Head and Neck Medicine by Alexandros G.Sfakianakis: 02/27/18

Although uveitis is reported as a rare adverse event (AE) associated with dabrafenib/trametinib therapy or nivolumab, the occurrence of severe uveitis is extremely rare. We describe two cases of Vogt–Koyanagi–Harada (VKH)-like uveitis developing after the sequential administration of nivolumab and dabrafenib/trametinib therapy. Interestingly, both cases had HLA-DRB1*04:05, which is strongly associated with VKH disease, and achieved biologically complete remission after the treatment for uveitis. Our cases suggest a possible correlation between VKH-like uveitis as an AE and the clinical outcomes of sequential administration of nivolumab and dabrafenib/trametinib therapy for the treatment of advanced melanoma.

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Unusual association between digital mucous cyst and acquired ungual fibrokeratoma: A case report

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Case of pyoderma gangrenosum-like sporotrichosis caused by Sporothrix globosa in a patient with ulcerative colitis

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Landiolol hydrochloride to successfully treat refractory ventricular arrhythmia during weaning from cardiopulmonary bypass

We effectively treated refractory ventricular arrhythmia (RVA) at the time of weaning from the cardiopulmonary bypass (CPB) during aortic valve replacement with landiolol for three patients who failed to respond to electrical defibrillation. Demographic data, comorbid factors, and preoperative finding were noted [Table 1].

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Human factors study in untrained adolescents comparing an epinephrine prefilled syringe (symjepi™) with EpiPen® autoinjector

Self- or caregiver administration of epinephrine is considered the treatment of choice for acute anaphylaxis (1). In June 2017, US FDA approved Symjepi™, a prefilled syringe used for the administration of epinephrine (2).

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Uses of biologics in allergic diseases: what to choose and when

Choosing a biologic therapy for asthma, urticaria, atopic dermatitis, or nasal polyps should be based on disease phenotype, relevant biomarkers, comorbid allergic conditions, and FDA approval status.

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The Eosinophil: for better or worse, in sickness and in health

Key messages

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Epinephrine auto-injector needle lengths can both subcutaneous and periosteal/intraosseous injection be avoided?

Administration of epinephrine should be intramuscularly in the anterolateral aspect of the thigh. The length of the epinephrine autoinjector, EAI, needle should assure intramuscular injection.

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Surgical Care and Otolaryngology in Global Health

Surgical access is inadequate for most people. The Lancet Commission on Global Surgery established 6 indicators to measure surgical access: geographic accessibility, density of surgical providers, number of procedures performed, perioperative mortality, impoverishing expenditure, and catastrophic expenditure. Otolaryngology surgical, training, and research efforts use these 6 indicators to maximize impact and coordination of worldwide efforts in surgery. Research must be rigorous and consider the counterfactual. For otolaryngologists who want to contribute, focusing on 1 of the 6 indicators may be most impactful.

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Workforce Considerations, Training, and Diseases in Africa

Surgeons in sub-Saharan Africa face different challenges than those in developed countries: extreme shortages of otolaryngologists, speech pathologists, and audiologists; lack of training opportunities; and a paucity of otolaryngology services aggravated by population growth and aging. In addition to common Western diseases, patients have otolaryngology complications related to the human immunodeficiency virus, tuberculosis, malaria, and trauma. Less than 5% of the population has access to timely, safe, affordable surgery; 29 out of 52 African countries have no radiotherapy services. Discussion focuses on education and training, which can be achieved in several ways, some complimentary.

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Melanoma risk prediction using a multi-locus genetic risk score in the Women’s Health Initiative cohort

Single-nucleotide polymorphisms (SNPs) associated with melanoma have been identified though genome-wide association studies (GWASs). However, the combined impact of these SNPs on melanoma development remains unclear, particularly in post-menopausal women who carry lower melanoma risk.

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The Risk of Cardiovascular Events in Psoriasis Patients Treated with Tumor Necrosis Factor-alpha Inhibitors versus Phototherapy: An Observational Cohort Study

Psoriasis is a risk factor for cardiovascular events.

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Dermatologists are the primary treating physicians of skin cancer in the United States Medicare population

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Dermatology and climate change

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Title: Opioid, Alcohol, and Cannabis Misuse Among Patients with Hidradenitis Suppurativa: a population-based analysis in the United States

Patients with hidradenitis suppurativa (HS) experience chronic pain and have significant physical, emotional and psychological disease impact. These patients may be at risk for substance abuse.

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Surgical Pearl: Video chat to prevent wrong site surgery

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Similar survival of patients with multiple vs. single primary melanomas based on Utah SEER data (1973-2011)

Survival data are mixed comparing patients with multiple primary melanomas (MPM) to those with single primary melanomas (SPM).

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Drugs With a REMS: Benefit/Risk Counseling to Patients

Do you know what to do when counseling a patient on a drug with a REMS designation? Learn more with new guidance from the FDA.
FDA Expert Commentaries and Interviews

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Diagnosis and endoscopic endonasal management of nontraumatic pseudoaneurysms of the cranial base

Background

Nontraumatic pseudoaneurysms of the cranial base are rare and present unique diagnostic and treatment dilemmas compared with both true aneurysms and pseudoaneurysms outside of the cranial base. There is a dearth of knowledge regarding the management of these complicated lesions.

Methods

Nontraumatic pseudoaneurysms of the cranial base internal carotid artery (ICA) were retrospectively identified at the University of Pittsburgh Medical Center through a key word search of cranial base cases from 2010 to 2017.

Results

Three cases were identified, demonstrating pseudoaneurysms of the cavernous and petrous ICA. Each patient underwent diagnostic work-up with computed tomography, magnetic resonance imaging, and angiography, followed by endovascular occlusion and endoscopic endonasal surgery, which resulted in relief of presenting complaints and ablation of the pseudoaneurysm.

Conclusion

Symptomatic cranial base pseudoaneurysms should undergo treatment to obliterate the aneurysm and relieve the mass effect. First, formal angiography is necessary for accurate diagnosis and treatment planning. Next, endovascular occlusion is performed, with a preference for coiling or endoluminal reconstruction with a flow diverter. Last, endoscopic intervention follows in cases where: (1) decompression of vital structures is indicated; (2) diagnosis of the pseudoaneurysm cannot be definitively confirmed with angiography; or (3) the etiology of the confirmed pseudoaneurysm requires further investigation.

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Management of long-lasting phantosmia: a systematic review

Background

Interest in the pathophysiology and management of phantom smells has increased rapidly over the last decade. A PubMed search for the term "phantosmia" demonstrated a near-doubling of articles published on phantosmia within the past 7 years. We aimed to systematically review the literature on the management of phantosmia.

Methods

The PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990, using terms combined with pertinent Boolean search operators. We included articles evaluating management of phantosmia written in the English language, with original data and a minimum of 6 months of follow-up, on at least 2 patients and with well-defined and measurable outcomes.

Results

A total of 2151 unique titles were returned upon the initial search. Of these, 146 abstracts were examined, yielding 7 articles meeting the inclusion criteria. All articles were predominantly level 4 evidence. One prospective level 3 study was included. The studies included a total of 96 patients, with follow-up ranging from 6 months to 11 years. Endpoints were primarily based on subjective patient responses. Management options included observation and medical and surgical therapy. Olfactory mucosa excision was the only surgical intervention studied, with short-term symptomatic improvement in 10 of 11 patients. Forty-one patients were treated medically, which included antipsychotic, antimigraine, and antiseizure medications, transcranial stimulation, and topical cocaine application.

Conclusion

Despite increasing interest in the treatment of phantosmia and reports of successful therapies, there remains a paucity of data and lack of consensus regarding optimal management of this difficult condition.

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A challenge-response endoscopic sinus surgery specific checklist as an add-on to standard surgical checklist: an evaluation of potential safety and quality improvement issues

Background

The goal of this study was to develop and evaluate the impact of an aviation-style challenge and response sinus surgery–specific checklist on potential safety and equipment issues during sinus surgery at a tertiary academic health center. The secondary goal was to assess the potential impact of use of the checklist on surgical times during, before, and after surgery. This initiative is designed to be utilized in conjunction with the "standard" World Health Organization (WHO) surgical checklist. Although endoscopic sinus surgery is generally considered a safe procedure, avoidable complications and potential safety concerns continue to occur. The WHO surgical checklist does not directly address certain surgery-specific issues, which may be of particular relevance for endoscopic sinus surgery.

Methods

This prospective observational pilot study monitored compliance with and compared the occurrence of safety and equipment issues before and after implementation of the checklist. Forty-seven consecutive endoscopic surgeries were audited; the first 8 without the checklist and the following 39 with the checklist. The checklist was compiled by evaluating the patient journey, utilizing the available literature, expert consensus, and finally reevaluation with audit type cases. The final checklist was developed with all relevant stakeholders involved in a Delphi method.

Results

Implementing this specific surgical checklist in 39 cases at our institution, allowed us to identify and rectify 35 separate instances of potentially unsafe, improper or inefficient preoperative setup. These incidents included issues with labeling of topical vasoconstrictor or injectable anesthetics (3, 7.7%) and availability, function and/or position of video monitors (2, 5.1%), endoscope (6, 15.4%), microdebrider (6, 15.4%), bipolar cautery (6, 15.4%), and suctions (12, 30.8%).

Conclusion

The design and integration of this checklist for endoscopic sinus surgery, has helped improve efficiency and patient safety in the operating room setting.

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Do you know your guidelines? Diagnosis and management of cutaneous head and neck melanoma

Abstract

The following article is the next installment of the series "Do You Know Your Guidelines?" presented by the Education Committee of the American Head and Neck Society. Guidelines for the prevention, diagnosis, workup, and management of cutaneous melanoma are reviewed in an evidence-based fashion.

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Change in alcohol and tobacco consumption after a diagnosis of head and neck cancer: Findings from head and neck 5000

Abstract

Background

Tobacco and alcohol consumption are risk factors for developing head and neck cancer, and continuation postdiagnosis can adversely affect prognosis. We explored changes to these behaviors after a head and neck cancer diagnosis.

