kraissl used the term "normal wrinkle line." Above the nose, "curving vertical lines" were observed. Straith et al used the terms "normal tension line," and "Langer line." In the glabellar area, the horizontal lines from the upper eyelids became "curved vertically" until meeting the supra-brow horizontal line. Borges used the term "relaxed skin tension line." At the medial end of the eyebrow, his relaxed skin tension line ran obliquely upward and medially, to meet the contralateral line. Namikawa et al used the term "cleavage lines of the skin." It ran mediosuperiorly to inferolaterally, bordering the linea mediana anterior in glabellar area. Following the consensus of most authors, a curved vertical line following the glabellar frown is recommended for incisions for flaps or grafts. (C) 2017 by Mutaz B. Habal, MD.

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Vascular Precautions Before Sinus Lift Procedure.

The aim of the study was to evaluate the benefit of cone beam computed tomography (CBCT) and how to minimize injury to the posterior superior alveolar artery (PSAA) before sinus lift procedure. Cone beam computed tomography scans of 30 maxillary sinuses (15 patients) assessed to determine the location of PSAA presinus lift procedure. The data collected were used to extend the existed literature. The most common location of the PSAA was intraosseous (66.7%), the subantral distance mean was 5 +/- 1 mm, and the mean distance of PSAA from the crest was 15 +/- 1.6 mm. Cone beam computed tomography is valuable before the sinus lift procedure to exclude the presence of any lesion and to detect the location of the PSAA. The study recommends not to extend the upper border of the window beyond 16 mm from the residual crest during the lateral sinus approach. (C) 2017 by Mutaz B. Habal, MD.

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Acute myocardial infarction associated with thrombotic microangiopathy following a hump-nosed viper bite: a case report

Hump-nosed viper bite is the commonest cause of venomous snakebite in Sri Lanka. Despite initially being considered a moderately venomous snake more recent reports have revealed that it could cause significant...

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Inscope Medical Solutions launches laryngoscope with integrated suction

By EMS1 Staff Inscope Medical Solutions recently launched a laryngoscope with integrated, controllable suction. The Inscope Direct is a disposable laryngoscope that gives clinicians a clear view of the airway. The device features a built-in LED light source and an anti-clog design with two controllable suction inlets. It connects to standard suction tubing and is compatible with wall suction and powered ...

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Effect of remifentanil during cardiopulmonary bypass on incidence of acute kidney injury after cardiac surgery

Abstract

Background

Acute kidney injury (AKI) after cardiopulmonary bypass (CPB) is a well-known postoperative complication. Remifentanil, which is a commonly used ultra-short-acting opioid, has antiinflammatory and sympatholytic effects with improvement of microcirculation.

Methods

A retrospective study was conducted to clarify the effect of the use of remifentanil during CPB on the incidence of postoperative AKI. Patients who underwent valve surgery while under cardiopulmonary bypass between January 2012 and December 2014 in our hospital were enrolled in this study. The incidences of postoperative AKI were compared in patients who received remifentanil during CPB (group R) and those who did not (group N). Univariate and multivariate regression analyses were performed to determine risk factors for AKI.

Results

Eighty patients received remifentanil (group R) and 50 patients did not (group N). The incidences of AKI were not significantly different in group R and group N (51% vs. 36%, P = 0.10). In multivariate regression analysis, age [adjusted odds ratio (OR) 1.048, 95% CI 1.008–1.089, P = 0.017], male gender (adjusted OR 3.101, 95% CI 1.303–7.378, P = 0.011), and use of preoperative calcium channel blockers (adjusted OR 3.240, 95% CI 1.302–8.063, P = 0.011) and diuretics (adjusted OR 2.673, 95% CI 1.178–6.066, P = 0.019) were associated with the incidence of AKI. The use of remifentanil was not associated with AKI (adjusted OR 2.321, 95% CI 0.997–5.402, P = 0.051).

Conclusion

The use of remifentanil during CPB did not decrease the incidence of postoperative AKI after cardiac surgery.

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Orbitadekompression

Zusammenfassung

Die Orbitadekompression ist ein wirksamer Eingriff zur Senkung des intraorbitalen Drucks. Ursächlich können Erkrankungen mit schneller Druckerhöhung sein, z. B. Einblutungen, und solche mit langsamer Drucksteigerung, z. B. Tumoren oder endokrine Orbitopathie. Bei der reinen Fettgewebsdekompression wird peri- und retrobulbäres Fettgewebe aus der Orbita entnommen, bei der knöchernen Dekompression werden knöcherne Wandungen entfernt (1-Wand, 2‑Wand oder 3‑Wand-Dekompression). Häufig werden beide Verfahren miteinander kombiniert. Neuere Entwicklungen sind die transkonjunktivalen Zugangswege, über die ebenfalls Teile der knöchernen Wände reseziert werden können. Komplikationen sind Doppelbilder, die je nach Op.-Methode in bis zu 30 % der Fälle auftreten können, sowie Blutungen, Infektionen, Entwicklung einer chronischen Sinusitis und Läsionen der Dura mit konsekutiver Meningitis. In der Hand des erfahrenen Nasennebenhöhlen- und Kopf-Hals-Chirurgen ist der Eingriff komplikationsarm.

