Improving the Results of Endonasal Dacryocystorhinostomy with Mitomycin C Application: A Prospective Case–Control Study

Abstract

Many surgical advancement paved to surgical success in endonasal endoscopic dacryocystorhinostomy. Mitomycin C is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. The objective of the study was to evaluate the advantage of mitomycin C in primary endoscopic endonasal dacryocystorhinostomy without stenting. Randomised case control design. Tertiary academic centre in central India. 112 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups with or without mitomycin C intraoperative application. 112 eyes underwent endoscopic-dacryocystorhinostomy. Additional surgeries were done according to necessity. Mitomycin C was applied in concentration of 0.4 mg/dl for 5 min. Patients were followed up on OPD-basis at the end of 1st week, 1st month, 3rd month and over phone call at end of 1 year. Symptomatic improvement assessed by verbal enquiry and clinically by syringing by ophthalmologist. 8 patients underwent septal surgery in case group and 4 in control group along with 1 concha bullosa correction in the case group (p < 0.05). Nil intraoperative complications (p < 0.05) and nil postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96.5% at 3rd month in case group and 96.4% and 92.9% at 1 month and 3 month respectively in control group. Nasal endoscopy of all surgical failures showed restenosis in both case group and control group except 1 patient with granulation in control group. Eventhough intraoperative mitomycin C application is effective in increasing the success rate of endonasal DCR surgery in standard nasolacrimal duct obstruction, and with no significant complications from its use, the study did not show added benefit in the primary endoscopic endoscopic dacryocystorhinostomy without stenting.

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Mitomycin-C in Post-endoscopic Septoplasty Synechiae: Does it Really Helps?

Abstract

Endoscopic septoplasty has advantage of magnified image and access to posterior part of the septum. Synechiae formation is a common complication of this procedure. The incidence of adhesions rises particularly in cases of submucosal flap tears which is sometimes unavoidable during spurectomy. Various procedures like septal splints, nasal packings have been tried to reduce the incidence of adhesions. Recently mitomycin-C is being tried to decrease post operative adhesions after Functional Endoscopic Sinus Surgery, endoscopic Dacrocystorhinostomy, with varying degree of success. Mitomycin-C has got anti fibroblastic activity, which inhibits the fibroblasts without hampering epithelization. Eighty (80) Patients undergoing septoplasty and spurectomy were observed for any submucosal flap tear, and those developing flap tear were included in the study. The patients were divided into 2 groups of 40 each. In group-1 topical mitomycin (0.4 mg/ml) was applied at the raw area for 5 min, similarly normal saline was applied in group-2 (control).The aim of study was to evaluate the role of mitomycin-C in preventing post operative adhesions in Endoscopic septoplasty. Adhesion rate was calculated at 1 month, and compared using Chi square test. P value < 0.05 was considered significant. The adhesion rate at 1 month was 17.5% in group-1 and 45% in group-2 (P = 0.008). Incidence of adhesion decreased significantly in mitomycin-C treated group. Mitomycin-C can routinely be used in septoplasty to prevent post op adhesions, particularly in cases of submucosal flap tears/concurrent turbinate reduction procedures.

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Cutaneous angioleiomyoma of the auricle: a painless variant of a painful tumour

Cutaneous angioleiomyomas (ALMs) are uncommon benign tumours of the skin which derive from the smooth muscle layer of dermal blood vessels. They usually present as tender nodules in the fifth or sixth decade of life, predominantly in the legs of females. These tumours rarely present on the head and neck, especially the ear. Head and neck ALMs differ from their more common leg counterparts in that they are painless. Additionally, they do not manifest with a female predominance. Herein, a new case of a painless auricular ALM in a 63-year-old man is reported.

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Genitalia self-mutilation commanded by hallucinations: a psychointensive case of Klingsor syndrome

Description 

One of the world's rarest cases recorded up to date stands a case of hallucination influenced genitalia self-mutilation (GSM). There are just 13 cases recorded on PubMed till date. What and who is Klingsor? It was derived from the name of a character in Parsifal (a German opera) who had engaged in the act of self-castration for gaining entry into the prestige brotherhood of the Knights of the Holy Grail. In one of the first recorded cases in 1990, the author argued that the term 'Klingsor' be applied to all cases of GSM to patients of psychotic illness and not just religious conflicts.1 Some literatures call this syndrome as Skoptic syndrome.

Various surveys done by psychologists found psychosis beneath the cases of men carrying out autocastration. One of the most famous cases documented of Thomas Corbett, the man behind the assassination of John Wilkes Booth and...

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Primary intratracheal schwannoma resected during bronchoscopy using argon plasma coagulation

A 63-year-old man presented with intermittent, progressively worsening dyspnoea associated with cough and blood-tinged sputum. Initial work-up showed left axis deviation on ECG, chest X-ray with an elevated left hemidiaphragm and a non-contrast CT chest that showed a multilobulated mass in the proximal trachea. Bronchoscopy showed a whitish-appearing lesion, which was then sampled and partially resected with pathology showing a schwannoma with no malignant cells. He felt partial relief post procedure; however, he presented a month later with similar symptoms of dyspnoea and a repeat CT scan showed enlargement of the mass in the same location. The patient underwent another flexible bronchoscopy and resection with argon plasma coagulation (APC)/electrocautery snare. APC/electrocautery is an effective interventional bronchoscopy technique that can be used to resect endoluminal lesions or extraluminal lesions that have infiltrated into the airway using flexible/rigid bronchoscopy. It is more cost-effective, safe, works well with vascular lesions and achieves excellent haemostasis as compared with Nd:YAG lasers.

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A rare cause of ascites in a renal transplant recipient

Thirty-five-year-old man, underwent renal transplantation 4 years back and was doing well. He now presented with complaints of ascites with engorged neck veins and dyspnoea on exertion for last 6 months. Examination showed elevated jugular venous pressure with two prominent descents, high pitched diastolic heart sound (pericardial knock). Echocardiography showed characteristic features of thickened pericardium, septal bounce, expiratory flow reversal in hepatic veins and phasic variation of mitral inflow, suggestive of constrictive pericarditis. The patient was started on empirical antitubercular therapy and diuretics. The patient symptomatically improved, but in view of persisting constrictive physiology he was planned for pericardiectomy.

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Dental management of a patient with 22q11.2 deletion syndrome (22q11.2DS)

22q11.2 deletion syndrome (22q11.2DS) is one of the most common microdeletion syndromes, with an incidence of approximately 1/2000–1/4000 live births; it is thought to be mainly attributable to a de novo deletion. The clinical phenotype of this syndrome is highly variable. Certain craniofacial and oral features are common to most patients with 22q11.2DS, including a high prevalence of dental caries; abnormalities of tooth shape, eruption and number; and enamel defects such as hypomineralisation and hypoplasia. This report focuses on the dental features and management of an 8-year-old boy with 22q11.2DS. Dental treatments were carried out under general anaesthesia. In summary, facial dysmorphism and common dental manifestations are typically noticeable in patients with this syndrome. Therefore, dentists need to be aware of the dental features of this condition in order to refer them to the adequate specialists. Cooperation among and experience with different specialties are mandatory to improve quality of life for patients with 22q11.2DS.

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Mid-ventricular takotsubo cardiomyopathy triggered by major depressive disorder after abortion

Description 

A 28-year-old gravida 7 para 5 woman presented from an outlying facility with non-radiating, crushing, severe left-sided chest pain. She was initially treated for a non-ST elevation myocardial infarction with ECG evidence of T wave inversions in leads II, III, aVF, V5, V6 and an abnormal troponin level at 0.56 ng/mL. Accordingly, left heart catheterisation was performed emergently and revealed normal coronary arteries without any obstruction (figure 1). Left ventriculography showed mid-ventricular hypokinesis with hyperdynamic apical and basal wall contraction, consistent with a mid-ventricular takotsubo cardiomyopathy (TCM) (video 1). The ejection fraction was estimated at 30%–35%.

