An autopsy case of non-traumatic fat embolism syndrome

Fat embolism syndrome (FES) occurs after long bone fractures and the symptoms appear 24–72 h after the initial trauma. Fat emboli can affect both the pulmonary and systemic circulation. Apart from the most common type of FES that originates from bone fracture, non-traumatic FES has been also reported. We have experienced an autopsy case of non-traumatic FES. An 81-year-old man with hepatocellular carcinoma associated with alcoholic liver cirrhosis suddenly lost consciousness before transcatheter arterial chemoembolization treatment for his disease and died 5 h after the episode. At autopsy, numerous fat droplets were detected in the alveolar capillaries of the lung and glomerular capillaries of the kidney. Lipid analysis of lung autopsy specimens by thin-layer chromatography showed that the emboli were composed mainly of tristearin. Free fatty acids (FFA) has been considered to be the main component of fat emboli and can be a cause of acute respiratory distress syndrome (ARDS). However, in the present case, the lung specimen contained tristearin and ARDS did not occur. This is the first report of non-traumatic FES in which lipid analysis of human autopsy specimens has been conducted.

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Dedifferentiated carcinoma with clear cell carcinoma of the endometrium: A case report

Endometrial dedifferentiated carcinoma consists of a combination of undifferentiated and differentiated carcinomas. To date, clear cell carcinoma components in endometrial dedifferentiated carcinoma have not been reported. We report the first case of endometrial dedifferentiated carcinoma with clear cell carcinoma in a 58-year-old woman. The uterine corpus was completely replaced and enlarged by a heterogeneous mass. The endometrial cut surface showed a yellowish papillary growing mass involving endometrium and deeper myometrium. Microscopically, the three components (endometrioid carcinoma, FIGO grade 1, clear cell carcinoma and undifferentiated carcinoma) were noted with differentiated carcinoma components lining the endometrial cavity, while undifferentiated carcinoma components were identified in deeper endometrium and myometrium. Our histologic diagnosis was supported by the pattern of immunoreactivity. Tumor cells showed loss of expression of MLH1/PMS2 protein and displayed high microsatellite-instability in all three components. Furthermore, all three components including clear cell carcinoma had loss of PTEN and ARID1A expression. Our observations suggest that the three components derived from a monoclonal origin, as the three components had in common specific genetic alterations.

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Linear dimensions of normal upper airway structure by magnetic resonance imaging in Chinese Han infants and preschool children

To establish normative data of upper airway structure in Chinese Han infants and preschool children.

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Restless Legs Syndrome after High Risk TIA and Minor Stroke: Association with Reduced Quality of Life

Restless Legs Syndrome (RLS) is a movement disorder associated with poor quality of life and depressive symptoms in the general population. Emerging evidence suggests that RLS is closely linked with cerebrovascular disease. We assessed the impact of RLS on quality of life after stroke and transient ischemic attack (TIA).

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Spinal Transection Alters External Urethral Sphincter Activity during Spontaneous Voiding in Freely Moving Rats

Journal of Neurotrauma , Vol. 0, No. 0.


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Letter to Editors: Detection of endolymphatic hydrops using traditional MR imaging sequences

We would like to comment on the manuscript entitled “Detection of endolymphatic hydrops using traditional MR imaging sequences.” by Keller et al. [1]. It is of great clinical value if non-contrast MR imaging can be used to differentiate the endo- and perilymph space as the authors have stated. We read this article with great interest and thank the authors for citing our six papers. However, there are some critical points that need to be clarified in this paper.

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Precision oncology using a limited number of cells: optimization of whole genome amplification products for sequencing applications

Abstract

Background

Sequencing analysis of circulating tumor cells (CTCs) enables “liquid biopsy” to guide precision oncology strategies. However, this requires low-template whole genome amplification (WGA) that is prone to errors and biases from uneven amplifications. Currently, quality control (QC) methods for WGA products, as well as the number of CTCs needed for reliable downstream sequencing, remain poorly defined. We sought to define strategies for selecting and generating optimal WGA products from low-template input as it relates to their potential applications in precision oncology strategies.