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Evaluating Multipulse Integration as a Neural-Health Correlate in Human Cochlear Implant Users: Effects of Stimulation Mode

Abstract

Previous psychophysical studies have shown that a steep detection-threshold-versus-stimulation-rate function (multipulse integration; MPI) is associated with laterally positioned electrodes producing a broad neural excitation pattern. These findings are consistent with steep MPI depending on either a certain width of neural excitation allowing a large population of neurons operating at a low point on their dynamic range to respond to an increase in stimulation rate or a certain slope of excitation pattern that allows recruitment of neurons at the excitation periphery. Results of the current study provide additional support for these mechanisms by demonstrating significantly flattened MPI functions in narrow bipolar than monopolar stimulation. The study further examined the relationship between the steepness of the psychometric functions for detection (d' versus log current level) and MPI. In contrast to findings in monopolar stimulation, current data measured in bipolar stimulation suggest that steepness of the psychometric functions explained a moderate amount of the across-site variance in MPI. Steepness of the psychometric functions, however, cannot explain why MPI flattened in bipolar stimulation, since slopes of the psychometric functions were comparable in the two stimulation modes. Lastly, our results show that across-site mean MPI measured in monopolar and bipolar stimulation correlated with speech recognition in opposite signs, with steeper monopolar MPI being associated with poorer performance but steeper bipolar MPI being associated with better performance. If steeper MPI requires broad stimulation of the cochlea, the correlation between monopolar MPI and speech recognition can be interpreted as the detrimental effect of poor spectral resolution on speech recognition. Assuming bipolar stimulation produces narrow excitation, and MPI measured in bipolar stimulation reflects primarily responses of the on-site neurons, the correlation between bipolar MPI and speech recognition can be understood in light of the importance of neural survival for speech recognition.

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Lesão por arma de fogo-paralisia facial

Lesão por arma de fogo-paralisia facial

http://ift.tt/2gPHlpF

Evaluating Multipulse Integration as a Neural-Health Correlate in Human Cochlear Implant Users: Effects of Stimulation Mode

Abstract

Previous psychophysical studies have shown that a steep detection-threshold-versus-stimulation-rate function (multipulse integration; MPI) is associated with laterally positioned electrodes producing a broad neural excitation pattern. These findings are consistent with steep MPI depending on either a certain width of neural excitation allowing a large population of neurons operating at a low point on their dynamic range to respond to an increase in stimulation rate or a certain slope of excitation pattern that allows recruitment of neurons at the excitation periphery. Results of the current study provide additional support for these mechanisms by demonstrating significantly flattened MPI functions in narrow bipolar than monopolar stimulation. The study further examined the relationship between the steepness of the psychometric functions for detection (d' versus log current level) and MPI. In contrast to findings in monopolar stimulation, current data measured in bipolar stimulation suggest that steepness of the psychometric functions explained a moderate amount of the across-site variance in MPI. Steepness of the psychometric functions, however, cannot explain why MPI flattened in bipolar stimulation, since slopes of the psychometric functions were comparable in the two stimulation modes. Lastly, our results show that across-site mean MPI measured in monopolar and bipolar stimulation correlated with speech recognition in opposite signs, with steeper monopolar MPI being associated with poorer performance but steeper bipolar MPI being associated with better performance. If steeper MPI requires broad stimulation of the cochlea, the correlation between monopolar MPI and speech recognition can be interpreted as the detrimental effect of poor spectral resolution on speech recognition. Assuming bipolar stimulation produces narrow excitation, and MPI measured in bipolar stimulation reflects primarily responses of the on-site neurons, the correlation between bipolar MPI and speech recognition can be understood in light of the importance of neural survival for speech recognition.

http://ift.tt/2yXnOLZ

Shaping the nasal dorsum

Abstract

Shaping a proper dorsum must constitute an essential part of rhinoplasty. This article addresses the main current concepts that play a significant role in dorsal modifications: proper exposure at the keystone, component separation and incremental reduction, straightening the septum and positioning it in the midline, mobilizing and reshaping the nasal bones by osteotomies and osteoplasties, and finally reconstituting a barrel vault of appropriate width and proper contour. The importance of power tools and piezoelectric instrumentation is highlighted, as well as the relevance of simulation and computed tomography (CT) imaging as key to bone and septal work. Finally, the key principles of rebuilding the dorsum in revision rhinoplasty are detailed.

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Disseminierte rotbräunliche Papeln bei einem jungen Mann

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Dexamethasone attenuates methacholine-mediated aquaporin 5 downregulation in human nasal epithelial cells via suppression of NF-κB activation

Background

Cholinergic stimulation plays a major role in inflammatory airway diseases. However, its role in airway surface liquid homeostasis and aquaporin 5 (AQP5) regulation remains unclear. In this study we sought to determine the effects of methacholine and dexamethasone on AQP5 expression in human nasal epithelial cells (HNEpC).

Methods

HNEpC were cultured with methacholine or dexamethasone at 4 concentrations in vitro. The subcellular distribution of AQP5 was explored using immunocytochemistry. The pharmacologic effects of methacholine and dexamethasone on the expression of the phosphorylation of cyclic adenosine monophosphate–responsive element binding protein (p-CREB), AQP5, and nuclear factor-kappaB (NF-κB) were examined using Western blotting.

Results

AQP5 was found to be located in cell membrane and cytoplasm and present in every group without a statistically significant difference. Methacholine inhibited expression of AQP5 and p-CREB in HNEpC, whereas dexamethasone increased these protein levels dose-dependently in a statistically significant manner. In turn, HNEpC treated with methacholine and dexamethasone showed the same trends as those intervened separately with these 2 drugs. Moreover, dexamethasone had the ability to reverse the inhibitory effect of methacholine. Western blotting revealed that, after incubation with 10⁻⁴ mol/L methacholine, NF-κB increased significantly, by 186.67%, compared with the untreated control group. Again, such an increase could be significantly reversed after dexamethasone treatment.

Conclusion

NF-κB activation is important for inhibition of p-CREB/AQP5 expression after methacholine intervention, and dexamethasone adjusts it to the opposite side. This observation could provide additional insight into the anti-inflammatory effects of glucocorticoids that contribute to maintaining airway surface liquid and mucosal defense.

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Evaluation of patient nasal saline irrigation practices following endoscopic sinus surgery

Background

Functional endoscopic sinus surgery (FESS) is an effective treatment for chronic rhinosinusitis (CRS). Postoperative management strategies after FESS often vary from surgeon to surgeon. Recent data suggests that nasal saline irrigation following FESS is almost universally recommended; however, patient adherence has not been formally evaluated. The purpose of this study is to evaluate postoperative nasal irrigation practices and its effects on short-term outcomes in post-FESS patients.