Figure 1

Coronary angiogram showing normal coronary arteries. (A) Left anterior oblique 30 view. (B) Right anterior oblique 10 cranial 40 view. (C) Left anterior oblique 45 caudal 25 view.

Video 1

Left ventriculogram.

Medical history was significant for an elective abortion...

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A case of young diabetes and parasuicide

Wolfram syndrome is a rare monogenic cause of juvenile onset diabetes mellitus. It is a non-autoimmune, insulin-deficient state with concurrent or consequent optic atrophy. Here we depict the case of a 16-year-old young girl afflicted with this condition, who presented with parasuicide on a background of depressive disorder. The aetiology of this presentation was attributable to multiple physical ailments and a genetic predisposition conferred by the disease-causing mutation for which she tested positive. She was managed with intensive insulin therapy and specific psychotherapy. Her case highlights the importance of recognising and addressing these comorbidities associated with Wolfram syndrome, so as to curtail disastrous consequences.

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Subperiosteal haematoma of the orbit secondary to frontal sinusitis

Reported is the case of a 79-year-old woman initially diagnosed with periorbital abscess on the background of a recent upper respiratory tract infection. Unexpectedly, intraoperative findings were that of a haematoma rather than an abscess. Subperiosteal orbital haematoma (SOH) is an extremely rare complication of rhinosinusitis. In contrast to the more common periorbital abscess, it is seldom listed as a complication of sinusitis. A review of reported cases suggests an older patient demographic are affected by SOH in contrast to periorbital abscess which typically affects paediatric patients. Given current demographic trends toward an older patient population with multiple comorbidities, failure to consider SOH as a differential will have important implications on preoperative workup, perioperative care and final outcome for patients. We present this case as a reminder of a rare but important complication of a common disease.

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Custom 3D-printed finger proximal phalanx as salvage of limb function after aggressive recurrence of giant cell tumour

Giant cell tumours (GCT) of the finger phalanges are extremely rare but have a high rate of recurrence. This report details the case of a GCT of the proximal phalanx of the fourth finger in a 64-year-old man. The patient was initially subjected to systemic neoadjuvant denosumab treatment, and subsequent aggressive curettage, sparing of the articular joints, local cryotherapy and autologous intercalary fibular bone graft. Finger function after surgery was considered satisfactory, despite limited proximal interphalangeal (PIP) joint motion. Aggressive local GCT recurrence was noted at the 32-month follow-up, with entire articular and diaphyseal phalangeal destruction. The patient refused amputation and, after analysing several reconstruction options, he was treated by entire en bloc resection and reconstruction employing a 3D-printed custom titanium implant. At the 24-month follow-up, the patient is free of disease and pain, and has a stable finger, good metacarpal–phalangeal joint motion, fusion of the PIP joint, a good Musculoskeletal Tumour Society score, and functional ability.

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Suspicious breast pseudocalcifications

Description 

We present a follow-up case of an invasive right ductal breast carcinoma in a 72-year-old woman.

A follow-up mammography study (figure 1) performed 1 year after right lumpectomy (wide local excision) shows postsurgical changes in the right breast and reveals 'de novo' coarse/amorphous microcalcifications in the left breast axis. Some of these calcifications show radiolucent centre, and can only be depicted in the craniocaudal mammographic images, raising concern for hypothetic cutaneous location, although presenting suspicious features.

Figure 1

Mammographic images showing postlumpectomy (wide local excision) changes in the right upper outer quadrant and coarse and amorphous calcifications in the left breast. Blue square shows the magnification of the calcifications, revealing some calcifications with radiolucent centre.

Cancer biomarkers and clinical status were unremarkable.

An ultrasound (US) evaluation was further advised. The patient was told not to apply any cream, lotion or deodorant on...

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Severe pulmonary hypertension associated with hepatic arteriovenous malformation in a patient with hereditary haemorrhagic telangiectasia

We report a case of 46-year-old Asian woman with a history of recurrent epistaxis who presented with dyspnoea on exertion. Physical examination revealed mucocutaneous telangiectasias and signs of heart failure. Further evaluation showed huge hepatic arteriovenous malformation and severe pulmonary hypertension. This case demonstrates an uncommon manifestation of hereditary haemorrhagic telangiectasia presented with severe pulmonary hypertension.

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Primary peritoneal hepatoid adenocarcinoma: a diagnostic and therapeutic conundrum in patients with gastrointestinal bleeding

Description 

A 50-year-old man with a history of iron-deficiency anaemia and fatty liver disease presented to the emergency department complaining of black tarry stools with associated weakness and shortness of breath for 1 week. At presentation, contrast-enhanced CT revealed multiple hypervascular masses in the abdomen and pelvis with the largest lesion located in the right lower quadrant, abutting the right psoas muscle (figure 1). Laboratory evaluation demonstrated a haemoglobin level of 5.5 g/dL (normal, 13.5–17.5 g/dL). Upper endoscopy showed a mass, which was making an extrinsic impression into the stomach (figure 2). Colonoscopy was unremarkable for abnormalities. Endoscopic ultrasound-guided fine-needle aspiration (FNA) of the lesion adjacent to the stomach was performed using a 22-gauge needle (Expect Slimline; Boston Scientific, Natick, Massachusetts, USA). The FNA was positive for metastatic carcinoma with hepatic features. Furthermore, capsule endoscopy identified blood clots surrounding the multiple, small intestinal masses. These lesions were...

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Endogenous bacterial endophthalmitis and subretinal abscess complicating diabetic ketoacidosis

Description 

A 26-year-old Lithuanian man with type 1 diabetes, diagnosed at aged 14, presented to the emergency department with shortness of breath as well as left flank pain. The patient was taking a basal-bolus (Actrapid/Lantus) regimen of insulin and had no other medical conditions. The patient was found to be in diabetic ketoacidosis (blood glucose level 21 mmol/L, pH 7.10) and diagnosed with chest sepsis based on bilateral consolidation on a chest X-ray. The patient was admitted to the high dependency unit and treated empirically with intravenous flucloxacillin and ceftriaxone. Blood cultures grew a fully sensitive Staphylococcus aureus. The patient's flank pain failed to improve and on day 3 of admission CT of the abdomen and pelvis demonstrated a left 4.9 cm intermedius muscle abscess (figure 1). There were additional small focal collections in the left psoas, right psoas and right erector spinae muscle. Radiologically guided aspiration of the left intermedius...

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MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.

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Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: an updated systematic review and meta-analysis

Abstract

Objective

The aim of the present study is to update the results of two previous meta-analyses, published in 2006 and 2012, on the survival percentages of atraumatic restorative treatment (ART) restorations and ART sealants. The current meta-analysis includes Chinese publications not investigated before.

Materials and methods

Until February 2017, six databases were interrogated (two English, one Portuguese, one Spanish and two Chinese). Using six exclusion criteria, a group of six independent reviewers selected 43 publications from a total of 1958 potentially relevant studies retrieved. Confidence intervals and/or standard errors were calculated and the heterogeneity variance of the survival rates was estimated.

Results

The survival percentages and standard errors of single-surface and multiple-surface ART restorations in primary posterior teeth over the first 2 years were 94.3% (± 1.5) and 65.4% (± 3.9), respectively; for single-surface ART restorations in permanent posterior teeth over the first 3 years, they were 87.1% (± 3.2); and for multiple-surface ART restorations in permanent posterior teeth over the first 5 years, they were 77% (± 9.0). The mean annual dentine-carious-lesion-failure percentages in previously sealed pits and fissures using ART sealants in permanent posterior teeth over the first 3 and 5 years were 0.9 and 1.9%, respectively.

Conclusions

ART single-surface restorations presented high survival percentages in both primary and permanent posterior teeth, whilst ART multiple-surface restorations presented lower survival percentages. ART sealants presented a high-caries-preventive effect.

Clinical relevance

ART is an effective evidence-based option for treating and preventing carious lesions in primary and permanent posterior teeth.