Methods

Demographic and clinical data were collected from 973 people newly diagnosed with oral cavity, oropharyngeal, or laryngeal cancer. Tobacco and alcohol consumption were additionally collected 4 and 12 months later.

Results

The prevalence of high alcohol consumption reduced from 54.3% at diagnosis to 41.4% at 12 months, and smoking reduced from 21.0% to 11.7%. Changes in behavior were dynamic, for example, 44% of smokers at 12 months were not smoking at diagnosis or 4 months. Several factors were associated with alcohol consumption, whereas only tumor site and comorbidities were associated with smoking.

Conclusion

A diagnosis of head and neck cancer can result in important changes in alcohol consumption and smoking prevalence. However, these changes are dynamic in the first year after diagnosis.

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Supine positioning for the subscapular system of flaps: A pictorial essay

Abstract

Background

This pictorial essay demonstrates a modification to the positioning, prepping, and draping technique for the subscapular system of flaps allowing the patient to be placed supine and without the need for a second assistant during the harvest or closure.

Methods and Results

We performed a literature review focusing on the positioning of the patient during the harvest of the subscapular system of flaps. A supine modification harvest prepping, draping, and position is then described in pictorial essay format. The technique is made possible with the use of a Mayo stand to position the arm.

Discussion

A literature review demonstrates limited description of nonlateral decubitus position harvest of the scapular flap. A novel positioning technique is described in pictorial essay format to demonstrate the ease and feasibility without the need for a second assistant during the case, an important goal in the era of limited resident duty hours.

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Improved labelling for consumers with food allergy

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Issue Information

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Forthcoming Meetings

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Cover Image

The cover image, by Y. J. Jeon et al., is based on the Original Article Type III interferons are critical host factors that determine susceptibility to Influenza A viral infection in allergic nasal mucosa, DOI: 10.1111/cea.13082.

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Time to Reconsider Management of the Temporomandibular Joint in Juvenile Idiopathic Arthritis

Publication date: Available online 26 February 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Cory M. Resnick, Thomas K. Pedersen, Shelly Abramowicz, Marinka Twilt, Peter B. Stoustrup

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Patient-Specific Topographic Anatomy of the Deep Circumflex Iliac Artery Flap: Comparing Standard and Modified Computed Tomographic Angiography

Publication date: Available online 26 February 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): V. Behrens, A. Modabber, C. Loberg, A. Herrler, A. Prescher, A. Ghassemi
PurposeComputed tomographic angiography (CTA) is reported to give insight into patient-specific anatomy of the flap pedicle preoperatively. We compared information available from standard CTA (s-CTA) with that gained by modifying the conventional CTA technique (modified CTA [m-CTA]). Dissected cadavers served as the control group.Materials and MethodsWe evaluated 16 s-CTA scans (32 deep circumflex iliac arteries [DCIAs]) and 12 m-CTA scans (17 DCIAs) using 3-dimensional software (Vesalius; ps-medtech, Amsterdam, The Netherlands). We dissected 17 cadavers (n = 34) to serve as the control group. The positions of 4 landmarks (anterior superior iliac spine, origin of DCIA, origin of ascending branch, and crossing of horizontal branch and iliac crest) were defined in a 3-dimensional coordinate system.ResultsWe found significant differences concerning the distances from the origin of the DCIA to the femoral bifurcation (P < .05) and the anterior superior iliac spine to the crossing point of the horizontal branch with the iliac crest (P < .05) between CTA scans and cadaveric studies. The imaging quality of the m-CTA scans was shown to be more consistent than and superior to that of the s-CTA scans. The visible length of the DCIA was longer on m-CTA scans (mean, 134.32 mm) than on s-CTA scans (mean, 73.62 mm). We could evaluate the branching off of perforators and the relation of the pedicle to the surrounding bone and soft tissue in more detail on m-CTA scans. Standard CTA allowed the bilateral evaluation of the pedicle, whereas m-CTA allowed the evaluation of the injected side only.ConclusionsThe quality and quantity of information available from CTA could be improved by modifying the s-CTA examination by injection as close as possible to the target vessel. Standard CTA delivered information about both sides, whereas m-CTA may need an additional injection for contralateral-side imaging.

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Piezotome-Genioplasty reduces post-surgical morbidity and enhances patient satisfaction: a randomized clinical trial

Publication date: Available online 27 February 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Troedhan Angelo
PurposeRecent clinical studies have shown piezotomes to possibly establish the new "state-of-art" for osteotomies in maxillofacial surgery. The investigator hypothesized genioplasty-surgery with piezotomes might decrease post-surgical morbidity and increase overall patient satisfaction when compared to genioplasty with traditional instruments.MethodsThe investigator implemented a randomized clinical trial. The sample was composed of patients undergoing reductive genioplasty. The predictor variable was genioplasty performed with traditional instruments and traditional sliding genioplasty protocol (control-group) or ultrasonic surgical devices "Piezotome II" and "Piezotome SOLO M+" with a piezotome-adapted 3D-curved osteotomy surgical protocol (test-group). The primary outcome variable was overall long-term patient-satisfaction determined by Genioplasty Outcome Evaluation (GOE). Other study variables were postsurgical morbidity staged by Universal Pain Assessment Scale (UPAS), analgesic intake, neurosensory two-point-discrimination-test of lip and chin and surgery duration. Descriptive and bivariate statistics were computed by SPSS 22.0 and the p value was set at .05.ResultsThe sample was composed of 48 patients undergoing reductive genioplasty either with "Piezotome" (10 male / 13 female, aged from 24-56 yrs) or traditional sliding genioplasty ( 11 male / 14 female, aged from 26-54 yrs). No statistically significant difference was found for surgery duration between test- and control-group. There was a statistically significant association between reduced postsurgical morbidity (p<0,05) and higher overall long-term patient satisfaction with genioplasty outcome (p<0,05) when piezotomes were used for performing the genioplasty.ConclusionThe results of this study suggest the use of piezotomes and piezotome-adapted surgical protocols to be advantageous in genioplasty-surgery compared to traditional surgical instruments and traditional surgical protocols.

Graphical abstract

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Erratum

Publication date: Available online 26 February 2018
Source:Journal of Oral and Maxillofacial Surgery

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Sunscreen habits and skin cancer rates in patients with vitiligo in Australia

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Comparison of the efficacy of venous coupler and hand-sewn anastomosis in maxillofacial reconstruction using microvascular fibula free flaps: a prospective randomized controlled trial

Publication date: Available online 26 February 2018
Source:International Journal of Oral and Maxillofacial Surgery

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In reply

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Ultrasound versus fiberscope-guided tracheal intubation

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Which Antibiotic Regimen Prevents Implant Failure or Infection after Dental Implant Surgery? A Systematic Review and Meta-analysis

Publication date: Available online 26 February 2018
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Fabio Rodríguez Sánchez, Carlos Rodríguez Andrés, Iciar Arteagoitia Calvo
ObjectiveTo assess which antibiotic regimen prevents dental implant failures or postoperative infections following dental implant placement.Materials and MethodsSystematic review and meta-analysis. Data sources: Pubmed, Cochrane, Science Direct, and EMBASE via OVID were searched up to August 2017. Only randomized controlled clinical trials (RCT) using antibiotics were included. Outcome measures were set on dental implant failures or postoperative infection incidence after dental implant surgery. Three reviewers independently undertook risk of bias assessment and data extraction. Stratified meta-analyses of binary data using fixed-effects models were performed using Stata 14.0. The risk ratio (RR) and 95% confidence interval (CI) were estimated.ResultsNine articles were included corresponding to 15 RCTs. All RCTs tested only oral amoxicillin. Implant-failure analysis: overall RR=0.53 (P=.005, 95% CI: 0.34-0.82) and overall NNT=55 (95% CI, 33-167). Single-dose oral amoxicillin preoperatively (SDOAP) is beneficial (RR=0.50, CI: 0.29-0.86. P=.012), when compared to postoperative oral amoxicillin (POA): RR= 0.60, CI: 0.28-1.30. P=.197). Postoperative-infection analysis: overall RR=0.76 (P=0.250, 95% CI: 0.47-1.22). Neither SDOAP (RR=0.82, CI=0.46-1.45, P=.488) nor POA (RR=0.64, CI=0.27-1.51, P=.309) are beneficial. I²=0.0%, chi-squared tests P≈1.ConclusionOnly SDOAP is effective and efficacious at preventing implant failures, but it was not significant for postoperative infections following dental implant surgeries.

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The multi-receptor inhibitor axitinib reverses tumor-induced immunosuppression and potentiates treatment with immune-modulatory antibodies in preclinical murine models

Abstract

Cancer immunotherapies have significantly improved the prognosis of cancer patients. Despite the clinical success of targeting inhibitory checkpoint receptors, including PD-1 and/or CTLA-4 on T cells, only a minority of patients derive benefit from these therapies. New strategies to improve cancer immunotherapy are therefore needed. Combination therapy of checkpoint inhibitors with targeted agents has promisingly shown to increase the efficacy of immunotherapy. Here, we analyzed the immunomodulatory effects of the multi-receptor tyrosine kinase inhibitor axitinib and its efficacy in combination with immunotherapies. In different syngeneic murine tumor models, axitinib showed therapeutic efficacy that was not only mediated by VEGF–VEGFR inhibition, but also through the induction of anti-cancer immunity. Mechanistically, a significant reduction of immune-suppressive cells, including a decrease of tumor-promoting mast cells and tumor-associated macrophages was observed upon axitinib treatment. Inhibition of mast cells by axitinib as well as their experimental depletion led to reduced tumor growth. Of note, treatment with axitinib led to an improved T cell response, while the latter was pivotal for the therapeutic efficacy. Combination with immune checkpoint inhibitors anti-PD-1 and anti-TIM-3 and/or agonistic engagement of the activating receptor CD137 resulted in a synergistic therapeutic efficacy. This demonstrates non-redundant immune activation induced by axitinib via modulation of myeloid and mast cells. These findings provide important mechanistic insights into axitinib-mediated anti-cancer immunity and provide rationale for clinical combinations of axitinib with different immunotherapeutic modalities.