Methods

Eighty-two patients were followed prospectively following FESS at a tertiary-academic medical institution for 3 postoperative visits. Patients were surveyed on their irrigation practices (start date, frequency, and volume per irrigation per side), and adherence to prescribed antibiotic and steroid regimens. At each visit, 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaires and endoscopic examinations were evaluated by the Lund-Kennedy Endoscopy Score (LKES). Factors evaluated include: patient demographics (age, sex, ethnicity), preoperative Lund-Mackay and SNOT-22 scores, comorbidities, extent of procedure, and use of nasal packing and/or spacers.

Results

Adherence to irrigation instructions was 82.9%. Factors significantly associated with compliance with irrigation instructions included younger age (p = 0.0022), prior irrigation (p < 0.0001), revision surgery (p = 0.0014), and non-native English language speaking (p = 0.0095). Patients were more likely to irrigate with larger volumes if they were younger (p = 0.0284), had prior irrigation (p < 0.0001), or had revision surgery (p = 0.0056).

Conclusion

Multiple factors are associated with patient compliance with nasal saline irrigation after FESS. Ethnic and cultural considerations, such as language barriers, should also be considered to improve outcomes. Identification of patients who may be noncompliant could potentially benefit from increased preoperative counseling to improve adherence rates.

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Efficacy of nasal irrigation with 200 μg/mL amphotericin B after functional endoscopic sinus surgery: a randomized, placebo-controlled, double-blind study

Background

Previous studies have shown controversial results of topical amphotericin B (AMB) nasal irrigation for chronic rhinosinusitis (CRS). The purpose of this study was to evaluate the efficacy of 200 μg/mL AMB nasal irrigation as an adjuvant therapy after functional endoscopic sinus surgery (FESS).

Methods

Patients with CRS who had received FESS for treatment were recruited and assigned to 1 of 2 groups at random at 1 month postsurgery. In the AMB group patients received nasal irrigation with 200 μg/mL of AMB for 2 months on a daily basis. In the control group normal saline irrigation was given instead. Before FESS and before and after nasal irrigation, patients' sinonasal symptoms were assessed through a questionnaire that was a Taiwanese version of the 22-item Sino-Nasal Outcome Test (TWSNOT-22). In addition, patients received endoscopic examination, acoustic rhinometry, smell test, saccharine transit test, and bacterial cultures obtained from their middle meati.

Results

A total of 73 patients completed the study between December 2014 and January 2017. Among them, 37 received nasal irrigation with AMB solution, and 36 with saline. In the AMB group, scores of TWSNOT-22 dropped significantly after irrigation compared with before (p = 0.005). In the control group, TWSNOT-22 scores did not changed after irrigation (p = 0.451). However, there were no significant differences in TWSNOT-22, endoscopic score, smell test, saccharine transit test, and bacterial culture rate after irrigation between 2 groups.

Conclusion

Our study showed that in post-FESS care, nasal irrigation with 200 μg/mL of AMB did not provide additional benefit compared with saline irrigation.

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The clinical response to omalizumab in CSU patients is linked to and predicted by IgE levels and their change

Abstract

Background

Omalizumab is an effective and well-tolerated treatment for chronic spontaneous urticaria (CSU). Markers and predictors of response are largely unknown, but needed to optimize omalizumab treatment. Omalizumab targets IgE, and IgE levels may be linked to the effects of treatment. We evaluated if response rates to treatment with omalizumab in patients with CSU are linked to their baseline IgE levels, their IgE levels after omalizumab treatment, and the ratio of on treatment IgE and baseline IgE levels.

Methods

CSU patients (n=113) were treated with omalizumab 300 mg/4 weeks for 12 weeks, when their treatment responses, i.e. no, partial, or complete response, were assessed by use of the urticaria activity score, physician and patient visual analog scale, and treatment effectiveness score. Total IgE levels were measured before treatment (bIgE) with omalizumab and 4 weeks thereafter (w4IgE).

Results

Non-responders to omalizumab had significantly lower bIgE levels (17.9IU/ml, 17.0-55.0IU/ml) than partial responders (82.0IU/ml, 46.2-126.5IU/ml, p=0.008) and complete responders (73.7IU/ml, 19.45-153.8IU/ml, p=0.032). Non-responders also had lower w4IgE levels and lower ratios of w4IgE/bIgE levels than partial and complete responders (p<0.001). Non-response to omalizumab was best predicted by patients' w4IgE/bIgE ratios, significantly better than by bIgE levels (p=0.016).

Conclusions

In CSU, total IgE levels and their change predict the response to treatment with omalizumab. The assessment of pre- and post-treatment IgE levels and their ratio may help to improve the management of CSU in patients who require omalizumab treatment.

This article is protected by copyright. All rights reserved.

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Neoadjuvant Pembrolizumab + Epacadostat Prior to Curative Surgical Care for Squamous Cell Carcinoma of the Head and Neck

Condition:   Squamous Cell Carcinoma of the Head and Neck
Interventions:   Drug: Pembrolizumab;   Drug: Epacadostat
Sponsor:   University of Chicago
Not yet recruiting

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Serum Immunological Profiles in Head and Neck Cancer Patients Receiving Curative Radiotherapy

Condition:   Head and Neck Cancers Patients
Intervention:   Diagnostic Test: Serum levels of immunologic profiles
Sponsor:   National Taiwan University Hospital
Recruiting

http://ift.tt/2zSmf11

Soforttypreaktionen auf Protonenpumpeninhibitoren am Beispiel von Pantoprazol und Omeprazol

Zusammenfassung

Protonenpumpeninhibitoren (PPIs) gehören zu den am häufigsten eingenommenen Medikamenten weltweit. Allergien auf diese Substanzgruppe sind selten, können aber zu schweren Soforttypreaktionen führen. Insbesondere treten auch Kreuzreaktionen zwischen den verschiedenen PPIs auf. In dieser Fallserie werden 4 Patienten mit Soforttypreaktionen auf die Protonenpumpenhemmer Pantoprazol und/oder Omeprazol beschrieben.