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Significant bleeding from Meckel’s diverticulum after blunt abdominal trauma: a case report

Meckel's diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have report...

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CME examination

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Answers to CME examination

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Editorial Board

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Table of Contents

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Dermatology Calendar

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Urticaria: A comprehensive review

Urticaria is a common clinical condition presenting with wheals (hives), angioedema, or both. Urticaria has a complex pathogenesis, along with a high disease burden, a significant impact on quality of life, and high health care costs. The first article in this continuing medical education series covers the definition, classification, epidemiology, diagnosis, and work-up of urticaria, taking into account the recent literature and the best available evidence.

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Quick note from your Editors

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The case of the dog and the blue light

Over the past decade, as the number of emotional support animals has increased dramatically, more requests for accommodation have occurred in medical practices.1 While clinicians frequently will accommodate an emotional support animal, there are important differences between service animals and emotional support animals in the United States under the Americans with Disabilities Act (ADA). The ADA defines a service animal as an animal that has been individually trained to do work or perform tasks for an individual with a disability.

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JAAD Case Reports Article List

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CME examination

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Answers to CME examination

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October Iotaderma (#296)

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Urticaria: A comprehensive review

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H1 antihistamines alone or in combination with other classes of medications, including H2 antihistamines, leukotriene receptor antagonists, or first-generation H1 antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti–immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H1 antagonists.

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Clinically amelanotic or hypomelanotic melanoma: Anatomic distribution, risk factors, and survival

The recognition and diagnosis of clinically amelanotic or hypomelanotic melanoma is a challenge.

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Information for Readers

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September iotaderma (#295)

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Journal Based CME Instructions and Information

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Camp Discovery: Changing lives for 25 years

The first session of Camp Discovery was held in Minnesota in 1993. Then and each year since, children age 8 to 16 years with "significant skin diseases" have attended the American Academy of Dermatology's (AAD's) Camp Discovery program free of charge (Figs 1 and 2). Each camper has been nominated by an AAD member dermatologist. Counselors with skin disease serve as role models and sympathetic supporters. Details of the Camp Discovery program, its founding, and its early evolution were reviewed in 2 previous publications in the Journal of the American Academy of Dermatology.

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Stigmatizing Attitudes Toward Persons with Psoriasis Among Laypersons and Medical Students

Perceived stigma among patients with psoriasis contributes to poor health. Stigmatizing attitudes toward persons with psoriasis are prevalent among laypersons. Medical students and people who have heard of/know someone with psoriasis report less stigmatizing attitudes. Educational campaigns for the public and medical trainees may reduce stigma toward patients with psoriasis.

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The Clinical Spectrum of Cutaneous Melanoma Morphology

Melanoma can mimic many cutaneous lesions, impairing correct diagnosis. By clustering of diagnostic assignments, five common melanoma morphological groupings were identified: typical, nevus-like, amelanotic/NMSC-like, SK-like, and lentigo/lentigo maligna-like. Awareness of the diversity of melanoma appearances and their associated clinical factors may help dermatologists improve their diagnostic accuracy.

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Reduced CD8 + T cells infiltration can be associated to a malignant transformation in potentially malignant oral epithelial lesions

Abstract

Objective

The aim of this study was to evaluate the immunohistochemical expressions of PD1, CD4⁺, and CD8⁺ in premalignant lesions (OPML) that were transformed into oral squamous cell carcinoma OSCC (OPML-OSCC), in OSCC and also in premalignant lesions that were not transformed into OSCC (OPML-NOSSC).

Materials and methods

Retrospective analyses were performed in order to verify the demographic characteristics of the patients. CD4, CD8, and PD1 IMH studies were carried out on OPML and OSCC samples from 11 patients with OPML-OSCC and OPML, together with samples from 14 patients with OPML-NOSCC. The differences between OPML-OSCC and OPML-NOSCC were analyzed.

Results

Non-homogenous leukoplakia, together with the related oral subsite, and the lack of an exposure to tobacco, were all associated with malignant transformations. There were no statistical differences in the PD1 expression and the CD4⁺ cells in OPML-OSCC and OPML-NOSCC. A significant increment in the CD8⁺ cells was noted in the OPML that evolved into carcinomas when compared with OPML-NOSCC (p = 0.05), whereas there were higher CD8⁺ cells levels in the carcinomas when compared with the OPML that evolved into carcinomas (p = 0.027).

Conclusions

CD8⁺ cells infiltrate more in OPML-NOSCC than in OPML-OSCC. Carcinoma is more infiltrated by CD8⁺ cells than its associated OPML.

Clinical relevance

Understanding immunological factors associated with malignant transformation of oral premalignant lesions can open a new way to treat this disease.

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The Extended Purse-String Rhytidectomy

Facial plast Surg
DOI: 10.1055/s-0038-1672176

Facelifts remain a critical part of a facial plastic surgeon's cosmetic practice. Techniques continue to evolve, while at the same time patients demand less invasive procedures with less morbidity. The authors present a facelift plication technique using wide purse-string sutures placed into the superficial musculoaponeurotic system and platysma. This is a retrospective review with a level of evidence 3 set at a medical spa and tertiary referral center designed to assess a purse-string suture technique using an inner followed by an outer purse-string, with refinements being made during the timeframe of the review. One hundred and eighteen patients were reviewed and 95 were included in the study given the inclusion criteria of a minimum of 1-year follow-up. Based on the subjective judgment of the primary surgeon, 37 patients were found to have excellent results, while 43 patients were judged as having good results. The judgment was based on the physical exam improvement of the aging aspects of the patient, and patient satisfaction. Ten patients displayed fair results (the patients were marginally happy), and five patients were noted to have poor results (they were notably unhappy). Complications included eight hematomas, five patients with prominent scars, and one patient with skin loss in the temple region. There were no cases of facial nerve injury. The extended purse-string rhytidectomy is a good alternative to traditional facelift techniques. This offers a plication method that results in the vertical vector that is now considered of paramount importance with all facelifts. The authors feel that it is a valuable tool that can be considered in most patients presenting for aging face surgery.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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A 2-Year Follow-up Study of an Absorbable Implant to Treat Nasal Valve Collapse

Facial plast Surg
DOI: 10.1055/s-0038-1672213

The safety and effectiveness of an absorbable implant for lateral cartilage support have been recently demonstrated in subjects with nasal valve collapse (NVC) at 12 months postprocedure. This follow-up study aimed to assess whether the safety and effectiveness of the implant persist in these patients for 24 months after the procedure. Thirty subjects with Nasal Obstruction Symptom Evaluation (NOSE) score ≥ 55 and isolated NVC were treated; 14 cases were performed in an operating suite under general anesthesia and 16 cases were performed in a clinic-based setting under local anesthesia. The implant, a polylactic acid copolymer, was placed with a delivery tool within the nasal wall to provide lateral cartilage support. Subjects were followed up through 24 months postprocedure. Fifty-six implants were placed in 30 subjects. The mean preoperative NOSE score was 76.7 ± 14.8, with a range of 55 to 100. At 24 months, the mean score was 32.0 ± 29.3, reflecting an average within-patient reduction of −44.0 ± 31.1 points. There were no device-related adverse events in the 12 to 24 months period. There were five subjects who exited the study prior to the 24-month follow-up. Four of the five subjects who exited were elected for further intervention and one subject was lost to follow-up. This study demonstrates safety of an absorbable implant for lateral nasal wall support and symptom improvement in some subjects with NVC at 24 months postprocedure.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Long-term postoperative control of eosinophilic chronic rhinosinusitis recurrence by inserting a steroid-eluting, sinus-bioabsorbable device reduces the dosage of oral steroid

We employed a steroid-eluting, sinus-bioabsorbable device for local treatment after surgery for eosinophilic chronic rhinosinusitis (ECRS). One year later, we investigated its efficacy in suppressing recurrence and reducing the use of oral steroids.