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Defective HLA class I antigen processing machinery in cancer

Abstract

Malignant transformation of cells is frequently associated with defective HLA class I antigen processing machinery (APM) component expression. This abnormality may have functional relevance, since it may have a negative impact on tumor cell recognition by cognate T cells. Furthermore, HLA class I APM abnormalities appear to have clinical significance, since they are associated with poor prognosis in several malignant diseases and may play a role in the resistance to immune checkpoint inhibitor-based immunotherapy. In this paper, we have reviewed the literature describing abnormalities in HLA class I APM component expression in many types of cancer. These abnormalities have been reported in all types of cancer analyzed with a frequency ranging between a minimum of 35.8% in renal cancer and a maximum of 87.9% in thyroid cancer for HLA class I heavy chains. In addition, we have described the molecular mechanisms underlying defects in HLA class I APM component expression and function by malignant cells. Lastly, we have discussed the clinical significance of HLA class I APM component abnormalities in malignant tumors.

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Ipilimumab in metastatic melanoma patients with pre-existing autoimmune disorders

Abstract

Background

Ipilimumab and programmed death (PD) 1-antibodies are effective treatment options in metastatic melanoma. The safety and efficacy of ipilimumab in patients with pre-existing autoimmune disorders (AD) has only been evaluated in a selected number of patients.

Methods

We performed a retrospective analysis in 14 German skin cancer centers for patients with metastatic melanoma and pre-existing AD treated with ipilimumab.

Results

41 patients with 44 pre-existing AD were treated with ipilimumab (thyroiditis n = 15, rheumatoid n = 11, dermatologic n = 10, Crohn's disease/ulcerative colitis n = 3, neurological n = 2, sarcoidosis n = 2, pancreatitis n = 1). 3 out of 41 patients had two AD, 11 patients required immunosuppressants at the time of induction of ipilimumab. 12 patients (29.2%) experienced a flare of their pre-existing AD, mainly patients with rheumatoid or dermatologic diseases. Additional immune-related adverse events (irAEs) occurred in 12 patients (29.2%). In 23 patients (56%) neither a change of their AD nor additional irAEs were observed. Objective responses were seen in five patients (one complete remission, four partial remissions, 12.1%).

Conclusion

This is the largest series of patients with pre-existing AD and treatment with ipilimumab reported. Flares of pre-existing AD were observed but manageable. Response rates and occurrence of new irAEs were comparable to previous trials. Thus, in this patient subgroup, ipilimumab can be a treatment option after a thorough discussion of pros and cons and taking severity and activity of the preexisting AD into account.

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Special Circumstances of Resuscitation

https://youtu.be/5CE6Do-QM_4

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

https://plus.google.com/communities/115462130054650919641?sqinv=VFJWaER0c2NCRl9ERzRjZWhxQmhzY09kVV84cjRn ,

,https://plus.google.com/u/0/+AlexandrosGSfakianakis ,

https://www.youtube.com/channel/UCQH21WX8Qn5YSTKrlJ3OrmQ ,

https://www.youtube.com/channel/UCTREJHxB6yt4Gaqs4-mLzDA ,

https://twitter.com/g_orl?lang=el,

https://www.instagram.com/alexandrossfakianakis/,

Summary of Key Issues and Major Changes

Experience with treatment of patients with known or suspected opioid overdose has demonstrated that naloxone can be administered with apparent safety and effectiveness in the first aid and BLS settings. For this reason, naloxone administration by lay rescuers and HCPs is now recommended, and simplified training is being offered. In addition, a new algorithm for management of unresponsive victims with suspected opioid overdose is provided.
Intravenous lipid emulsion (ILE) may be considered for treatment of local anesthetic systemic toxicity. In addition, a new recommendation is provided, supporting a possible role for ILE in patients who have cardiac arrest and are failing standard resuscitative measures as the result of drug toxicity other than
local anesthetic systemic toxicity.
The importance of high-quality CPR during any cardiac arrest has led to a reassessment of the recommendations about relief of aortocaval compression during cardiac arrest in pregnancy. This reassessment has resulted in refined recommendations about strategies for uterine displacement.

https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Should catheter-directed thrombolysis be the standard of care for pregnancy-related iliofemoral deep vein thrombosis?

A 33-year-old, 8-week pregnant woman presented with mottling, pain and swelling of her left leg. Ultrasound Doppler scan revealed a large left iliofemoral deep vein thrombosis and the patient was diagnosed with phlegmasia cerulea dolens. After 24 hours of treatment with unfractionated heparin, there were minimal improvements in her symptoms. Catheter-directed thrombolysis was performed, following multidisciplinary consultation with the patient. An underlying May-Thurner lesion was identified and successfully stented. Radiation exposure to the fetus was minimised with the use of intravenous ultrasound and very low-dose fluoroscopy. Total radiation exposure to the fetus is 1.38 mGy, which is equivalent to 8 months of background radiation exposure. No immediate complication occurred and patient's symptoms completely resolved. On further follow-up, her iliofemoral veins remained patent with good flow and there were no recurrence of symptoms. A healthy infant was successfully delivered at 40 weeks gestation.

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Primary spontaneous pneumothorax in conjunction with Marfan syndrome

A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior. Diagnostic imaging revealed a spontaneous right-sided pneumothorax due to ruptured subpleural bullae in the apex of the right lung. Smaller subpleural bullae were also noted in the apex of the left lung. A chest tube was placed to reduce the right pneumothorax successfully.

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Persistent wrist monarthritis: down to the bone

A minority of osteoid osteomas are found to be juxta-articular and within the small bones of the wrist. We present a 30-year-old man diagnosed with an osteoid osteoma of the lunate bone, presenting with 3 years of left wrist pain, swelling and reduced range of motion. Given the patient's background and laboratory testing, consideration was given to both inflammatory and infectious causes and the diagnosis was delayed, requiring repeat interval imaging and assisted by multiple imaging modalities. Management by surgical excision led to resolution of pain and swelling. In cases of a prolonged isolated monarthritis, juxta-articular osteoid osteoma should be considered in the differential.

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Ruptured hepatocellular carcinoma disguising as heterotopic pregnancy

The incidence of hepatocellular carcinoma (HCC) in pregnancy is rare but is typically aggressive, with a 1-year survival rate of 23%. One of the complications of HCC is spontaneous rupture, resulting in haemoperitoneum. A 36-year-old pregnant Chinese immigrant who was positive for hepatitis B virus and in her first trimester presented to the emergency department of Wyong Hospital, Hamlyn Terrace, New South Wales, Australia, with severe epigastric and right upper quadrant pain and haemodynamic instability. Spontaneous rupture of a heterotopic pregnancy was initially suspected. However, histopathological staining of the lesions excised during surgery revealed HCC. To our knowledge, this is the first case of spontaneous rupture of HCC with haemoperitoneum during pregnancy in Australia. As developed countries receive global migrants, similar cases may be seen in the future. Epidemiological studies suggest that immigrants from China and Vietnam have the highest incidence of chronic hepatitis B virus carrier status.

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'Barely a scratch: Capnocytophaga canimorsus causing prosthetic hip joint infection following a dog scratch

Capnocytophaga canimorsus is a commensal organism commonly found in the oral cavity of cats and dogs. Infections with this organism are rare and can affect both immunocompetent and immunocompromised individuals. The authors present a case of C. canimorsus causing indolent prosthetic hip joint infection in a healthy 66-year-old woman following a history of being scratched by her pet dog. The patient had an atypical history of chronic, low-grade infection which is unusual, as this organism is more frequently associated with acute presentations and fulminant sepsis. This patient was treated successfully with a two-stage exchange of her hip prosthesis and broad-spectrum antibiotics.

C. canimorsus is a very rare cause of prosthetic joint infection but an important pathogen to consider, particularly in culture-negative joint infections and a history of animal exposure.

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Obstructive uropathy from complete bladder and bilateral ureteral incarceration within an inguinal hernia

A 59-year-old man with a medical history of hypertension, gout and obesity presented to the hospital with a chief complaint of worsening scrotal oedema. The patient endorsed associated symptoms of decreased force of stream on urination, stranguria and hesitancy with slight dysuria. Physical exam showed an effaced umbilicus and phallus with a hidden scrotum estimated to be 30x20x30 cm in size. Imaging and lab findings led to a diagnosis of total bladder herniation within an incarcerated right inguinal hernia. Surgical repair of the inguinal hernia and replacement of the bladder and ureters led to a resolution of urinary symptoms with no evidence of vesicoureteral reflux or urinary retention.

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Teriparatide-induced atrial tachycardia

We present the case of a patient who presented with worsening chest pain and tachycardia. We were able to monitor her remotely through her pacemaker. She had been started on the injectable medication teriparatide (Forteo) and since then she had an increase in her symptoms. She was found to have intermittent atrial tachycardia with 1:1 conduction and occasional atrioventricular block transiently, coinciding with her injection of teriparatide. This specific-associated arrhythmia has yet to be described.

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The man that lost (part of) his mind

An 84-year-old man presented to the emergency department following recurrent falls over several weeks and onset of new left-sided weakness. CT of the brain revealed a large air cavity (pneumatocoele) in the right frontal lobe thought to be secondary to an ethmoidal osteoma communicating through the cribriform plate allowing air to be forced into the skull under pressure. Subsequent MRI confirmed these findings and also revealed a small focal area of acute infarction in the adjacent corpus callosum. The patient had a prolonged hospital stay, declined neurosurgical intervention and was discharged home on secondary stroke prevention.