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Alopecia areata is characterized by expansion of circulating Th2/Tc2/Th22, within the skin-homing and systemic T-cell populations

Abstract

Background

Characterizing blood profile of alopecia areata (AA) is not only important for treatment advancements, but also for possibly identifying peripheral biomarkers that will eliminate the need for scalp biopsies. We aimed to compare frequencies of skin homing (CLA⁺) vs. systemic (CLA^-) "polar" CD4⁺ and CD8⁺ and activated T-cell subsets in AA vs. AD and control blood.

Methods

Flow cytometry was used to measure IFN-γ, IL-13, IL-9, IL-17, and IL-22 cytokines in CD4⁺ and CD8⁺ T-cells. ICOS and HLA-DR were used to define mid and long term T-cell activation. We compared peripheral blood from 32 moderate-to-severe AA adults with 43 moderate-to-severe AD patients and 30 age-matched controls.

Results

AA patients had increased CLA⁺/CLA^- Th2 (P<0.007), CLA⁺ Tc2 (P=0.04) and CLA⁺ Th22 (P<0.05) frequencies than controls. Except of CLA^- Tc1 cells (P=0.03), IFN-γ levels were mostly similar between AA, AD and controls (P>0.1). ICOS and HLA-DR activation were significantly higher in AA than controls (P<0.05). T regulatory cells were significantly decreased in AA patients than controls (P<0.01) and were correlated with activated CD8⁺ T-cells and with multiple cytokine subsets (P<0.05). While Th2 and Tc2 clustered with disease severity, IFN-γ producing cells were linked with AA duration.

Conclusions

AA is accompanied by Th2/Tc2 activation in skin homing and systemic subsets, correlating with disease severity, while IFN-γ is linked to disease chronicity. These data hint for a possible role of diverse T-cells subsets in disease pathogenesis, and emphasize the systemic nature of AA supporting the need for systemic therapeutic strategies in severe patients.

This article is protected by copyright. All rights reserved.

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Pigeon tick bite: a neglected cause of idiopathic nocturnal anaphylaxis

Abstract

Anaphylaxis is a serious systemic allergic reaction with rapid onset and potentially life-threatening. We report in detail a case of severe nocturnal anaphylaxis due to pigeon tick bite showing the diagnostic value of the extract and the recombinant allergen in the diagnostic procedures (basophil activation test, IgE-immunoblot and experimental ImmunoCAP). Apart from the presented case we describe that, during the last 10 years, we have collected 28 cases of allergy to Argas reflexus from several European countries. We suspect that this allergy is underdiagnosed because of the lack of diagnostic reagents. Because of the growing number of pigeons in Middle and Southern Europe cities, some cases of idiopathic anaphylaxis could potentially be caused by Argas reflexus in those countries. The identification of pigeon ticks as a trigger of anaphylaxis would greatly improve medical care and advice for these patients as the parasite can be exterminated by eradication measures in order to avoid further incidents.

This article is protected by copyright. All rights reserved.

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Intranasal administration of allergen increases specific IgE whereas intranasal Omalizumab does not increase serum IgE levels – a pilot study

Abstract

Background

Administration of the therapeutic anti-IgE antibody omalizumab to patients induces strong increases of IgE antibody levels.

Objective

To investigate the effect of intranasal administration of major birch pollen allergen Bet v 1, omalizumab or placebo on the levels of total and allergen-specific IgE in patients with birch pollen allergy.

Methods

Based on the fact that intranasal allergen application induces rises of systemic allergen-specific IgE we performed a double-blind placebo-controlled pilot trial in which birch pollen allergic subjects were challenged intranasally with omalizumab, placebo or birch pollen allergen Bet v 1. Total and allergen-specific IgE, IgG and basophil sensitivity were measured before and 8 weeks after challenge. For control purposes, total, allergen-specific IgE levels and omalizumab-IgE complexes as well as specific IgG levels were studied in subjects treated subcutaneously with either omalizumab or placebo. Effects of omalizumab on IgE production by IL-4/anti-CD40-treated PBMCs from allergic patients were studied in vitro.

Results

Intranasal challenge with Bet v 1 induced increases of Bet v 1-specific IgE levels by a median of 59.2% and this change differed significantly from the other treatment groups (p=0.016). No relevant change of allergen-specific and total IgE levels were observed in subjects challenged with omalizumab. Addition of omalizumab did not enhance IL-4/anti-CD40-induced IgE production in vitro. Significant rises in total IgE (mean IgE before: 131.83 kU/L to mean IgE after: 505.23 kU/L) and the presence of IgE-omalizumab complexes were observed after subcutaneous administration of omalizumab.

Conclusion

Intranasal administration of allergen induced rises of allergen-specific IgE levels whereas intranasal administration of omalizumab did not enhance systemic total or allergen-specific IgE levels.

This article is protected by copyright. All rights reserved.

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Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis

Abstract

Background

Optimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown.

Methods

A systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases.

Results

Of the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17).

Conclusion

Less than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.

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Stage II recurrent nasopharyngeal carcinoma: Prognostic significance of retropharyngeal nodal metastasis, parapharyngeal invasion, and carotid encasement

Abstract

Background

The purpose of this study was to assess the predictability of the American Joint Committee on Cancer (AJCC) staging system on patients with stage II recurrent nasopharyngeal carcinoma (NPC).

Method

We conducted a retrospective review of the surgical outcome for patients with recurrent NPC and retropharyngeal lymph node (RLN) metastasis (group I), recurrent NPC and parapharyngeal space (PPS) invasion (group II), and recurrent NPC and internal carotid artery (ICA) encasement (group III).