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Risk factors and prognosis for the primary intraosseous carcinoma of the jaw

Primary intraosseous carcinoma (PIOC) is a rare but aggressive type of odontogenic tumour arising within the jawbone. Diagnosis criteria and treatment strategy remain difficult and controversial. The present study aimed to clarify the clinicopathological features and determine prognostic factors in management of PIOC. A retrospective study of 30 patients with PIOC, treated at the Hospital of Stomatology of Sun Yat-sen University between 2009 and 2017, was conducted. Clinical, histopathological and treatment modality data were collected.

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Bone grafting in orthognathic surgery: a systematic review

Bone grafting has been used in orthognathic surgery to fill the gaps created by jaw repositioning, with the intention of improving healing and stability. Since the majority of orthognathic cases have a satisfactory result, the decision to graft or not is a clinical dilemma. A systematic review of the literature was performed on the use of bone grafts in orthognathic surgery. A search of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials yielded 1927 articles published up until 2018.

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Predictors of Sentinel Lymph Node Positivity in Thin Melanoma Using the National Cancer Database

Presence of dermal mitoses and invasion to Clark level IV-V are important factors in predicting SLN positivity, even when accounting for ulceration and Breslow thickness. Continued evaluation of possible predictors of SLN positivity is necessary to establish clear guidelines when to proceed with SLNB in thin melanoma.

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Barriers to Compounding in Physician Offices: The Future is Now!

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Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) severity score: A useful tool for assessing disease severity and predicting fatal cytomegalovirus disease

The clinical course of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms is unpredictable. We developed a scoring system to predict development of cytomegalovirus disease and complications. Using this scoring system, cytomegalovirus disease and complications could be preventable by prompt treatment with anti- cytomegalovirus agents.

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Prevention of Thermal Burns from Magnetic Resonance Imaging in Patients with Tattoos

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Mineral sunscreens not recommended by Consumer Reports: What lies beneath the surface?

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Reply

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Sirolimus for the treatment of “verrucous” venous malformation: are we missing the lymphatic malformation component?

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Global Epidemiology and Clinical Spectrum of Rosacea, Highlighting Skin of Color: Review and Clinical Practice Experience

Rosacea is infrequently reported among nonwhite populations worldwide, but difficulty detecting its characteristics in darker skin may lead to underdiagnosis. This paper provides strategies for recognizing and treating rosacea in skin of color. This information may help reduce disparities in managing rosacea across diverse populations with the disease.

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Cutaneous angioimmunoblastic T-cell lymphoma: Epstein–Barr Virus positivity and its effects on clinicopathological features

1. Epstein–Barr virus in situ hybridization is positive in 19 of 42 (45.2%) patients with cutaneous angioimmunoblastic T-cell lymphoma. 2. Epstein–Barr virus-positive cutaneous angioimmunoblastic T-cell lymphoma is associated with distinctive clinicopathological features but shows no significant differences in survivals compared to Epstein–Barr virus-negative cutaneous angioimmunoblastic T-cell lymphoma.

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Resident and Fellow Engagement in Safety and Quality

Beyond educational and institutional requirements, there is a need for trainees (residents and fellows) to learn patient safety and quality improvement skills in order to achieve the ultimate goal of providing better patient care. Key steps to engagement include creating a safety and quality culture, supporting faculty development, and selecting appropriate curricular resources. Efforts to align the goals and processes of the graduate medical education institution and teaching hospital can foster a unified mission. Faculty must be prepared to teach and reinforce these topics on a regular basis. Both didactic instruction and experiential learning are necessary components for trainee education.

https://ift.tt/2MJ4BTF

Preventing and Managing Operating Room Fires in Otolaryngology—Head and Neck Surgery

Otolaryngologists are at high risk of surgical fire. During surgery in the head and neck region there is close proximity of 3 essential elements: an ignition source, a fuel, and an oxidizing agent. In this article, the authors highlight the scenarios where fire may occur and offer steps that surgeons can take to minimize risk for their patients. By understanding the elements of the fire triad, otolaryngologists can decrease the risk of surgical fire, through careful control of oxidizers, ignition sources, and potential fuels in the operating room.

https://ift.tt/2phmOOQ

Evaluation and Management of Facial Nerve Schwannoma

Facial nerve schwannomas are benign peripheral nerve sheath tumors that arise from Schwann cells, and most commonly present with facial paresis and/or hearing loss. Computed tomography and MRI are critical to diagnosis. Management decisions are based on tumor size, facial function, and hearing status. Observation is usually the best option in patients with good facial function. For patients with poor facial function, the authors favor surgical resection with facial reanimation. There is growing evidence to support radiation treatment in patients with progressively worsening moderate facial paresis and growing tumors.

https://ift.tt/2MMMKLs

Research Analysis: Key takeaways from PART and Airways-2 Trials

Comparing endotracheal, laryngeal tube and supraglottic airway device intubation during out of hospital cardiac arrest

https://ift.tt/2DaxU22

Leserbrief zu Steger et al. Methadon gegen Krebs

https://ift.tt/2xmMfTL

Effects and parameters of the photobiomodulation in experimental models of third-degree burn: systematic review

Abstract

This systematic review was performed to identify the role of photobiomodulation therapy in experimental models of third-degree burns used to induce oxidative stress. EMBASE, PubMed, and CINAHL databases were searched for studies published between January 2003 and January 2018 on the topics of photobiomodulation therapy and third-degree burns. Any study that assessed the effects of photobiomodulation therapy in animal models of third-degree burns was included in the analysis. A total of 17 studies were selected from 1182 original articles targeted on photobiomodulation therapy and third-degree burns. Two independent raters with a structured tool for rating the research quality critically assessed the articles. Although the small number of studies limits the conclusions, the current literature research indicates that photobiomodulation therapy can be an effective short-term approach to accelerate the healing process of third-degree burns, to increase and modulate the inflammatory process, to accelerate the proliferation of fibroblasts, and to enhance the quality of the collagen network. However, differences still exist in the terminology used to describe the parameters and the dose of photobiomodulation therapy.

https://ift.tt/2NSPNGH

Status of Superficial Esophageal Cancers Treated by Endoscopy "OESOFARE"

Condition:   Superficial Esophageal Cancers
Intervention:  
Sponsor:   Nantes University Hospital
Not yet recruiting

https://ift.tt/2PKx1yw

Assessing Timing of Enteral Feeding Support in Esophageal Cancer Patients on Muscle functTion and Survival

Conditions:   Esophageal Cancer;   Nutrition Aspect of Cancer;   Postoperative Complications;   Muscle Weakness;   Sarcopenia;   Jejunostomy; Complications
Intervention:   Other: delayed start enteral support @ POD5
Sponsor:   University Hospital, Gasthuisberg
Not yet recruiting

https://ift.tt/2xju7Kr

HRQOL in Thyroid Cancer and Thyroid Tumours

Conditions:   Thyroid Nodule;   Thyroid Cancer;   Quality of Life
Intervention:  
Sponsor:   Oslo University Hospital
Recruiting

https://ift.tt/2PLTZ8j

Is Tongue-Lip Adhesion or Mandibular Distraction More Effective in Relieving Obstructive Apnea in Infants with Robin Sequence?

Publication date: Available online 18 September 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Cory M. Resnick, Carly E. Calabrese, Rohit Sahdev, Bonnie L. Padwa

Abstract

Objective

Tongue-lip adhesion (TLA) and mandibular distraction osteogenesis (MDO) are the most common operations for obstructive apnea (OA) in infants with Robin sequence (RS). The purpose of this study is to compare early outcomes of TLA and MDO on resolution of OA.

Methods

Retrospective cohort study of infants with RS treated with TLA or MDO from 2005-2018. To be included, patients had to have polysomnograms (PSG) pre- and postoperatively unless intubated or tracheostomy dependent. Patients were excluded if the operation occurred after 1 year-of-age. The primary predictor variable was type of operation (TLA or MDO). The primary outcome variable was "successful resolution of OA", defined as: (1) postoperative apnea-hypopnea index (AHI)<5, (2) postoperative OA severity score 0-1 (no/mild OA), and (3) no need for additional airway intervention during the first year-of-life. Descriptive, bivariate and regression analyses were performed. Statistical significance was set at p<0.05.