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Use of oral immunosuppressive drugs in the treatment of atopic dermatitis in the Netherlands

Abstract

Background

Although atopic dermatitis (AD) is a very common skin disease, data on the percentage of patients with really difficult to treat AD are scarce. From socio-economic perspective it is important to have more insight in these numbers, as new very effective, but expensive, treatment options will be available in the near future for difficult to treat AD. Estimating the number of AD patients using oral immunosuppressive drugs can give an impression of the percentage of difficult to treat patients in the total AD population.

Objective

To give an overview of the use of oral immunosuppressive drugs in patients with AD in the Netherlands.

Methods

Prescription data of oral immunosuppressive drugs in the Netherlands were extracted from a pharmaceutical database (NControl) containing data of 557 million prescriptions and 7.2 million patients. An algorithm, based on the WHO Anatomical Therapeutic Chemical (ATC) codes, was used to identify patients with AD. The prescription of oral immunosuppressive drugs in patients with AD between January 1^st 2012 and January 1^st 2017 was evaluated.

Results

Based on the algorithm, 65 943 patients with AD were selected. 943 AD patients (1.4%) used cyclosporine A, methotrexate, azathioprine or mycophenolic acid. Methotrexate was most commonly used, followed by azathioprine and cyclosporine A. A switch in medication was rarely seen. In the evaluation period a decrease in the prescription of cyclosporine A was seen, together with an increase of the prescription of methotrexate. In 31% of the patients who stopped treatment, the discontinuation took place within the first months of treatment.

Conclusion

In this study population, 1.4% of the AD patients used oral immunosuppressive drugs for their eczema in a five year period. Methotrexate was the most commonly used systemic drug in the Netherlands for the treatment of AD.

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Surgical treatment of hidradenitis suppurativa: an analysis of postoperative outcome, cosmetic results and quality of life in 255 patients

Abstract

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with increasing incidence. Severe disease stages are seen as a therapeutic challenge and pose the threat of significant restrictions in patients' life quality.

Objectives

We evaluated postoperative outcome after wide local excision for HS as well as postoperative course, cosmetic results, disease recurrence and quality of life.

Methods

All patients receiving radical surgical treatment for HS (Hurley III) between 2006-2015 were identified and received a letter-based survey. They were asked about postoperative course, cosmetic results, recurrence and life quality.

Results

255 patients (103 men, 152 women) answered the questionnaire. 95% of patients reported disease-specific restrictions in everyday life. 72% of patients did not experience any postoperative adverse events, however, postoperative pain with need for analgesics was reported in 38%. The majority of patients (80%) were very satisfied or satisfied after surgery, 85% of patients would recommend surgery to other affected persons.

Limitations

The retrospective design of the study was a limitation.

Conclusions

The well-known negative psychological and social effects are a relevant part of HS and emphasize the importance of immediate therapy. Since long-lasting local disease-control can be achieved, surgery should be considered as first-line therapy.

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Thumb necrotic ulcers caused by weeverfish. Case report and review of the literature

Abstract

a 59-year-old Caucasian man presented to our department with a three weeks history of erythema and edema of the left hand, and a necrotic ulcer of the left thumb, after a holiday in Greece, associated with extreme pain. No other skin or mucosal lesions were present. Systemic symptoms such as nausea, vomiting, hypotension, seizures, cardiac arrhythmias, or paralysis were denied. The local erythematous reaction started after fishing, during which the patient was attacked by a weeverfish (Fig. 1A); the wound was treated with topical antiseptics and antibioticum ointments, and seemed to granulate, but in the following week massive edema of the left hand developed (Fig. 1B), together with a rapidly progressive necrotic ulceration of the left thumb (Fig. 1C).

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Imiquimod anal tampons treatment of anal intraepithelial neoplasia

Abstract

The prevalence of Human Papillomavirus (HPV) in men who have sex with men (MSM) is high, reaching 85-93% prevalence in HIV-positive men. High-risk HPV are strongly associated with development of high degrees of anal intraepithelial neoplasia (AIN) which, later on, can develop in anal squamous carcinoma. The growing incidence of anal cancer during last years is particularly important in MSM and HIV-positive patients, in which the coexistence of multiple serotypes of HPV reduces the probability of eliminating the AIN. The treatments for anal dysplasia have shown limited effectiveness. Imiquimod (1-[2-methylpropyl]-1H-imidazo-[4,5-c]-quinolin-4-amine) has been successfully used for different neoplasia.

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Insulin resistance in hidradenitis suppurativa: a case-control study

Abstract

Background

The association between chronic inflammatory diseases, such as rheumatoid arthritis and psoriasis, and insulin resistance (IR) has been well established. Hidradenitis suppurativa (HS) is a chronic inflammatory cutaneous disease that affects the apocrine gland-bearing areas of the body.

Objective

We aimed to determine the prevalence of IR in patients with HS.

Methods

This cross-sectional, case-control study enrolled 137 subjects, 76 patients with HS and 61 age- and gender-matched controls. Demographic data, clinical examination of HS patients, anthropometric measures, cardiovascular risk factors and laboratory studies were recorded. The homeostasis model assessment of IR (HOMA-IR) was calculated in all participants by measuring fasting plasma glucose and insulin levels.

Results

The median (IQR) HOMA-IR value in HS patients was significantly higher [2.0 (1.0-3.6)] than in controls [1.5(0.9-2.3)] (p=0.01). The prevalence of IR was significantly higher in cases (43.4%) compared with controls (16.4%) (p=0.001). In the linear regression multivariable analysis after adjusting for age, sex and body mass index (BMI), HS remained as a significant factor for a higher HOMA-IR [2.51(0.18) vs 1.92(0.21); p=0.04]. The HOMA-IR value and the prevalence of IR did not differ significantly among HS patients grouped by severity of the disease.

Conclusion

Our results show an increased frequency of IR in HS. Thus, we suggest HS patients to be evaluated for IR and managed accordingly.

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Effect of atopic skin stressors on natural moisturizing factors and cytokines in healthy adult epidermis

Abstract

Background

Epidermal deficiency of filaggrin, and the derived natural moisturizing factors (NMF), is associated with increased risk of atopic dermatitis (AD). While filaggrin gene mutations cause filaggrin deficiency, there is limited insight in causative environmental factors.

Objective

To explore the effect of selected exogenous skin stressors on NMF and skin cytokines levels in healthy adult epidermis.

Material and methods

40 healthy volunteers (18-49 years) were exposed to hard, soft, and chlorinated water, 0.5% SLS, house dust mite, cat allergen, staphylococcal enterotoxin B (SEB), cooling and histamine. Participants were tape-stripped and biophysiological measurements were performed. NMF was determined after 24 and 48 hours, while skin cytokines were measured after 24 hours for selected exposures.

Results

At 24 hours, a significant decrease in NMF was observed for soft (0.51±0.19) and hard water (0.61±0.32) compared to occlusion alone (0.71±0.18). Hard water led to increased levels of IL-4, IFN-ɣ and IL-10. Exposure to house dust mite and SEB led to a significant decrease in NMF after 24 hours (0.77 ±0.28 and 0.80±0.28, respectively) compared to occlusion alone (1.00±0.42). House dust mite led to an increase in IFN-ɣ, IL-2 and IL-4, as compared to the non-occluded control site.

Conclusion

Based on experimental exposure to selected atopic skin stressors such as different water types, allergens and SEB, we conclude that NMF levels are decreased along with increased secretion of various skin cytokines in healthy individuals. Our data highlight environmental factors that might play a role in AD pathophysiology, but needs confirmation in AD patients.

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Globular adiponectin acts as a melanogenic signal in human epidermal melanocytes

Summary

Background

Adiponectin is an adipocyte-derived cytokine which circulates as a full-length protein and a fragment containing the globular domain of adiponectin (gAd). A recent study has reported the anti-melanogenic effects of full-length adiponectin.

Objectives

To examine the involvement of gAd in melanogenesis and its action mechanisms.

Methods

The effects of gAd on melanogenesis and its mechanism of action were investigated in human epidermal melanocytes and reconstructed epidermis, and they included the levels of melanin content, cellular tyrosinase activity, cAMP production and protein kinase A (PKA) activity, expression and phosphorylation of signaling molecules.

Results

Exogenous gAd increased the melanin content, and the mRNA levels of microphthalmia-associated transcription factor (MITF) and its downstream genes tyrosinase and tyrosinase-related protein (TRP)-1, but not TRP-2, were increased by gAd. However, cAMP production and PKA activity were not affected by gAd. Moreover, attempts to elucidate the underlying mechanism behind the gAd-mediated effect revealed that gAd could regulate melanogenesis by upregulating MITF through phosphorylation of the cAMP response element-binding protein (CREB). In addition, upregulation of MITF was mediated through activation of adenosine monophosphate-activated protein kinase (AMPK)-p38MAPK signaling. Taken together, these findings indicate that promotion of melanogenesis by gAd occurs through increased expression of the MITF gene, which is mediated by activation of the AMPK-p38MAPK-CREB pathway.

Conclusions

These findings suggest that gAd contributes to epidermal homeostasis via its effect on melanocyte biology, and products of adipose tissue could affect epidermal biology.

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Tracheal injury detected immediately after median sternotomy by inexperienced surgeons: two case reports

Although median sternotomy is standard during cardiac surgery, the procedure is associated with a risk of injury to mediastinal organs. Here, we discuss two cases of tracheal injury following median sternotomy...

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Purpura induced by laser hair removal: a case report

Laser hair removal is an effective and safe method for the permanent reduction of unwanted hair. Common side effects include temporary pain, transient erythema, and perifollicular edema. Purpuric eruption is a...

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Does local factors alter discharge times after surgery?

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Evaluation of eczema, asthma, allergic rhinitis and allergies among the Grade-1 children of Iqaluit

Little is known about the prevalence of asthma, allergic rhinitis, eczema and allergies among Canadian Inuit children, especially those living in the arctic and subarctic areas.