Results

Between 1990 and 2013, 145 patients received an operation for stage II recurrent NPC (group I, n = 62; group II, n = 65; and group III, n = 18). The rate of local tumor recurrence was significantly higher in groups II and III. The rate of systemic metastasis was significantly higher in group III (16.7%). Accordingly, the 5-year overall survival was significantly worse for patients in group III (group I: 81.2%; group II: 68.4%; and group III: 48.5%).

Conclusion

The significantly worse prognosis of recurrent NPC encasing the ICA warrants an upstage to the T3 classification in the current AJCC staging system.

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Efficacy of postoperative neck irradiation for regional control in patients with pN0 oral tongue cancer: Propensity analysis

Abstract

Background

The purpose of this study was to investigate whether adjuvant radiotherapy (RT) is efficacious for regional control and survival in patients with pN0 oral tongue cancer.

Methods

Clinicopathological features of 166 patients with pN0 oral tongue cancer were compared between those who underwent adjuvant RT to the neck (neck RT-positive) and those who did not (neck RT-negative). Study endpoints were isolated regional recurrence and 3-year regional recurrence-free survival (RRFS). Propensity score matching was also performed.

Results

Cox regression analysis did not reveal any significant predictor of isolated regional recurrence, including RT field. Three-year RRFS showed modest improvement in neck RT-positive group compared to neck RT-negative group before (92.2% vs 91.9%) and after propensity analysis (93.8% vs 83.3%), without statistical significance (log-rank P = .85 and .37, respectively).

Conclusion

Despite more frequent unfavorable factors, the neck RT-positive group had a comparable oncologic outcome to the neck RT-negative group, suggesting that a marginal benefit in regional control might be expected from extending the RT field to the neck for pN0 oral tongue cancer.

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Submandibular gland cancer: Specific features and treatment considerations

Abstract

Background

In the absence of unified treatment protocol, we evaluated the management and outcomes of submandibular gland cancers in an unselected patient series.

Methods

We included all patients with resected submandibular gland cancer treated at the Helsinki University Hospital from 2000 to 2010 with a 5-year minimum follow-up.

Results

Twenty-five patients with cancer represented 30% of submandibular gland neoplasms, and most were adenoid cystic carcinomas (ACCs; 56%). At presentation, 3 patients showed clinical signs of probable malignancy. Of 22 neck dissection specimens, 5 patients (20%) had metastases with an occult metastasis rate of 4%. Cancer recurred in 11 patients (44%), of which 7 (28%) were only at a distant site. The 5-year disease-specific survival (DSS) and overall survival (OS) rates were 76%, and disease-free survival (DFS) was 68%.

Conclusion

Most tumors were ACCs differing from the histological pattern of parotid gland cancers. Occult metastases were rare. The rarity of submandibular gland cancer, its variable histological pattern, and varying biological behavior warrant centralized management.

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Swallowing outcomes after cricopharyngeal myotomy: A systematic review

Abstract

Background

No practice guidelines have been established for swallowing outcomes after cricopharyngeal myotomy (CPM). The purpose of this systematic review was to summarize evidence for swallowing outcomes in patients undergoing CPM to treat symptomatic cricopharyngeal dysfunction, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol.

Methods

Swallowing outcomes examined included penetration/aspiration ratings, manometric measures, patient-rated dysphagia scales, clinician-rated dysphagia scales, diet level, and weight.

Results

Three databases were queried for studies published between January 1995 and July 2015, resulting in a total of 122 full-text eligible records. Studies were screened and reviewed, culminating in 10 studies meeting inclusion criteria. Critical appraisal of study design, swallowing outcomes measures, and statistical analysis were summarized.

Conclusion

This systematic review revealed insufficient evidence for guiding clinical practice. Future investigations should use validated patient-rated and clinician-rated instruments as well as detailed high-resolution manometry measures to optimally capture postoperative swallowing outcomes.

http://ift.tt/2A0nex4

Complications and donor site morbidity of 3-layer reconstruction with iliotibial tract of the anterior skull base: Retrospective analysis of 186 patients

Abstract

Background

Anterior skull base reconstruction after resection of sinonasal cancers may be challenging when pedicled flaps are unavailable. The purpose of the present study was to analyze the complication rate and donor site morbidity of 3-layer reconstruction with the iliotibial tract (ITT).

Methods

We retrospectively reviewed all anterior skull base reconstructions with ITT performed from 2007 to 2015. Donor site morbidity was investigated by a dedicated questionnaire. Factors impacting on cerebrospinal fluid (CSF) leak were assessed using the Fisher's exact test.

Results

One hundred eighty-six patients were included. The overall complication rate was 9.7%. A CSF leak occurred in 11 patients (5.8%). Twenty patients (10.8%) and 130 patients (69.9%) underwent previous or adjuvant radiotherapy, respectively. Neither radio(chemo)therapy nor age impacted the risk of CSF leak. Six patients (3.2%) experienced complications at the donor site. The questionnaire demonstrated minimal functional and aesthetic morbidity.

Conclusion

Three-layer reconstruction with the ITT is a safe procedure with acceptable complication rate and donor site morbidity.