Results

43 patients were included: TLA, n=19 (44%); MDO, n=24 (56%). Eighteen subjects (41%) were syndromic. Patients in the TLA group were significantly younger at operation (28.2±23.1 days) compared to the MDO group (87.1±81.7 days, p=0.002). The MDO group had more severe preoperative OA (AHI=20.5±14.9; OA severity score=4.7±0.8) than the TLA group (AHI=17.6±31.0; OA severity score=3.6±1.4, p<0.041). Postoperative AHI and OA severity score for the TLA group were 11.7±19.5 (33.5% reduction, p=0.496) and 2.3±1.8 (improvement by 1.3±2.4 levels, p=0.051), respectively. Postoperative AHI and OA severity score for the MDO group were 1.1±1.8 (94.6% reduction, p<0.001) and 0.2±0.4 (improvement by 4.6±0.8 levels, p<0.0001), respectively. Successful resolution of OA occurred in 9 patients (47%) in the TLA group and 22 (92%) patients in the MDO group. Post-operative complications were similar.

Conclusion

MDO is more effective than TLA in relieving OA in infants with RS.

https://ift.tt/2NYgAl7

Is the Vazirani-Akinosi nerve block a better technique than the conventional inferior alveolar nerve block for beginners?

Publication date: Available online 18 September 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Komagan Prabhu Nakkeeran, Poornima Ravi, Guruprasad Thulasi Doss, Krishna Kumar Raja

Abstract

PURPOSE

To compare the efficacy and comfort of the inferior alveolar nerve block and the Vazirani-Akinosi block, when given by dental trainees.

METHODS

In this prospective, randomized controlled trial, patients requiring extraction of mandibular teeth received either the conventional inferior alveolar nerve block (IAN group), or the Vazirani-Akinosi block (VA group). Objective parameters evaluated included ease of locating landmarks, incidence of positive aspiration, and failure rate. Patient comfort during injection was assessed using Visual Analogue Scale. Statistical analysis was done using unpaired t test and Fischer's extract test.

RESULTS

One hundred patients were included in each group. Landmarks were easier to locate in the VA group. Positive aspiration was more in the IAN group (0.08%) as compared to the VA group(0.01%) (p < 0.05). The incidence of failed blocks was higher in the IAN group as compared to the VA group. Patients appeared to experience less pain with VA injection as compared to the IAN injection.

CONCLUSION

The current study showed that the dental trainees found the Vazirani-Akinosi technique more straightforward to perform. It had a higher success rate and lower incidence of positive aspiration, and was also more comfortable for patients than the conventional inferior alveolar nerve block.

https://ift.tt/2OzUT7Y

A Retrospective Study of Patient Outcomes Following Temporomandibular Joint Replacement with Alloplastic Total Joint Prosthesis at Massachusetts General Hospital

Publication date: Available online 18 September 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Rohit Sahdev, Brendan W. Wu, Nina Anderson, Shehryar N. Khawaja, Somi Kim, David A. Keith

Abstract

Background

Disorders of the temporomandibular joint (TMJ) occur frequently, with a prevalence of 15-18%. Total joint replacement (TJR) surgery is indicated for severe joint damage associated with impaired function, pain, or occlusal change where other treatments have been unsuccessful.

Purpose

The aim of this study was to assess changes in pain and range of motion (ROM), as well as post-operative complications and comorbidities, in subjects receiving TJR surgery at the Massachusetts General Hospital (MGH).

Methods

This study is a retrospective review that describes the clinical variables in patients following alloplastic TMJ reconstruction at MGH from 2000-2015. Clinical variables included primary diagnosis, number of previous surgeries, comorbidities, pre- and post-operative pain, pre-, intra-, and post-operative ROM, and complications.

Results

Data was obtained from 95 patients undergoing a total of 108 surgeries, with an average follow-up of 4.48±3.38 years. The most common primary indications for TJR were ankylosis (44%) and inflammatory disease (23%). Maximum inter-incisal opening improved by a mean of 7.7±10.27 mm and pain decreased by a mean of 1.5±3.29 points on the visual analogue scale. Transient facial nerve palsy (25%) was the most common post-operative complication; however, long-term complications were rare. The most frequent comorbidities were psychiatric disorders (56%) and gastrointestinal disease (46%). Psychiatric patients had similar pre-operative pain (6.0±2.90), but significantly higher post-operative pain (4.7±2.58), than non-psychiatric patients. Twenty-eight percent of the patients had prior failed TMJ implant materials, specifically Proplast-Teflon (Vitek, Houston, TX). These patients were significantly older (50.4±8.26 years) and had smaller pre-operative ROM (21.7±8.85 mm) and smaller post-operative ROM (28.3±9.59 mm).

Conclusion

Patients gained a statistically significant (p<0.01) increase in ROM and reduction in pain. TJR is an effective treatment option in patients with limited mouth opening or severe pain.

https://ift.tt/2NUuAft

β-Adrenergic signaling blocks murine CD8 + T-cell metabolic reprogramming during activation: a mechanism for immunosuppression by adrenergic stress

Abstract

Primary and secondary lymphoid organs are heavily innervated by the autonomic nervous system. Norepinephrine, the primary neurotransmitter secreted by post-ganglionic sympathetic neurons, binds to and activates β-adrenergic receptors expressed on the surface of immune cells and regulates the functions of these cells. While it is known that both activated and memory CD8⁺ T-cells primarily express the β2-adrenergic receptor (β2-AR) and that signaling through this receptor can inhibit CD8⁺ T-cell effector function, the mechanism(s) underlying this suppression is not understood. Under normal activation conditions, T-cells increase glucose uptake and undergo metabolic reprogramming. In this study, we show that treatment of murine CD8⁺ T-cells with the pan β-AR agonist isoproterenol (ISO) was associated with a reduced expression of glucose transporter 1 following activation, as well as decreased glucose uptake and glycolysis compared to CD8⁺ T-cells activated in the absence of ISO. The effect of ISO was specifically dependent upon β2-AR, since it was not seen in adrb2^−/− CD8⁺ T-cells and was blocked by the β-AR antagonist propranolol. In addition, we found that mitochondrial function in CD8⁺ T-cells was also impaired by β2-AR signaling. This study demonstrates that one mechanism by which β2-AR signaling can inhibit CD8⁺ T-cell activation is by suppressing the required metabolic reprogramming events which accompany activation of these immune cells and thus reveals a new mechanism by which adrenergic stress can suppress the effector activity of immune cells.

https://ift.tt/2QIhNeT

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction

To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrogra...

https://ift.tt/2Ni2WcV

Improving vaccination uptake in pediatric Cochlear implant recipients

An Infectious Disease vaccine specialist joined our institution's Cochlear Implant Team in 2010 in order to address the high percentage of non-compliance to immunization prior to surgery identified previously ...

https://ift.tt/2D8wO6N

Carcinoembryonic antigen levels correlated with advanced disease in medullary thyroid cancer

Medullary thyroid cancer (MTC) cells are capable of secreting various tumor markers including calcitonin and carcinoembyronic antigen (CEA). The purpose of this study is to determine whether abnormal CEA level...

https://ift.tt/2Np2OZj

Prenatal Diet and the Development of Childhood Allergic Diseases: Food for Thought

Abstract

Purpose of Review

The development of allergic disease is shaped by genetics and the environment, including diet. Many studies suggest a role for maternal diet during pregnancy. In this article, we discuss potential mechanisms by which specific nutrients, particular foods, and dietary patterns may influence allergic disease development and review studies examining the relationship between prenatal diet and the risk of childhood allergy.

Recent Findings

The combination of in utero exposures and genetic predisposition may contribute to the development of allergic disease by altering immune and organ development. Inflammation predominates in the first and third trimesters whereas the second trimester is characterized by anti-inflammatory and Th2 immune responses. Maternal dietary exposures during pregnancy may interact with inherited genetic risk factors influence immune system development.