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Quantity Over Quality: Metrics in Solid Organ Transplantation

No abstract available

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Management of severe portopulmonary hypertension with dual oral therapy prior to liver transplantation

No abstract available

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Small-for-size syndrome does not occur in intestinal transplantation without liver containing grafts

ABSTRACTBackgroundThe ideal donor in intestinal transplantation is generally considered to be 50 – 70% of recipient body weight. This may be due to concerns for "small for size" syndrome as seen in liver transplantation. We report our experience using smaller donors (donor-recipient weight ratio, DRWR 50%. We examined patient and graft survival and enteral autonomy from parenteral nutrition as surrogate markers for safety of using smaller donors and ease of abdominal wall closure between groups to determine the value.ResultsThere was no difference in overall patient and graft survival, time to enteral autonomy from parenteral nutrition and weight gain after ITX over time between groups. Need for complicated abdominal closure techniques were significantly more frequent in the control group than in the study group (34.6% versus 6.9%, p = 0.01). Secondary abdominal closure occurred more frequently in the control group (15.4% versus 0%, p = 0.014). Wound revisions also occurred more frequently in the control group (15.4% versus 0%, p = 0.028).ConclusionsOur data suggest that ITX using smaller donors (DRWR ≤ 50%) seems to be an acceptable practice without adverse impact on surgical complications, nutritional autonomy, and patient and graft survival. Abdominal wall closure seems easier in recipients of smaller donors and 'small for size' syndrome as described in liver transplantation does not occur with intestinal allografts. Background The ideal donor in intestinal transplantation is generally considered to be 50 – 70% of recipient body weight. This may be due to concerns for "small for size" syndrome as seen in liver transplantation. We report our experience using smaller donors (donor-recipient weight ratio, DRWR 50%. We examined patient and graft survival and enteral autonomy from parenteral nutrition as surrogate markers for safety of using smaller donors and ease of abdominal wall closure between groups to determine the value. Results There was no difference in overall patient and graft survival, time to enteral autonomy from parenteral nutrition and weight gain after ITX over time between groups. Need for complicated abdominal closure techniques were significantly more frequent in the control group than in the study group (34.6% versus 6.9%, p = 0.01). Secondary abdominal closure occurred more frequently in the control group (15.4% versus 0%, p = 0.014). Wound revisions also occurred more frequently in the control group (15.4% versus 0%, p = 0.028). Conclusions Our data suggest that ITX using smaller donors (DRWR ≤ 50%) seems to be an acceptable practice without adverse impact on surgical complications, nutritional autonomy, and patient and graft survival. Abdominal wall closure seems easier in recipients of smaller donors and 'small for size' syndrome as described in liver transplantation does not occur with intestinal allografts. CORRESPONDENCE: Jang I Moon, One Gustave L. Levy Place, Box 1104. New York, NY 10029–6574. jang.moon@mountsinai.org AUTHORSHIP Jang Moon: Participated in research design, data collection, statistical analysis and composing manuscript. Thomas D Schiano: Participated in research design and reviewing data. Alyssa Burnham: Participated in data collection. Kwai Lam: Participated in data collection. Kishore R Iyer: Participated in research design, reviewing data and composing manuscript. DISCLOSURE The authors declare no conflicts of interests. FUNDING This study does not have funding support. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Survival and quality of life impact of a risk-based allocation algorithm for deceased donor kidney transplantation

Background To determine the incremental gains in graft and patient survival under a risk-based, deceased donor kidney allocation compared to the current Australian algorithm. Methods Risk-based matching algorithms were applied to first graft, kidney only recipients (n=7513) transplanted in Australia between 1994 and 2013. Probabilistic models were used to compare the waiting time, life and quality-adjusted life years and graft years between the 8 risk-based allocation strategies against current practice. Results Compared to current practice, KDRI-EPTS matching of the lowest 20% of scores reduced median waiting time by 0.64 years (95% CI: 0.52–0.73) for recipients aged ≤ 30 years, but increased waiting time by 0.94 years (95% CI: 0.79 – 1.09) for recipients aged > 60 years. Among all age groups, the greatest gains occurred if KDRI-EPTS matching of the lowest 30% of scores was used, incurring a median overall gain of 0.63 (95% CI: 0.03–1.25) life years and 0.78 (95% CI: 0.30 – 1.26) graft years compared to current practice. A median gain in survival of 1.91 years for younger recipients (aged 30–45 years) was offset by a median reduction in survival (by 0.95 life years) among the older recipients. Prioritisation of lower quality donor kidneys for older candidates reduced the waiting time for recipients aged > 45 years, but no changes in graft and patient survivals were observed. Conclusions Risk-based matching engendered a moderate, overall increase in graft and patient survival, accrued through benefits for recipients aged ≤ 45 years but disadvantage to recipients aged > 60 years. Corresponding author: Germaine Wong, Sydney School of Public Health, The University of Sydney, Camperdown, 2006 Australia. Email: germaine.wong@health.nsw.gov.au Acknowledgments We would like to thank all clinicians, nurses, patients and clinical research staff who have contributed data to the Australia and New Zealand Dialysis and Transplant Registry. Funding: The study is funded by the BEAT-CKD Program Grant (APP1092579). Contributors: VC and GW had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses. VC and GW conceived and designed the study. All authors acquired and interpreted the data, revised the manuscript, and gave final approval of the manuscript. VC and GW drafted the manuscript. VC and GW and JY were responsible for the statistical analyses and the figures. Disclosure: No authors have any financial relationships with any organisations that might have any interests in the submitted work, and no other relationships or activities that may have influenced the conduct of the submitted work. Ethical approval: Only de-identified data were used. Ethics approval for this study was not required. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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The Changing Epidemiology of Posttransplant Lymphoproliferative Disorder in Adult Solid Organ Transplant Recipients Over 30 Years: A Single Center Experience

AbstractBackgroundPosttransplant lymphoproliferative disorders (PTLD) are a complication of solid organ transplantation (SOT) associated with Epstein-Barr virus (EBV).MethodsWe analyzed the incidence of and risk factors for PTLD among adult SOT recipients at our center over 30 years (1984–2013). We also compared PTLD incidence before and after a prevention strategy of EBV viral load monitoring in EBV serology mismatched patients was adopted in 2001 (ie transplant era 1 (1983–2001) vs era 2 (2002–13)).ResultsAmong 4171 SOT patients, 109 developed PTLD. Cumulative incidence at 1, 10 and 20 years posttransplant was 0.95, 2.3 and 3.5 per 100 person-years, respectively. Beyond the first year peak of almost exclusively EBV positive PTLD, a lower incidence of PTLD, predominantly EBV negative, persisted for 20 years. Thoracic transplant (hazard ratio (HR) 2.1, p=0.007) and negative EBV serology (HR 7.7, p

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Predicting Liver Allograft Discard: The Discard Risk Index

AbstractBackgroundAn index that predicts liver allograft discard can effectively grade allografts and can be used to preferentially allocate marginal allografts to aggressive centers. Aim: to devise an index to predict liver allograft discard using only risk factors available at the time of initial DonorNet offer.MethodsUsing univariate and multivariate analyses on a training set of 72,297 deceased donors, we identified independent risk factors for liver allograft discard. Multiple imputation was used to account for missing variables.ResultsWe identified 15 factors as significant predictors of liver allograft discard; the most significant risk factors were: total bilirubin > 10 mg/dl (OR 25.23, CI 17.32-36.77), donation after cardiac death (OR 14.13, CI 13.30-15.01), and total bilirubin 5 – 10 mg/dl (OR 7.57, CI 6.32-9.05). The resulting Discard Risk Index (DSRI) accurately predicted the risk of liver discard with a C-statistic of 0.80. We internally validated the model with a validation set of 37,243 deceased donors and also achieved a 0.80 C-statistic. At a DSRI at the 90th percentile, the discard rate was 50% (OR 32.34 CI 28.63-36.53), while at a DSRI at the 10th percentile only 3% of livers were discarded.ConclusionsThe use of the DSRI can help predict liver allograft discard. The DSRI can be used to effectively grade allografts and preferentially allocate marginal allografts to aggressive centers in order to maximize the donor yield and expedite allocation. Background An index that predicts liver allograft discard can effectively grade allografts and can be used to preferentially allocate marginal allografts to aggressive centers. Aim: to devise an index to predict liver allograft discard using only risk factors available at the time of initial DonorNet offer. Methods Using univariate and multivariate analyses on a training set of 72,297 deceased donors, we identified independent risk factors for liver allograft discard. Multiple imputation was used to account for missing variables. Results We identified 15 factors as significant predictors of liver allograft discard; the most significant risk factors were: total bilirubin > 10 mg/dl (OR 25.23, CI 17.32-36.77), donation after cardiac death (OR 14.13, CI 13.30-15.01), and total bilirubin 5 – 10 mg/dl (OR 7.57, CI 6.32-9.05). The resulting Discard Risk Index (DSRI) accurately predicted the risk of liver discard with a C-statistic of 0.80. We internally validated the model with a validation set of 37,243 deceased donors and also achieved a 0.80 C-statistic. At a DSRI at the 90th percentile, the discard rate was 50% (OR 32.34 CI 28.63-36.53), while at a DSRI at the 10th percentile only 3% of livers were discarded. Conclusions The use of the DSRI can help predict liver allograft discard. The DSRI can be used to effectively grade allografts and preferentially allocate marginal allografts to aggressive centers in order to maximize the donor yield and expedite allocation. Corresponding Author: Abbas Rana, MD, Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1425, Houston, Texas 77030, USA. Telephone: (713) 321–8423. Fax: (713) 610–2479. abbas.rana@bcm.edu Authorship Page Abbas Rana MD: Study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript Rohini R. Sigireddi BA: Drafting of manuscript Karim J. Halazun MD: Critical revision of manuscript Aishwarya Kothare: Critical revision of manuscript Meng-Fen Wu MS: Critical revision of manuscript Hao Liu PhD: Critical revision of manuscript Michael L. Kueht MD: Critical revision of manuscript John M. Vierling MD: Drafting of manuscript Norman L. Sussman MD: Critical revision of manuscript Ayse L. Mindikoglu MD: Critical revision of manuscript Tamir Miloh MD: Critical revision of manuscript N. Thao N. Galvan MD: Critical revision of manuscript Ronald T. Cotton MD: Critical revision of manuscript Christine A. O'Mahony MD: Critical revision of manuscript John A. Goss MD: Drafting of manuscript Disclosures: None Funding: None Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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International Liver Transplant Society Consensus Statement on IMMUNOSUPPRESSION IN LIVER TRANSPLANT RECIPIENTS