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42 Annual Congress of AOMSI Nagpur 16–18 Nov 2017

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DDA-zertifizierter Kurs für Tropen- und Reisedermatologie und „International Conference for Tropical and Clinical Dermatology“

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Panorama Dermatologische Praxis

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Rötliche Läsion am Stamm

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Oridonin induces apoptosis in human oral cancer cells via phosphorylation of histone H2AX

Oridonin, a natural diterpenoid purified from Rabdosia rubescens, has displayed beneficial biological activities, including anti-proliferation and anti-angiogenesis effects, in various types of cancers. However, the anti-cancer potential of oridonin and its mechanism in oral cancer have never previously been studied. In this study, we assessed the role of oridonin as an inducer of apoptosis in HSC-3 and HSC-4 human oral cancer cells. Our results showed that oridonin reduces the viability of human oral cancer cells and significantly increases the expression of γH2AX, a well-known marker of DNA damage. 4′,6-Diamidino-2-phenylindole (DAPI) staining and western blotting showed that oridonin causes nuclear condensation and fragmentation, and induces cleavage of poly(ADP-ribose) polymerase (PARP). Moreover, oridonin-induced γH2AX accumulation was partially abrogated by Z-VAD, a pan-caspase inhibitor. Taken together, our results suggest that oridonin can effectively induce apoptosis by augmenting the expression of γH2AX in response to DNA damage and might be a promising anti-cancer drug candidate for the treatment of oral cancer.

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Dental hygienist attendance and its covariates in an ageing Swedish cohort

Delegation of tasks between professional groups is important to make health-care services accessible and effective for ageing people. Focussing on a Swedish 1942 birth cohort and guided by Andersen's Behavioral Model, this study assessed dental hygienist attendance from age 50 to age 70 and identified covariates at the population-averaged and person-specific levels. In 1992, a census of 50-yr-old subjects was invited to participate in a questionnaire survey. Of the 6,346 respondents, 3,585 completed follow-ups in 1997, 2002, 2007, and 2012. Multiple logistic regression analysis was conducted using a marginal model and a random intercept model. Cochran's Q test revealed that significantly more respondents confirmed dental hygienist attendance in 2012 than in 1992 (57.2% in 2012 vs. 26.0% in 1992). Population-averaged ORs for dental hygienist attendance across time were 3.5 at age 70 yr compared with age 50 yr (baseline); 2.0 if being a regular rather than an irregular dental attendee; and 0.7 if being of non-native origin compared with native origin. The corresponding person-specific ORs were 8.9, 3.2, and 0.5. Consistent with Andersen's Behavioral Model, predisposing, enabling, and need-related factors were associated with dental hygienist attendance at population-averaged and person-specific levels. This has implications for promoting dental hygienist attendance among ageing people.

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Editorial Board

Publication date: July–September 2017
Source:Alergologia Polska - Polish Journal of Allergology, Volume 4, Issue 3





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Acute Endophthalmitis Caused by Leuconostoc spp. following Intravitreal Bevacizumab Injection

We present a case of acute endophthalmitis caused by Leuconostoc spp. following intravitreal bevacizumab injection. An 86-year-old immunocompetent female developed acute endophthalmitis after intravitreal injection of bevacizumab for neovascular age-related macular degeneration. The patient presented with pain, visual acuity of hand motions, hypopyon, and dense vitritis 96 h after treatment. She was treated with vitreous and anterior chamber tap followed by intravitreal injections of 1 mg vancomycin, 2.25 mg ceftazidime, and 400 μg dexamethasone. Cultures revealed growth of Leuconostoc spp., a genus of gram-positive bacteria that is inherently resistant to vancomycin. Due to persistent inflammation, pars plana vitrectomy (PPV) with intravitreal injection of 0.4 mg amikacin was performed 16 days later, followed by resolution of endophthalmitis and return of vision to 20/40. In conclusion, the management of acute endophthalmitis caused by Leuconostoc spp., a gram-positive coccobacillus, can be particularly challenging due to its inherent resistance to vancomycin. PPV with intravitreal amikacin led to resolution of endophthalmitis. Our case expands the number of cases of endophthalmitis caused by Leuconostoc spp. and highlights the possibility of Leuconostoc-related endophthalmitis in an outpatient setting in an immunocompetent host.
Case Rep Ophthalmol 2017;8:510–514

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PTH levels (pg/mL) at initial diagnosis and during different treatments.

Figure 1: PTH levels (pg/mL) at initial diagnosis and during different treatments.

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(A) Ki-67 labeling index of lung metastatic lesion. (B) PTH immunostaining of brain lesion.

Figure 3: (A) Ki-67 labeling index of lung metastatic lesion. (B) PTH immunostaining of brain lesion.

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Atypical manifestation of parathyroid carcinoma with late-onset distant metastases

Summary

Parathyroid carcinoma is an extremely rare endocrine malignancy that accounts for less than 1% of cases of primary hyperparathyroidism. We report a 44-year-old woman who presented with fatigue and diffuse bone pain. Laboratory findings revealed highly elevated serum calcium and parathyroid hormone (PTH) levels and a 4.5 × 3 × 2.5 cm cystic lesion in the lower pole of the right thyroid lobe that was shown histologically to be a parathyroid carcinoma. Ten years later, the patient developed brain and pulmonary metastases and recurrence of PTH-related hypercalcemia. Treatment of hypercalcemia along with localized radiotherapy and various chemotherapy regimens failed to induce a biochemical or radiological response. In conclusion, parathyroid carcinoma is a rare neoplasia that may develop metastases even after prolonged follow-up, for which there is no evidence-based treatment besides surgery. Different chemotherapeutic schemes did not prove to be of any benefit in our case highlighting the need for registering such patients to better understand tumor biology and develop specific treatment.

Learning points:

Metastases can develop many years after parathyroid cancer diagnosis.

Surgery is the only curative treatment for parathyroid carcinoma.

Chemotherapy and radiotherapy prove to be ineffective in parathyroid cancer treatment.