Summary

There are varied results regarding the impact of maternal prenatal diet on the development of childhood allergies. Well-designed randomized controlled studies are needed to clarify this area.

https://ift.tt/2NnXMvR

Management and outcomes of pediatric vocal cord paresis in Chiari malformation

Publication date: Available online 18 September 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Minyoung Jang, Phillip Biggs, Lauren North, Andrew Foy, Robert Chun

Abstract

INTRODUCTION

Pediatric vocal cord paresis (VCP) has a variety of etiologies, including congenital neurologic disease. Arnold-Chiari Malformation (ACM) is one such disease with known VCP association. The natural history, need for tracheostomy, and rate of decannulation in this patient population is not well characterized.

OBJECTIVE

To provide prognostic information on infants with ACM and VCP.

METHODS

A retrospective chart review was conducted of patients with both ACM and VCP. Clinical outcomes and disease progression were determined using flexible laryngoscopy, serial clinical exams, and operative reports from otolaryngology and neurosurgery services.

RESULTS

Eighteen patients were included in this study, four with ACM Type I and 14 with ACM Type II. These groups were analyzed separately. For ACM I, the average age at diagnosis was 25 months and two (50%) required tracheostomy. Three subjects (75%) achieved VCP resolution, with two doing so after neurosurgical decompression. For ACM II, the average age at diagnosis was eight months and 12 patients (86%) underwent tracheostomy. Four subjects with tracheostomy (33%) achieved decannulation, with three of these demonstrating VCP resolution. In total, six ACM II patients had complete and one had partial VCP resolution, all of whom underwent decompression. Two patients initially had normal endoscopic exams despite stridor and VCP was only noted on serial exams.

DISCUSSION

This study represents the largest series of pediatric patients with VCP and ACM. The majority needed decompression (80%) and tracheotomy (78%). Tracheostomy decannulation typically occurred only after decompression and resolution of VCP. No children diagnosed at age < 1 month were decannulated. Early decompression was associated with successful avoidance of tracheostomy in majority of Chiari I but not Chiari II patients. Serial endoscopies were required to confirm VCP in some patients. This information could potentially aid in management and counseling parents of children with VCP and CM.

https://ift.tt/2Nn52Ig

Significance of neck dissection for the treatment of clinically-evident medullary thyroid carcinomas: A systematic review

Publication date: Available online 17 September 2018

Source: Auris Nasus Larynx

Author(s): Soon-Hyun Ahn, Eun Jae Chung

Abstract

Objective

The survival benefit of prophylactic lateral neck dissection in medullary thyroid carcinomas remains unclear; thus, recent clinical guidelines have deferred the recommendation of lateral neck dissection. This review is to assess the role of lateral neck dissection in treatment of clinically overt medullary thyroid carcinoma.

Methods

A meta-analysis was performed on full-text publications written in English sourced using Embase and Medline databases. Publications with data regarding lateral neck dissection and clinical outcome were included.

Results

The frequently performed central neck dissection was significantly correlated with a higher biological cure rate (p = 0.047) and lower structural recurrence rate (p = 0.002). The frequency of ipsilateral lateral neck dissection was significantly negatively correlated with the rate of died of disease (p = 0.017).

Conclusion

The frequency of lateral neck dissections and rate of died of disease had a reverse correlation suggesting that prophylactic lateral neck dissection has a significant impact on survival.

https://ift.tt/2OyLttk

Langzeitfolgen nach Behandlung testikulärer Malignome

Zusammenfassung

Hintergrund

Dank moderner onkologischer Behandlungen ist Hodenkrebs („testicular cancer", TC) inzwischen heilbar. Doch für die Überlebenden ergeben sich aus langfristigen nachteiligen Folgen für ihre Gesundheit („adverse health outcomes", AHOs) Risiken für eine höhere Mortalität und eine beeinträchtigte gesundheitsbezogene Lebensqualität („health-related quality of life", HR-QoL).

Ziel

Ziel der Arbeit war eine Übersicht über AHOs nach onkologischer Behandlung maligner Hodentumoren.

Material und Methoden

Veröffentlichte Studien und früher erstellte Übersichtsarbeiten wurden zusammengefasst.

Ergebnisse

Fünfundzwanzig Jahre nach Erstdiagnose kommt es zu einer Verringerung der Überlebensraten, im Wesentlichen aufgrund von behandlungsbezogenen Zweitmalignomen und/oder von kardiovaskulären Erkrankungen bei Vorliegen einzelner Komponenten des metabolischen Syndroms. Mit zunehmendem Alter wird die Cisplatin-induzierte Ototoxizität für TCS („testicular cancer survivors", Hodenkrebsüberlebende) zu einem klinisch relevanten Problem, die Toxizität für periphere Nerven dagegen ist nur sehr selten von wesentlicher klinischer Bedeutung. Angst („anxiety") ist die wichtigste psychische AHO, nicht depressive Störungen. Die HR-QoL der meisten Patienten ist gut, doch die Arbeitsfähigkeit kann durch eine sehr intensive Behandlung beeinträchtigt werden.

Schlussfolgerung

Wenn sowohl Patienten als auch im Gesundheitswesen Tätige die möglichen langfristigen AHOs nach erfolgreicher Behandlung maligner Hodentumoren kennen und präventive wie therapeutische Maßnahmen initiieren, können sie zur Verringerung der langfristigen Mortalität und Morbidität und zur Verbesserung der Lebensqualität beitragen. Im Rahmen einer risikoadaptierten TC-Behandlung sollte eine Radiatio so weit wie möglich vermieden werden. Bisher vorliegende Daten weisen auf vorzeitige Alterungsprozesse bei intensiv behandelten TCS hin. Um diese vorläufigen Beobachtungen zu überprüfen, bedarf es umfangreicherer Studien und längerer Follow-up-Zeiten.

https://ift.tt/2QG9cJj

Tone-in-noise detection deficits in elderly patients with clinically normal hearing

Publication date: Available online 17 September 2018

Source: American Journal of Otolaryngology

Author(s): Massimo Ralli, Antonio Greco, Marco De Vincentiis, Adam Sheppard, Giampietro Cappelli, Ilaria Neri, Richard Salvi

Abstract

Purpose

One of the most common complaints among the elderly is the inability to understand speech in noisy environments. In many cases, these deficits are due to age-related hearing loss; however, some of the elderly that have difficulty hearing in noise have clinically normal pure-tone thresholds. While speech in noise testing is informative, it fails to identify specific frequencies responsible for the speech processing deficit. Auditory neuropathy patients and animal models of hidden hearing loss suggest that tone-in-noise thresholds may provide frequency specific information for those patients who express difficulty, but have normal thresholds in quiet. Therefore, we aimed to determine if tone-in-noise thresholds could be a useful measure in detecting age-related hearing deficits, despite having normal audiometric thresholds.

Materials & methods

We tested this hypothesis by measuring tone-in-noise thresholds in 11 Old (62.4 ± 5 years) and 21 Young (23.1 ± 2.2 years) patients with clinically normal thresholds. Tone thresholds were measured in a quite sound field, then in 20, 30 and 40 dB HL broadband noise.