No abstract available

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Improvement of Color Vision Following Posterior Cranial Vault Distraction for Crouzon Syndrome

Crouzon syndrome (CS) is one of the craniosynostosis syndromes that leads to early fusion of cranial sutures and increased intracranial pressure. Intracranial hypertension is a serious complication that may lead to vision loss and cognitive impairment. Early detection and management are necessary to prevent complications. The authors present a patient with CS who underwent posterior cranial vault reconstruction with internal distraction after multiple episodes of headache and papilledema. The patient was unaware of any loss of color vision before the surgery; however, he noted an improvement in his color vision after the surgery. Color vision deficits may be an early sign of intracranial hypertension and finding these deficits using noninvasive testing methods may be an indication for early intervention. Address correspondence and reprint requests to Arlen D. Denny, MD, Department of Plastic Surgery, Children's Hospital of Wisconsin, PO Box 1997, Suite C340, Milwaukee, WI 53201-1997; E-mail: adenny@chw.org; Kristen A. Klement, MD, Medical College of Wisconsin, Hartland, WI; E-mail: kklement@mcw.edu Received 30 April, 2017 Accepted 11 November, 2017 This work was supported by resources of the Department of Plastic Surgery, Medical College of Wisconsin. The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Dental Anomalies in Different Types of Cleft Lip and Palate: Is There Any Relation?

Aim: The aims of this study were to evaluate the prevalence of dental anomalies in Turkish patients with different types of cleft lip and palate (CLP) and investigate the relationship between the type of cleft and the dental anomaly. Methods: Eighty-eight patients with cleft lip and/or palate (mean age: 14.1 ± 6.4 years) were enrolled in this retrospective study. Dental models, panoramic radiographs, and intraoral photographs of these patients were evaluated to detect any maxillary dental anomaly (number and size anomalies). Two hundred fifty unaffected subjects (mean age: 15.2 ± 7.2 years) composed the control group. Data were evaluated using the independent t test, χ2, Fischer exact test, and the odds ratio. Results: Dental anomaly frequency was significantly higher in the cleft group compared with the control group. Tooth agenesis was the most common dental anomaly, followed by microdontia and supernumerary tooth. Lateral incisor agenesis was seen in 69% of the unilateral CLP, in 78% of the bilateral CLP, and in 18% of the cleft palate patients. A significant association was revealed between the right unilateral CLP and the right lateral incisor agenesis (P = 0.0001), the left unilateral CLP and the left lateral incisor agenesis (P = 0.002), and the bilateral CLP and the bilateral lateral incisor agenesis (P = 0.0001). Conclusion: Dental anomalies are more frequently seen in patients with CLP compared with the general population. There is a relationship between the cleft type and the ipsilateral lateral incisor agenesis. Address correspondence and reprint requests to Derya Germec Cakan, DDS, PhD, Department of Orthodontics, Faculty of Dentistry, Yeditepe University, Bagdat cad. No. 238, Goztepe 34728, Istanbul, Turkey; E-mail: dgermec@gmail.com Received 7 June, 2017 Accepted 12 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Cervical Spine Dysmorphism in Congenital Muscular Torticollis

Background: Congenital muscular torticollis is a common childhood musculoskeletal anomaly that might result in permanent craniofacial deformity, facial asymmetry, and changes in the cervical vertebrae, if not treated during early childhood. Although there have been many studies on cervical vertebral changes, their onset in children has not been previously studied. Methods: Fifteen patients (aged

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Closure of Oroantral Communication With Plasma-Rich Fibrin Membrane

Oroantral communication (OAC) is the opening between the maxillary sinus and oral cavity. It may cause oroantral fistula or maxillary sinusitis if left untreated. The surgical closure of the OAC within 48 hours was recommended to avoid the complications like sinus infections. The aim of this study is to evaluate the treatment of OACs with plasma-rich fibrin (PRF) which is safe and easy to implement in the OACs. This study was conducted with the patients, who required the treatment of the OAC, which was developed after the posterior maxillary tooth extraction in the Dental and Maxillofacial Department of the Faculty of Dentistry in Adnan Menderes University. Plasma-rich fibrin membranes were inserted in layers into the tooth socket so that they covered the OAC. Then these membranes were fixated with the sutures to the surrounding gingiva. Antibiotic (amoxicillin/clavulanic acid 1000 mg), analgesic (dexketoprofen trometamol and/or paracetamol), and oral rinse (0.2% chlorhexidine digluconate) agents were prescribed to all patients. The patients were examined in the 3rd and 7th days and 2 months after the operation. All patients tolerated PRF perfectly, and the soft tissue recovery was completed without any problem. Full epithelization was observed in the defect area in all patients. The OAC did not relapse in any patient. Plasma-rich fibrin technique is a simple and effective method, which can be used in the treatment of OACs with a diameter of 5 mm or less with a low risk of complications. Address correspondence and reprint requests to Umut Demetoglu, DDS, PhD, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Adnan Menderes University, Aydin, Turkey; E-mail: uddt2005@hotmail.com Received 31 July, 2017 Accepted 13 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Robin Sequence: Continuing Heterogeneity in Nomenclature and Diagnosis

Objective: Heterogeneity in both nomenclature and diagnostic criteria has hindered the interpretation of research into the congenital condition most widely known as (Pierre) Robin syndrome or sequence. In 2009, the discussion regarding its diagnosis and nosology was reopened to converge on a uniform eponym and standard set of diagnostic criteria. The objective of this study was to assess the impact of this debate. Materials and Methods: This is a retrospective review of the nomenclature and diagnostic criteria employed in studies about this condition that were indexed in the MEDLINE literature database (PubMed) and published during 2009 to 2016. Results: A total of 440 studies were retrieved of which the majority used the eponyms "Pierre Robin sequence" (62.0%) or "Robin sequence" (23.4%). During the study period, there was a significant shift toward the use of "sequence" in preference over "syndrome." Only 71.4% of studies mentioned their criteria for diagnosis, which remained heterogeneous throughout the study period. Conclusion: Since 2009, the debate has not produced a consensus eponym and standard diagnosis. This is unfortunate given the enduring controversies over the optimal management of a condition associated with a high morbidity and mortality. A renewed effort is needed to arrive at a workable consensus to enhance the retrievability of relevant literature and facilitate the interpretation of outcome studies. Address correspondence and reprint requests to Daan P.F. van Nunen, MD, Cleft Center Utrecht, Division of Plastic and Reconstructive Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands; E-mail: D.P.F.vanNunen@gmail.com Received 23 September, 2017 Accepted 15 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Innovate Global Plastic and Reconstructive Surgery: Cleft Lip and Palate Charity Database

Background: There is an emerging interest in global surgery. The Lancet Commission on Global Surgery recognizes the important role that nongovernmental organizations (NGOs) play in the delivery of cleft lip and/or palate (CLP) surgical care. To better address the unmet burden of surgical disease, the commissioners propose the use of a centralized registry to maximize coordination of global surgical volunteerism efforts. This study aims to create a comprehensive database of CLP organizations. Methods: A systematic search of the following resources was conducted: The Plastic Surgery Foundation, Smile Train, Wikipedia, Google, and lists of surgical NGOs. A secondary review of each organization's website was performed to verify inclusion criteria and to extract data. Organizations were classified as providing surgical or nonsurgical care. Results: Thirty-one organizations providing CLP care were reviewed, with 30 that met inclusion criteria. Of the 20 surgical NGOs, 50% use a diagonal approach of international outreach, 40% a vertical one-way approach, and 10% a horizontal approach. All 10 of the nonsurgical NGOs provide care through a horizontal approach. Their offices are distributed across North America (43%), Asia (27%), Europe (23%), and Australia (7%). Forty-three percent of the organizations provide CLP surgeries or services in more than 1 country; 93% do so with a multidisciplinary team. A majority of the organizations established collaborations with host institutions (80%). Conclusion: To the authors' best knowledge, this database includes the largest collection of CLP organizations. This list will be made publicly available to inform surgical care planning, facilitate collaboration, and promote further research. Address correspondence and reprint requests to Pinkal S. Patel, BSc, MD Candidate, Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8; E-mail: pinkal.patel@medportal.ca Received 23 September, 2017 Accepted 22 December, 2017 Presented at: 71st Annual Meeting of the Canadian Society of Plastic Surgeons in Winnipeg, Manitoba; June 21–24, 2017. The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Comment on Orbital Fat Prolapse Into the Nasal Cavity in Orbital Blowout Fracture

No abstract available

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Scanning Electron Microscopy Evaluation of Root Surfaces After Instrumentation With Two Piezoelectric Devices