Patient registering is required in order to delineate underlining pathology and offer specific treatment.

http://ift.tt/2yWZvO9

Complement activation: an atypical presentation of an atypical syndrome

A 42-year-old Hispanic female and long-distance runner was seen for evaluation of fatigue. Her physical examination showed petechiae and ecchymoses in upper extremities, abdominal distension and bilateral ankle oedema. Laboratory workup revealed anaemia, thrombocytopenia, hypoalbuminemia and proteinuria of 1.4 g/24 hours. No schistocytes were found on peripheral blood smear. CT of her abdomen revealed diffuse small lymphadenopathy and hepatomegaly. Bone marrow biopsy demonstrated normal trilineage hematopoiesis with no hemophagocytosis. The patient was started on oral prednisone with no improvement and was subsequently admitted to the hospital for pulsed steroids, intravenous immunoglobulin and rituximab. Her proteinuria became nephrotic range, and a renal biopsy revealed features of thrombotic microangiopathy limited to the glomerular capillaries. ADAMTS13 was low which is >10% of normal, and a diagnosis of atypical haemolytic–uraemic syndrome (aHUS) was made. Eculizumab was started with prompt response. Whole exome sequencing demonstrated mutation in SPTA1, which has been associated with red blood cell membrane diseases but has not been described in patients with aHUS.

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Cortical blindness as a rare presentation of hemorrhagic cerebral hyperperfusion syndrome following vertebral angioplasty

Cerebral hyperperfusion syndrome (CHS) is a well-documented complication after carotid endarterectomy or stenting. In contrast, CHS following vertebral revascularization is extremely rare. Here we present a case of a 77-year-old man with high-grade vertebral stenosis who subsequently underwent balloon angioplasty, complicated by hemorrhagic CHS manifesting as cortical blindness, although strict postoperative blood pressure control was administered. To our knowledge, cortical blindness as a presentation of hemorrhagic CHS has not previously been reported. This study highlights the fact that identifying high-risk patients, as well as making an individual therapeutic plan, is important prior to revascularization. Further studies are needed to elucidate the exact mechanism of this condition and thereby prevent it.

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15,000 Case Reports Published

We are pleased to announce BMJ Case Reports has now published over 15,000 cases online. BMJ Case Reports is an important educational resource offering a high volume of cases in all disciplines so that healthcare professionals, researchers and others can easily find clinically important information on common and rare conditions.

Seema Biswas, Editor in Chief of BMJ Case Reports, says, "Publishing our 15 000th case report has been a remarkable achievement. We would like to thank our authors and reviewers as we celebrate the largest repository of case reports in the world. These cases are ideal for case-based learning. Our cases are free to download to use as teaching materials for all our fellows.."

Amongst our 15,000 cases, we have published over 3,316 Images In… and 70 Global Health cases, and received submissions from 119 countries. Since introducing an additional Open Access option upon acceptance in 2016, we have also published 96 Open Access articles in the past 12 months, making them freely available to view online.

Please visit our website to browse our archive of published articles, view our FAQs and find instructions on how to submit your case report.

We would like to take this opportunity to thank all of our authors, editors and reviewers for their contributions to the journal, and look forward to further expanding our collection of case reports.

http://ift.tt/2iIzj5T

Adult-onset Still's disease in a patient with psoriasis vulgaris showing inverse correlation of disease activity

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Eruptive multiple seborrheic keratoses with a palm tree-like pattern without underlying malignancy

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Two cases of skin infection during psoriasis treatment with brodalumab

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Non-lesional skin biopsy for a diagnosis of neuronal intranuclear inclusion disease

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Complete excision of proliferating core in auricular keloids significantly reduces local recurrence: A prospective study

Abstract

Keloids are mysterious soft-tissue tumors that are characterized by excessive reparative processes composed of collagen-forming fibroblasts and inflammatory cells. Generally, complete tumor excision regardless of sufficient margin is considered as a first-line treatment because they are considered reactive rather than a neoplastic condition. Recently, a specific part of the keloids is being highlighted as an important microstructure for local recurrence, but there has been very little evidence. We conducted a prospective study to evaluate the relationship of recurrence and several clinicopathological parameters with specific focus on surgical resection margin. A total 87 cases of auricular keloids from 71 patients were included. The resection margins were carefully evaluated by an exhaustive grossing method and thorough microstructural assessment. During up to 48.8 months of the follow-up period, local recurrence has been monitored and documented. The clinicopathological data including symptoms, bilaterality, size, location, prior treatment and operation history, gross type and etiology were collected and analyzed. Positive margin status was significantly related to tumor recurrence (P < 0.0001). Complete excision warrants a lower recurrence of auricular keloids in an Asian population. The most reasonable explanation for this seems to be remnant "proliferating core", which may serve a key role in local recurrence.

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How to get thicker hair

Many people want to help their hair look thick and full without chemical treatments. We look at several natural hair treatments, from eggs to castor oil.

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Haploidentical Stem cell transplantation with TCR alpha/Beta and CD19 depletion in a case of Unstable Hemoglobin disease

No abstract available

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Immunometabolism: novel monitoring and therapeutic approach in transplantation

No abstract available

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Cause for cautious optimism: Belatacept for patients with impaired kidney allograft function

No abstract available

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Improved pulse wave velocity and renal function in individualized calcineurin-inhibitor treatment by immunomonitoring: the randomized controlled Calcineurin Inhibitor-Sparing (CIS) Trial

Background A new immune monitoring tool which assesses the expression of nuclear factor of activated T-cells (NFAT)-regulated genes measures the functional effects of cyclosporine A. This is the first prospective randomized controlled study to compare standard pharmacokinetic monitoring by cyclosporine trough levels to NFAT-regulated gene expression (NFAT-RE). Methods Expression of the NFAT-regulated genes was determined by qRT-PCR at cyclosporine trough and peak level. Cardiovascular risk was assessed by change of pulse wave velocity from baseline to month 6. Clinical follow-up was 12 months. Results In total, 55 stable kidney allograft recipients were enrolled. Mean baseline residual NFAT-regulated gene expression was 13.1 ± 9.1 %. Patients in the NFAT-RE group showed a significant decline in pulse wave velocity from baseline to month 6 versus the standard group (-1.7 ± 2.0 vs. 0.4 ± 1.4 m/s, p

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CONTEMPORARY OUTCOMES OF COMBINED HEART-LIVER TRANSPLANT IN PATIENTS WITH CONGENITAL HEART DISEASE