Results

Despite having normal hearing (thresholds ≤25 dB HL), the Old patients had significantly worse tone-in-noise thresholds than the Young patients at 0.125, 4, and 8 kHz. Linear regression analysis showed that the growth of masking in Old and Young patients was nearly identical at all frequencies. However, the amount of masking at low and high frequencies was typically 10–18 dB greater in the Old patients compared to the Young, except near 1 kHz. The frequency-dependent changes in masking are discussed in the context of a "line busy" model and temporal bone studies of auditory nerve fiber loss.

https://ift.tt/2OwwVdy

Intranasal Lobular Capillary Hemangioma with Multiple Sites of Origin during Pregnancy: A Case Report and Literature Review

In the present case report, we describe a 33-year-old pregnant woman in the third trimester with a history of recurrent epistaxis leading to frequent visits to the emergency department. Each episode of epistaxis was managed by anterior nasal packing. During endoscopic examination, a left nasal mass was seen. She was admitted and managed conservatively until she delivered her baby without complication. After delivery, a CT scan was taken, which showed an enhancing mass in the middle and lower meatus of the nasal cavity with no bony erosions. For symptomatic relief and tissue diagnosis, endoscopic surgical removal was advised. An intraoperative examination revealed a red, smooth, and well-circumscribed mass occupying the left nasal cavity and originating from the medial surface of the inferior turbinate and the inferior surface of the posterior part of the middle turbinate. A complete en bloc resection of the mass was performed endoscopically. The mass was sent for histologic analysis, which confirmed the diagnosis of lobular capillary hemangioma. Eventually, upon follow-up at two weeks, one month, three months, and six months postsurgery, no evidence of recurrence was detected.

https://ift.tt/2xm5j4x

Prenatal Diet and the Development of Childhood Allergic Diseases: Food for Thought

Abstract

Purpose of Review

The development of allergic disease is shaped by genetics and the environment, including diet. Many studies suggest a role for maternal diet during pregnancy. In this article, we discuss potential mechanisms by which specific nutrients, particular foods, and dietary patterns may influence allergic disease development and review studies examining the relationship between prenatal diet and the risk of childhood allergy.

Recent Findings

The combination of in utero exposures and genetic predisposition may contribute to the development of allergic disease by altering immune and organ development. Inflammation predominates in the first and third trimesters whereas the second trimester is characterized by anti-inflammatory and Th2 immune responses. Maternal dietary exposures during pregnancy may interact with inherited genetic risk factors influence immune system development.

Summary

There are varied results regarding the impact of maternal prenatal diet on the development of childhood allergies. Well-designed randomized controlled studies are needed to clarify this area.

https://ift.tt/2NnXMvR

The effect of anesthetic technique on µ-opioid receptor expression and immune cell infiltration in breast cancer

Abstract

Background

Clinical histological studies demonstrate that the distribution of natural killer (NK) cells, other immune cells and μ-opioid receptors (MOR) within cancer tissue can predict cancer prognosis. No clinical study has evaluated whether anesthetic technique influences immune cell and MOR expression within human breast cancer.

Methods

Excised preoperative biopsies and intraoperative breast cancer specimens from 20 patients randomly chosen from patients previously enrolled in an ongoing, prospective, randomized trial (NCT00418457) investigating the effect of anesthetic technique on long-term breast cancer outcome were immunohistochemically stained and microscopically examined by two independent investigators, masked to randomization, to quantify MOR and immune cell infiltration: CD56, CD57 (NK cells), CD4 (T helper cells), CD8 (cytotoxic T cells) and CD68 (macrophages). Patients had been randomized to receive either a propofol–paravertebral anesthetic with continuing analgesia (PPA, n = 10) or balanced general anesthetic with opioid analgesia (GA, n = 10).

Results

There were no differences between the groups in staining intensity in preoperative biopsy specimens. Expression intensity values (median 25–75%) for MOR in intraoperative resected biopsy were higher in GA 8.5 (3–17) versus PPA 1 (0–10), p = 0.04. The numbers of MOR-positive cells were also higher in GA patients. Expression and absolute numbers of CD56, CD57, CD4 and CD68 were similar in resected tumor in both groups.

Conclusion

General anesthesia with opioid analgesia increased resected tumor MOR expression compared with propofol–paravertebral anesthetic technique, but the anesthetic technique did not significantly influence the expression of immune cell markers.

https://ift.tt/2D8cPoN

Bone changes on lateral cephalograms and CBCT during treatment of maxillary narrowing using palatal osteodistraction with bone-anchored appliances

Publication date: Available online 18 September 2018

Source: Journal of Cranio-Maxillofacial Surgery

Author(s): Krzysztof Dowgierd, Maciej Borowiec, Marcin Kozakiewicz

https://ift.tt/2pix2i6

The prognostic role of PD-L1 expression for survival in head and neck squamous cell carcinoma: A systematic review and meta-analysis

Publication date: November 2018

Source: Oral Oncology, Volume 86

Author(s): Wei-fa Yang, May C.M. Wong, Peter J. Thomson, Kar-Yan Li, Yu-xiong Su

Abstract

Background

Programmed death-ligand 1 (PD-L1) is an immune checkpoint that is primarily located on the surface of tumor cells. PD-L1 expression detected by immunohistochemistry (IHC) assays has been widely studied to predict survival outcomes in head and neck squamous cell carcinoma (HNSCC) recently. We aimed to review comprehensively the prognostic role of PD-L1 expression for survival in HNSCC.

Methods

We systematically searched PubMed, Embase, Web of Science, Cochrane Library and Scopus to identify studies investigating the prognostic role of PD-L1 expression in HNSCC. All studies published before March 31, 2018 were screened. Included studies were assessed using the Quality in Prognosis Studies (QUIPS) tool. Data were extracted and overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), disease-specific survival (DSS) were combined and presented as hazard ratios (HR) with 95% confidence interval (CI) using the generic inverse-variance method.

Results

Twenty-three studies with 3105 patients were analysed. The overall positive rate of PD-L1 in HNSCC was 0.42 (95% CI: 0.36–0.48). There was no significant difference between PD-L1-positive and -negative HNSCC patients in OS (HR: 0.98; 95% CI: 0.71–1.37; p = 0.93), DFS (HR: 1.07; 95% CI: 0.68–1.70; p = 0.76), and DSS (HR: 0.90; 95% CI: 0.63–1.29; p = 0.56). An improved PFS was observed in patients with positive PD-L1 expression (HR: 0.71; 95% CI: 0.55–0.93; p = 0.01). In patients with low CD8+ tumor-infiltrating T cells, a poorer OS was detected in patients with positive PD-L1 expression (HR: 1.90; 95% CI: 1.07–3.36; p = 0.03). Patients with HPV-positive HNSCC were associated with increased PD-L1 expression (OR: 1.99; 95% CI: 1.50–2.64; p < 0.001). However, PD-L1 expression showed no significant benefit on OS in HPV-positive HNSCC (HR: 1.04; 95% CI: 0.65–1.65; p = 0.88).

Conclusions

PD-L1 expression detected by IHC was not recommended to predict survival in HNSCC patients. However, the positive PD-L1 expression might predict better PFS in patients with advanced HNSCC. The combined effects of PD-L1 expression and CD8+ tumor-infiltrating T cells should be further elucidated.

https://ift.tt/2DiZqdR

IMRT – Biomarkers for dose escalation, dose de-escalation and personalized medicine in radiotherapy for head and neck cancer

Publication date: November 2018

Source: Oral Oncology, Volume 86

Author(s): C.N. Andreassen, J.G. Eriksen, K. Jensen, C.R. Hansen, B.S. Sørensen, P. Lassen, J. Alsner, L.M.H. Schack, J. Overgaard, C. Grau

Abstract

Radiotherapy (RT) is an integral component in the management of head and neck cancer. Despite progress in several respects, a noteworthy proportion of the treated patients do not achieve complete response after RT. Regardless of novel dose delivery technologies, RT for head and neck cancer is still associated with acute as well as late toxicity. These challenges could potentially be addressed by means of personalized treatment. In this paper, we discuss the possibilities for dose escalation, dose de-escalation and allocation to systemic concomitant treatment based on prognostic and predictive markers for tumor control as well as predictive markers for normal tissue radiosensitivity.