Scanning electron microscopy evaluation of root surfaces after ultrasonic instrumentation was performed with 2 different metallic tips on piezoelectric devices. Fresh extracted teeth were collected for experimental observation and randomly divided into 2 groups: Test Group, where the root surfaces were treated using an iron, rough, double nano-structural coated (T-Black), corindone-treated tip, and Control Group where the root surfaces were treated with a conventional iron smooth tip. A scanning electronic microscope analysis was performed and the surface roughness and the amount of residual debris were evaluated. Descriptive and inferential statistics were performed. Twenty specimens were analyzed, 10 per group and a total of 21.4 × 106 μm2 has been observed. On treated area percentage of debris after ultrasonic scaling in Test Group was 1.9 ± 1.8%, while in Control Group it was 5.7 ± 4.3%. Within the limits of the study, it seems that the efficacy of the novel iron, rough, double nano-structural coated (T-Black), corindone-treated structure tip showed greater performance in terms of root surface debridement than the conventional iron smooth tip. The possibility to use a single tool (ultrasonic device with a specific tip) for the root planing procedure within the nonsurgical mechanical therapy may represent a significant advantage for the clinicians. The tested novel tip seems to be able to show the requested ideal characteristics. However, further clinical studies are needed to demonstrate the in vitro results. Address correspondence and reprint requests to Antonio Scarano, DDS, MD, MS, Via Dei Vestini 31, 66100 Chieti, Italy; E-mail: carmen.mortellaro@med.unipmn.it Received 11 August, 2017 Accepted 17 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Osteofascial Radial Forearm Free Flap Reconstruction of Midface Defect After Resection of Intraosseous Hemangioma

Introduction: Intraosseous hemangiomas of the midface are rare with few reported cases in the literature. Various reconstructive methods have been previously described, but none using vascularized bone graft secondary to the benign nature of the tumor and often relatively limited defect size. Clinical Report: The authors present the case of a 47-year-old man with a biopsy proven enlarging right maxillary intraosseous cavernous hemangioma which was resected primarily, resulting in a large defect involving the entire zygomaticomaxillary buttress and a portion of the right orbital floor and malar prominence. Given the structural involvement and the significant bony defect size, this was simultaneously reconstructed using an osteofascial radial forearm free flap and orbital floor titanium implant with satisfactory outcome. Address correspondence and reprint requests to Jeffrey Johnson, MD, Department of Otorhinolaryngology—Head and Neck Surgery, University of Texas Medical School at Houston, 6431 Fannin Street MSB 5.036 Houston, TX 77030; E-mail: jeffrey.johnson@uth.tmc.edu Received 12 November, 2017 Accepted 12 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Spontaneous Resolution of an Orbital Mass After Delivery: A Diagnostic Challenge

The authors report a 35-year-old woman who presented 1 month after delivery with the complaint of pain behind her left eye which started during her pregnancy. The patient described increased fullness with dependent head position and pain on left gaze but she had no proptosis and her ocular examination was normal. Magnetic resonance imaging (MRI) revealed an intraconal mass with inhomogeneous contrast enhancement. As the authors did not suspect malignity and her ocular examination was normal without any signs of inflammation, the authors followed the patient closely. Repeat MRI obtained 6 months after delivery revealed complete resolution of the mass. Upon disappearance of the lesion, the authors reviewed the case thoroughly and decided that orbital venous anomaly with intralesional hemorrhage/thrombosis was the most probable diagnosis. As hemorrhage or thrombosis occurring in orbital vascular anomalies may be a diagnostic challenge because of the localized lesion and distinct borders, careful interpretation of clinical characteristics and MRI findings and close follow-up is important in interpretation of orbital mass lesions, especially in pregnant or puerperal women. Address correspondence and reprint requests to Zeynep Dadaci, MD, Medova Hospital, Seyh Samil M. Dosteli C. No: 52/1, 42070 Selcuklu, Konya, Turkey; E-mail: zdadaci@hotmail.com Received 7 December, 2017 Accepted 29 December, 2017 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Comparison of the Effects of Cigarette Smoking on Male and Female Vocal Folds

Objective: To investigate effects of smoking cigarette on male and female larynges and compare them. Method: Eighteen adult Wistar Albino rats were included to study; 9 were male and 9 female. The exposure groups each contained 6 rats, and the control groups 3 rats. Six male constituted group 1 and 6 female constituted group 2. Group 1 and 3 were exposed to smoke. Group 2 and 4 were composed of 3 males and 3 females, respectively. Smoke from 10 cigarettes was delivered in each of the morning and afternoon daily for 1 month. At the end of 4 weeks, all rats were sacrificed and their larynges were evaluated histopathologically. Results: Microscobic evaluation of epithelium of vocal folds revealed no significant difference between study groups. There was also no difference between study and control groups. Subepitelial tissue showed no difference between study groups but angiogenesis and inflammation were higher in study groups. Epithelial analysis of false vocal folds showed significant difference between study groups. Female epithelium showed more hyperplastic and metaplastic changes. Conclusion: Cigarette smoke damaged both the vocal folds and false vocal folds. The female false vocal folds were more susceptible to damage than the males. Address correspondence and reprint requests to Erdi Ozdemir, MD, Darülaceze Cad. No:25 Okmeydani Şişli/Istanbul, Turkey; E-mail: erdiozdemir67@hotmail.com Received 16 August, 2017 Accepted 5 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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The Guiding Lateral Z Osteotomy for the Correction of Vertical Orbital Dystopia

Transcranial vertical orbital translocation is useful for correcting vertical orbital dysplasia. However, the technique is limited by the degree of uncertainty regarding the amount of vertical movement required after the osteotomy. As for landmark movement, Z osteotomy is performed as part of a box osteotomy. This technique is useful in that it is easy to know how far the orbit should be moved, and stabilization can be obtained. Address correspondence and reprint requests to Yoshiaki Sakamoto, MD, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ward, Tokyo 160–8582, Japan; E-mail: ysakamoto@z8.keio.jp Received 17 August, 2017 Accepted 5 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Large-Scale Skin Resurfacing of the Upper Extremity in Pediatric Patients Using a Pre-Expanded Intercostal Artery Perforator Flap

Background: The repair of extensive upper limb skin lesions in pediatric patients is extremely challenging due to substantial limitations of flap size and donor-site morbidity. We aimed to create an oversize preexpanded flap based on intercostal artery perforators for large-scale resurfacing of the upper extremity in children. Method: Between March 2013 and August 2016, 11 patients underwent reconstructive treatment for extensive skin lesions in the upper extremity using a preexpanded intercostal artery perforator flap. Preoperatively, 2 to 4 candidate perforators were selected as potential pedicle vessels based on duplex ultrasound examination. After tissue expander implantation in the thoracodorsal area, regular saline injections were performed until the expanded flap was sufficient in size. Then, a pedicled flap was formed to resurface the skin lesion of the upper limb. The pedicles were transected 3 weeks after flap transfer. Flap survival, complications, and long-term outcome were evaluated. Result: The average time of tissue expansion was 133 days with a mean final volume of 1713 mL. The thoracoabdominal flaps were based on 2 to 6 pedicles and used to resurface a mean skin defect area of 238 cm2 ranging from 180 to 357 cm2. In all cases, primary donor-site closure was achieved. Marginal necrosis was seen in 5 cases. The reconstructed limbs showed satisfactory outcome in both aesthetic and functional aspects. Conclusion: The preexpanded intercostal artery perforator flap enables 1-block repair of extensive upper limb skin lesions. Due to limited donor-site morbidity and a pedicled technique, this resurfacing approach represents a useful tool especially in pediatric patients. Address correspondence and reprint requests to Feng Xie, MD, PhD, Qingfeng Li, MD, PhD, and Chuanchang Dai, MD, PhD, Department of Plastic and Reconstructive Surgery, Ninth People's Hospital of Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, People's Republic of China; E-mail: xiefenghe@163.com; dr.liqingfeng@yahoo.com; dr.9hospital@hotmail.com Received 23 August, 2017 Accepted 5 January, 2018 JW and TH contributed equally to this work. This work was supported by National Natural Science Foundation of China (no. 81230042). The authors have no conflicts of interest to disclose. © 2018 by Mutaz B. Habal, MD.

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Craniovertebral Junction Abnormalities in Surgical Patients With Congenital Muscular Torticollis

Our clinical experience led us to realize that craniovertebral junction (CVJ) abnormalities were common in surgical patients with congenital muscular torticollis (CMT). This study aimed to report the concurrence rate of CVJ abnormalities in surgical patients with CMT, along with comprehensive evaluation of type of concurrent CVJ abnormalities. This was a retrospective cohort study in a tertiary hospital, including 41 subjects who underwent surgical release for CMT at the mean age of 8.38 years. The presence of CVJ abnormalities was analyzed, using craniofacial 3-dimensional computed tomography images. The concurrence rate of CVJ abnormalities was 70% in surgical patients with CMT. Subjects with CVJ abnormalities had, on average, 1.48 abnormalities. The CVJ abnormalities were rotation and lateral shift of the atlanto-axial joint along with rotation of atlanto-occipital joint, where rotation of the atlanto-axial joint was most common (82.76%). There is no patient with anterior shift of the atlanto-axial joint. Chronic mechanical tension by the contracted unilateral sternocleidomastoid muscle of CMT could be responsible for concurrent CVJ abnormalities. The CVJ abnormalities are more common in the atlanto-axial joint than in the atlanto-occipital joint. In conclusions, CVJ abnormality seems to be a common concurrent skeletal complication of CMT, at least, in surgical patients. The CVJ abnormality might be included in the list of skeletal complications of CMT. If CVJ abnormalities are significantly more common in surgical patients with CMT, CVJ abnormalities might be one of predictors of surgical patients with CMT. Address correspondence and reprint requests to Shin-Young Yim, MD, PhD, Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, The Center for Torticollis, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea; E-mail: syyim@ajou.ac.kr Received 24 August, 2017 Accepted 5 January, 2018 This work was supported by the grants through the National Research Foundation of Korea funded by the Ministry Science, ICT and Future Planning, Republic of Korea (2016R1A2B1010654). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Comment on: Facial Artery Myomucosal Flap, Pedicled Solely on the Facial Artery Experimental Design Study on Survival

No abstract available

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Ligaments of the Face: Past, Present, and Future

The aim of this study is to search for the origin of the term "ligament" in the face, present its status, and suggest a principle to rectify the use of unclear terminology. The structure that connects the zygoma to the skin was first presented by McGregor (1959). Kaye (1981), in describing his "extended facelift," wrote that the adherent area of the cheek over the malar eminence (McGregor's patch) usually requires sharp dissection. Bosse (1987) reported that the zygomatic ligament is quite solidly bound to the malar eminence and usually requires sharp dissection to release it. The origin of the term was introduced later by Furnas, who stated that when Preddy, a medical artist, prepared drawings for McGregor's slide presentations, she insisted on naming it "McGregor's patch." With the idea that "perhaps" the "retaining ligaments" of the face share a teleologic kinship with Cleland's ligaments or Grayson's ligaments of the hands, Furnas (1989) observed the structure that anchors the skin of the cheek to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle, and named it "the zygomatic ligaments." Subsequently, numerous articles have been published using different terminologies that cause confusion. To rectify the present confusing terminology of the ligament of face, the histologically proven structures should be designated by one term only following the Nomina Anatomica principles. Address correspondence and reprint requests to Kun Hwang, MD, PhD, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea; E-mail: jokerhg@inha.ac.kr Received 28 August, 2017 Accepted 7 January, 2018 This study was supported by a grant from Inha University Hospital. The authors report no conflict of interest. © 2018 by Mutaz B. Habal, MD.