ABSTRACT Background As more patients survive into adulthood with repaired congenital heart disease (CHD), transplant centers now have patients presenting with both end stage cardiac and hepatic failure. An understanding of the contemporary outcomes with combined heart liver transplantation (CHLT) in patients with CHD is needed. Methods A retrospective review of the outcomes of CHLT in CHD was conducted from 10/1/87 to 6/30/15 from United Network of Organ Sharing (UNOS) database. Propensity score matched cohorts were formed for the assessment of posttransplant outcome: CHLT with CHD, CHLT without CHD, and isolated heart transplant for congenital heart disease (HT-CHD). Cohorts were matched based on age, body-mass index, inotrope use, and ventilator support at the time of transplant. We assessed 30-day, 1-, 5-, and 10-year posttransplant survival. Results There were 61,437 heart transplants during the study period, out of which 190 (0.3%) were CHLT. Among CHLT, 41(22%) patients had CHD. In 26 (63%) of these, the indication for CHLT was hepatic congestion/cirrhosis of cardiac origin. In the matched cohorts, the overall survival for CHLT with CHD at 30-days, 1, 5, and 10-years was 95%, 86%, 83%, and 83% respectively; for CHLT without CHD, it was 100%, 92%, 92% and 63% respectively (versus CHLT with CHD: p=0.49); and for HT-CHD, it was 90%, 84%, 63%, and 39% (versus CHLT with CHD: p=0.03) respectively. Conclusions The posttransplant outcome of CHLT, with and without CHD, is comparable. But there is a trend towards better survival for CHLT for CHD compared to isolated heart transplant for CHD. Corresponding author before publication: Raheel Rizwan, MD, Research Fellow, Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Location S4.200AI, Cincinnati, Ohio 45229, Phone: 513-636-0902. Raheel.Rizwan@cchmc.org; Corresponding author after publication: Roosevelt Bryant III, MD, Associate Professor of Surgery, Surgical Director, Pediatric Heart Transplant Program, Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, 3333 Burnet Avenue – MLC 2004, Cincinnati, Ohio 45229, Phone: 513-636-4770, Fax: 513-636-3847. Roosevelt.BryantIII@cchmc.org AUTHORSHIP: Roosevelt Bryant 3rd Participated in idea, design and writing the manuscript Raheel Rizwan, MD: Participated in design, statistical analysis and writing the manuscript Farhan Zafar, MD: Participated in design, statistical analysis, review of the manuscript and suggestions to make the manuscript more yielding Shimul A. Shah: Participated in review of the manuscript and suggestions to make the manuscript more yielding Clifford Chin, MD: Participated in review of the manuscript and suggestions to make the manuscript more yielding James Tweddell, MD: Participated in review of the manuscript and suggestions to make the manuscript more yielding David L.S. Morales, MD: Participated in idea, design, review of the manuscript and suggestions to make the manuscript more yielding Disclosure(s): None of the authors have any disclosures related to the manuscript Funding Source(s): None Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Access to transplantation: Balancing Efficiency and Equity

No abstract available

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Does Portopulmonary Hypertension Impede Liver Transplantation in Cirrhotic Patients? A French Multicentric Retrospective Study

Background Portopulmonary hypertension is defined by the presence of pulmonary arterial hypertension associated with portal hypertension. Its presence is a major stake for cirrhotic patients requiring liver transplantation, with increased postoperative mortality and unpredictable evolution after transplantation. The aim was to study outcomes after liver transplantation in patients with portopulmonary hypertension and to identify factors associated with normalization of pulmonary hypertension. Methods Patients with portopulmonary hypertension who underwent liver transplantation between 2008 and 2016 in 8 French centers were retrospectively included. Pulmonary artery pressure was established by right catheterization before and after LT. Primary endpoint was the normalization of pulmonary artery pressure after liver transplantation. Results Twenty-three patients who received liver transplant between 2008 and 2016 were included. Two (8.7%) patients died in the immediate posttransplant period from right heart failure. With appropriate vasoactive medical treatment and liver transplantation, pulmonary arterial pressure was normalized in 14 patients (60.8%), demonstrating recovery from portopulmonary hypertension. In univariate analysis, the use of vasoactive combination therapy was the only prognostic factor for pulmonary arterial hypertension normalization after liver transplantation. Conclusions Treatment of portopulmonary hypertension with a combination of vasoactive drugs allows liver transplantation with acceptable postoperative cardiovascular-related mortality and normalization of pulmonary hypertension in the majority of patients. Corresponding author: Maud Reymond, MD, Hepatology, Trousseau University hospital, Avenue de La République, 37170 CHAMBRAY-LES-TOURS, Phone: +33-2-47-47-59-00 ; Fax: +33-2-47-47-84-28 ; Maud.reymond@hotmail.fr Maud REYMOND: research design, writing of the paper, and performance of the research, data analysis. Louise BARBIER: research design, writing of the paper, and performance of the research, data analysis. Ephrem SALAME: Participated in the performance of the research, correction of the manuscript Camille BESH: Participated in the performance of the research Jerome DUMORTIER: Participated in the performance of the research Georges-Philippe PAGEAUX: Participated in the performance of the research Christophe BUREAU: Participated in the performance of the research Sébastien DHARANCY: Participated in the performance of the research Claire VANLEMMENS: Participated in the performance of the research Armand ABERGEL: Participated in the performance of the research Marie-Lorraine WOEHL JAEGLE: Participated in the performance of the research Pascal MAGRO: Participated in the performance of the research Frederic PATAT: Participated in the performance of the research Emeline LAURENT: Participated in data analysis Jean-Marc PERARNAU: research design, writing of the paper, performance of the research, data analysis, and correction of the manuscript The authors declare no conflicts of interest. Funding: ARFMAD (Association pour la Recherche et la Formation en Maladies de l'Appareil Digestif) Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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