https://ift.tt/2phfXEZ

NLRP3 inflammasome regulates Th17 differentiation in rheumatoid arthritis

Publication date: Available online 17 September 2018

Source: Clinical Immunology

Author(s): Chunmei Zhao, Yibin Gu, Xiaoyun Zeng, Jing Wang

Abstract

Rheumatoid arthritis (RA) is one of the most common autoimmune diseases. Th17 has been shown to play am important role in the pathogenesis of RA. Accumulating data suggest the involvement of NLRP3 inflammasome in Th17 differentiation in autoimmune diseases. In the current study, we found that NLRP3 inflammasome is activated in CD4 T cells from RA patients. The activation of NLRP3 inflammasome was correlated with disease activities and IL-17A concentration in RA sera. Knockdown of NLRP3 suppressed Th17 differentiation. In addition, caspase-1 or IL-1 receptor inhibitor inhibits Th17 differentiation significantly. Further, ROS production is increased in CD4 T cells from RA patients. The inhibition of ROS production decreased NLRP3 inflammasome activation and IL-1β production in CD4 T cells, leading to the suppression of Th17 differentiation. These findings suggest a pathogenic role of NLRP3 inflammasome in RA by promoting Th17 cell differentiation. NLRP3 inflammasome could be a potential therapeutic target for the treatment of RA.

https://ift.tt/2xtdGKH

Editorial Board

Publication date: October 2018

Source: Autoimmunity Reviews, Volume 17, Issue 10

Author(s):

https://ift.tt/2D4LDYc

Psoriasiform skin eruption in a patient receiving certolizumab‐pegol for ankylosing spondylitis: Report of a case and review of the literature

Dermatologic Therapy, EarlyView.


https://ift.tt/2piI0Us

Peripheral blood toll‐like receptor 4 correlates response to candida immunotherapy of warts

Dermatologic Therapy, EarlyView.


https://ift.tt/2piv2X3

Understanding Conflict Management Styles in Anesthesiology Residents

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios. METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%–99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores. RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1–Q3 = 27–87) and accommodating (69th, Q1–Q3 = 30–94) styles, and the lowest scores for competing (32nd, Q1–Q3 = 10–57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1–Q3 = 14–16; counterpart: 16, Q1–Q3 = 15–16) and problem solving (self: 17, Q1–Q3 = 16–18; counterpart: 16, Q1–Q3 = 16–17), and lower scores for forcing (self: 13, Q1–Q3 = 10–15; counterpart: 13, Q1–Q3 = 13–15) and avoiding (self: 14, Q1–Q3 = 10–16; counterpart: 14.5, Q1–Q3 = 11–16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05). CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one's dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations.

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Preventing Adverse Events in Cataract Surgery

No abstract available

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Maternal Hemorrhage—Regional Versus General Anesthesia: Does It Really Matter?

No abstract available

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Beyond the “E” in OSCE

No abstract available

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Optimal Organization of Acute Pain Services: At the Confluence of Semantics, Logistics, and Economics

No abstract available

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Natural Born Survivors?

No abstract available

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Sevoflurane Protects Hepatocytes From Ischemic Injury by Reducing Reactive Oxygen Species Signaling of Hepatic Stellate Cells: Translational Findings Based on a Clinical Trial

BACKGROUND: Randomized controlled trials (RCTs) data demonstrate that sevoflurane postconditioning improves clinical outcomes of liver resection with inflow occlusion, presumably due to hepatocyte protection from ischemic injury. However, mechanisms remain unclear. This study examines liver biopsy samples obtained in an RCT of sevoflurane postconditioning to test the hypothesis that sevoflurane attenuates hepatocyte apoptosis. METHODS: Messenger ribonucleic acid (mRNA) of pro- and antiapoptotic regulators Bax and B-cell lymphoma 2 (Bcl2) was examined in hepatic biopsies obtained during the RCT. Hepatic stellate cells (HSCs) and hepatocytes were exposed to hypoxia/reoxygenation (H/R) in vitro to evaluate the effect of sevoflurane postconditioning on apoptosis. The role of HSC as a potential apoptosis trigger in hepatocytes through the production of reactive oxygen species induced by H/R was explored by transferring supernatants from H/R-exposed HSC to hepatocytes as target cells. RESULTS: In patients of the RCT, the Bax/Bcl2 mRNA ratio in liver tissue was markedly decreased in the sevoflurane arm (25% ± 21% reduction; P = .001). In vitro, H/R increased reactive oxygen species production in HSC by 33% ± 16% (P = .025), while it was abolished in the presence of sevoflurane (P

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Target-Controlled Infusion: Not a One-Sized-Fits-All Answer to Drug Administration

No abstract available

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I Contain Multitudes: The Microbes Within Us and a Grander View of Life

No abstract available

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Subspecialization … and Clinical Guidelines

No abstract available

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Special Cardiac Arrest Situations in the Perioperative Period

No abstract available

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An Intellectual Framework for Drug Administration Methods in Anesthesia: Three Practice Domains

No abstract available

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Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0–0.0009952).

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Identifying the Best Cut-Point for a Biomarker, or Not

No abstract available

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A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before–after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0–3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0–6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0–3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6–106.3 mg MEQs) versus 144.0 mg MEQs (68.9–238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1–124.0; P 50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

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To Thine Own Self Be True: A First Step Toward Learning How Anesthesiologists Deal With Adversity in the Operating Room

No abstract available

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Propensity Score Methods: Theory and Practice for Anesthesia Research

Observational data are often readily available or less costly to obtain than conducting a randomized controlled trial. With observational data, investigators may statistically evaluate the relationship between a treatment or therapy and outcomes. However, inherent in observational data is the potential for confounding arising from the nonrandom assignment of treatment. In this statistical grand rounds, we describe the use of propensity score methods (ie, using the probability of receiving treatment given covariates) to reduce bias due to measured confounders in anesthesia and perioperative medicine research. We provide a description of the theory and background appropriate for the anesthesia researcher and describe statistical assumptions that should be assessed in the course of a research study using the propensity score. We further describe 2 propensity score methods for evaluating the association of treatment or therapy with outcomes, propensity score matching and inverse probability of treatment weighting, and compare to covariate-adjusted regression analysis. We distinguish several estimators of treatment effect available with propensity score methods, including the average treatment effect, the average treatment effect for the treated, and average treatment effect for the controls or untreated, and compare to the conditional treatment effect in covariate-adjusted regression. We highlight the relative advantages of the various methods and estimators, describe analysis assumptions and how to critically evaluate them, and demonstrate methods in an analysis of thoracic epidural analgesia and new-onset atrial arrhythmias after pulmonary resection.

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Full manuscript title: Early subungual melanoma: A diagnostic and treatment challenge

Dermatologic Therapy, EarlyView.


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Poor Sleep, Worse Outcomes: Obstructive Sleep Apnea and Perioperative Care

No abstract available

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Opioids for Acute Pain Management in Patients With Obstructive Sleep Apnea: A Systematic Review

The intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with obstructive sleep apnea (OSA). The association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population. The aims of this systematic review were to summarize current evidence with respect to perioperative OIRD, changes in sleep-disordered breathing, and alterations in pain and opioid sensitivity in patients with OSA. A systematic literature search of studies published between 1946 and October 2017 was performed utilizing the following databases: Medline, ePub Ahead of Print/Medline In-process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed—NOT-Medline and ClinicalTrials.Gov. Of 4321 initial studies, 40 met the inclusion criteria. The Oxford level of evidence was assessed. Overall, high-quality evidence on the comparative impact of acute opioid analgesia in OSA versus non-OSA patients is lacking. The current body of evidence is burdened by significant limitations including risk of bias and large heterogeneity among studies with regard to OSA severity, perioperative settings, outcome definitions, and the presence or absence of various perioperative drivers. These factors complicate an accurate interpretation and robust analysis of the true complication risk. Nevertheless, there is some consistency among studies with regard to a detrimental effect of opioids in the presence of OSA. Notably, the initial 24 hours after opioid administration appear to be most critical with regard to life-threatening OIRD. Further, OSA-related increased pain perception and enhanced opioid sensitivity could predispose patients with OSA to a higher risk for OIRD without overdosing. While high-quality evidence is needed, retrospective analyses indicate that critical, life-threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.

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Society Guidelines Infographic: SASM Guideline on Intraoperative Management of OSA

No abstract available

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Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

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