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Pulling and Pushing Stem Cells to Control Their Differentiation

Much has already been done to achieve precisely controlled and customised regenerative therapies. Thanks to recent advances made in several areas relevant to regenerative medicine including the use of stimuli-responsive materials, 4-dimensional biofabrication, inducible pluripotent stem cells, control of stem cell fate using chemical and physical factors, minimal access delivery, and information-communication technology. In this short perspective, recent advances are discussed with a focus on a recent report on the use of mechanical stretching of nanoparticle-laden stem cells by using external magnetic field to induce defined cardiac line differentiation. Although more and more tools are becoming available for engineering tissue models tissues and the range of potential applications is expanding, there is still much work to be done before it is proved to work with human cells, form tissues and ultimately achieve application in the clinic. Address correspondence and reprint requests to Nureddin Ashammakhi, MD, PhD, Department of Surgery, Oulu University Hospital, P.O. Box 22, FI-90220 Oulu, Finland; E-mail: nureddin.ashammakhi@oulu.fi Received 23 November, 2017 Accepted 13 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Is Coincidental Rhinosinusitis a Predisposing Factor for Postoperative Central Nervous System Infection After Endoscopic Endonasal Transsphenoidal Surgery?

Background: To investigate the effect of rhinosinusitis in patients who undergo surgery via the endoscopic endonasal transsphenoidal approach (EETSA). Methods: The authors retrospectively reviewed the medical records of patients who underwent surgery via the EETSA between February 2009 and November 2016. In total, 505 patients were included in the study. Preoperative paranasal sinus computed tomography, sellar magnetic resonance imaging, and nasal endoscopy were performed for all the patients. Results: Fifteen patients without sphenoid sinusitis underwent surgery with the concomitant transsphenoidal approach and functional endoscopic sinus surgery, and showed no central nervous system (CNS) complication. During surgery via the EETSA, the presence of rhinosinusitis did not significantly affect the incidence of postoperative CNS infection (P = 0.051), except for sphenoid sinusitis (P = 0.003). Conversely, the incidence of postoperative CNS infection was not related significantly to the Lund–Mackay score or tumor size. The risk of CNS infection was 12.151-fold higher in patients with sphenoid sinusitis (95% confidence interval, 3.153–46.827; P ≤ 0.001). Conclusion: Surgery via the EETSA and functional endoscopic sinus surgery can be safely performed together in most patients with rhinosinusitis. However, sphenoid sinus infection appears to be a predisposing factor for postoperative CNS infection. Therefore, a separate surgical procedure for sphenoid lesions should be considered in these patients before the use of the EETSA. Address correspondence and reprint requests to Sung Won Kim, MD, PhD, Department of Otolaryngology—Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul 137-701, Republic of Korea; E-mail: kswent@catholic.ac.kr Received 16 October, 2017 Accepted 3 January, 2018 This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (No. NRF-2017R1D1A1B03027903) and by the Korea Health Industry Development Institute funded by the Ministry of Health and Welfare (HI14C3228). The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Review of “Why Do General Surgeons Decide to Retire? A Population-Level Survey” by Poushay HM, Kagedan DJ, Hallet J, Conn LG, Beyfuss K, Nadler A, Ahmed N, Wright FC in Ann Surg 267: e4–e5, 2018

No abstract available

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Skull Base Metastasis From Occult Renal Cell Carcinoma

Skull base metastases are extremely rare. The authors report a case of a 65-year-old man who presented with a headache and diplopia secondary to a skull base metastasis from occult renal cell carcinoma. Since there were no other systemic metastases, radical nephrectomy and radiotherapy of the unresectable skull base location were performed. He subsequently received immunotherapy with sunitinib, everolimus, and sorafenib with local and systemic control of the disease after 53 months from surgery. When metastasis is unresectable radical nephrectomy and radiotherapy aimed at the metastasis may be of benefit improving quality of life. Immunotherapy may provide alternative treatment strategies improving the outcomes of patients affected by this rare pathology with historically poor prognosis. Address correspondence and reprint requests to Maria Silvia Rosa, MD, Division of ENT Department—Head and Neck Surgery, University of Piemonte Orientale "A. Avogadro," Corso Mazzini 18, 28100 Novara, Italy; E-mail: m.silviarosa@gmail.com Received 18 September, 2017 Accepted 14 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Bronchiectasis in severe asthma: clinical features and outcomes

Publication date: Available online 27 February 2018
Source:Annals of Allergy, Asthma & Immunology
Author(s): Isabel Coman, Beatriz Pola-Bibián, Pilar Barranco, Gemma Vila-Nadal, Javier Dominguez-Ortega, David Romero, Carlos Villasante, Santiago Quirce
BackgroundBronchiectasis are increasingly identified in subjects with severe asthma and could contribute to disease severity.ObjectiveWe aimed to determine the prevalence of bronchiectasis in our population of subjects with severe asthma and to better characterize the clinical features of these patients and their outcomes.MethodsWe retrospectively reviewed the medical files of 184 subjects with confirmed severe asthma who had undergone a high resolution thoracic computed tomography and compared the characteristics and outcomes of subjects with and without bronchiectasis.ResultsBronchiectasis were identified in 86 (47%) patients. These patients had concomitant hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) (OR 2.24, 95% CI 1.00-5.03) and gastroesophageal reflux disease (GERD) (OR 1.89, 95% CI 1.05-3.41) more frequently than subjects without bronchiectasis, but less atopic dermatitis (OR 0.188, 95% CI 0.04-0.88). Subjects with bronchiectasis were more frequently hospitalized for asthma exacerbations (OR 2.09, 95% CI 1.08-4.05) and had higher blood eosinophil levels (464 vs 338, p 0.005) than subjects without bronchiectasis.ConclusionOur study suggests that in subjects with severe asthma, the presence of bronchiectasis is associated with more frequent hospitalizations, concomitant GERD, hypersensitivity to NSAIDs and higher blood eosinophilia. Bronchiectasis could represent an additional phenotypic feature of severe eosinophilic asthma.

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Treatment of hypereosinophilic syndrome and eosinophilic dermatitis with reslizumab

Publication date: Available online 26 February 2018
Source:Annals of Allergy, Asthma & Immunology
Author(s): Merin Kuruvilla
Hypereosinophilic syndrome (HES) is a rare disease defined by organ damage directly attributable to hypereosinophilia that is either primary (neoplastic), secondary (reactive) or idiopathic. The mainstay of therapy in idiopathic HES centers around systemic steroids, and cytoreduction with hydroxyurea and interferon-alfa in steroid refractory cases. We describe the successful treatment of recalcitrant, idiopathic cutaneous HES with reslizumab, a humanized interleukin-5 blocker.

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Human factors study in untrained adolescents comparing an epinephrine prefilled syringe (symjepi™) with EpiPen® autoinjector

Publication date: Available online 27 February 2018
Source:Annals of Allergy, Asthma & Immunology
Author(s): Ronald B. Moss, Karen Daniels, Thomas Moll, Dennis J. Carlo

http://ift.tt/2FzoZVc

Developmental characteristics of secondary cartilage in the mandibular condyle and sphenoid bone in mice

Publication date: May 2018
Source:Archives of Oral Biology, Volume 89
Author(s): Hidetomo Hirouchi, Kei Kitamura, Masahito Yamamoto, Kento Odaka, Satoru Matsunaga, Koji Sakiyama, Shinichi Abe
ObjectiveSecondary cartilage develops from osteochondral progenitor cells. Hypertrophic chondrocytes in secondary cartilage increase within a very short time and then ossify rapidly. In the present study, we investigated the sequential development process of osteochondral progenitor cells, and the morphology and size of hypertrophic chondrocytes in secondary cartilage.DesignICR mice at embryonic days (E) 14.5–17.5 were used. The mandibular condyle and the medial pterygoid process of the sphenoid bone were observed as secondary cartilage, and the cranial base and the lateral pterygoid process of the sphenoid bone, which is primary cartilage, were observed as a control. Thin sections were subjected to immunostaining and alkaline phosphatase (ALP) staining. Using a confocal laser microscope, 3D stereoscopic reconstruction of hypertrophic cells was performed. To evaluate the size of hypertrophic chondrocytes objectively, the cell size was measured in each cartilage.ResultsHypertrophic chondrocytes of secondary cartilage first expressed type X collagen (Col X) at E15.5. SRY-box 9 (Sox 9) and ALP were co-expressed in the fibroblastic/polymorphic tissue layer of secondary cartilage. This layer was very thick at E15.5, and then rapidly became thin. Hypertrophic cells in secondary cartilage were markedly smaller than those in primary cartilage.ConclusionsThe small hypertrophic cells present in secondary cartilage may have been a characteristic acquired in order for the cartilage to smoothly promote a marked increase in hypertrophic cells and rapid calcification.

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Αρχειοθήκη ιστολογίου

Τρίτη 27 Φεβρουαρίου 2018

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