Methods

Single pancreatic cancer cells (HPAF-II) were isolated using laser microdissection. WGA was performed using multiple displacement amplification (MDA), multiple annealing and looping based amplification (MALBAC) and PicoPLEX. Quality of amplified DNA products were assessed using a multiplex/RT-qPCR based method that evaluates for 8-cancer related genes and QC-scores were assigned. We utilized this scoring system to assess the impact of de novo modifications to the WGA protocol. WGA products were subjected to Sanger sequencing, array comparative genomic hybridization (aCGH) and next generation sequencing (NGS) to evaluate their performances in respective downstream analyses providing validation of the QC-score.

Results

Single-cell WGA products exhibited a significant sample-to-sample variability in amplified DNA quality as assessed by our 8-gene QC assay. Single-cell WGA products that passed the pre-analysis QC had lower amplification bias and improved aCGH/NGS performance metrics when compared to single-cell WGA products that failed the QC. Increasing the number of cellular input resulted in improved QC-scores overall, but a resultant WGA product that consistently passed the QC step required a starting cellular input of at least 20-cells. Our modified-WGA protocol effectively reduced this number, achieving reproducible high-quality WGA products from ≥5-cells as a starting template. A starting cellular input of 5 to 10-cells amplified using the modified-WGA achieved aCGH and NGS results that closely matched that of unamplified, batch genomic DNA.

Conclusion

The modified-WGA protocol coupled with the 8-gene QC serve as an effective strategy to enhance the quality of low-template WGA reactions. Furthermore, a threshold number of 5–10 cells are likely needed for a reliable WGA reaction and product with high fidelity to the original starting template.

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The role of neratinib in HER2-driven breast cancer

Future Oncology Ahead of Print.


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The role of neratinib in HER2-driven breast cancer

Future Oncology Ahead of Print.


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Spinal Transection Alters External Urethral Sphincter Activity during Spontaneous Voiding in Freely Moving Rats

Journal of Neurotrauma , Vol. 0, No. 0.


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An update: Epstein-Barr virus and immune evasion via microRNA regulation

Abstract

Epstein-Barr virus (EBV) is an oncogenic virus that ubiquitously establishes life-long persistence in humans. To ensure its survival and maintain its B cell transformation function, EBV has developed powerful strategies to evade host immune responses. Emerging evidence has shown that microRNAs (miRNAs) are powerful regulators of the maintenance of cellular homeostasis. In this review, we summarize current progress on how EBV utilizes miRNAs for immune evasion. EBV encodes miRNAs targeting both viral and host genes involved in the immune response. The miRNAs are found in two gene clusters, and recent studies have demonstrated that lack of these clusters increases the CD4⁺ and CD8⁺ T cell response of infected cells. These reports strongly indicate that EBV miRNAs are critical for immune evasion. In addition, EBV is able to dysregulate the expression of a variety of host miRNAs, which influence multiple immune-related molecules and signaling pathways. The transport via exosomes of EBV-regulated miRNAs and viral proteins contributes to the construction and modification of the inflammatory tumor microenvironment. During EBV immune evasion, viral proteins, immune cells, chemokines, pro-inflammatory cytokines, and pro-apoptosis molecules are involved. Our increasing knowledge of the role of miRNAs in immune evasion will improve the understanding of EBV persistence and help to develop new treatments for EBV-associated cancers and other diseases.

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A cross sectional analysis from a single institution’s experience of psychosocial distress and health-related quality of life in the primary brain tumor population

Abstract

Primary brain tumor patients experience high levels of distress. The purpose of this cross-sectional, retrospective study is to evaluate the level and different sources of psychosocial distress and how these pertain to health-related quality of life (HRQoL). The Primary and Recurrent Glioma registry at Duke’s The Preston Robert Tisch Brain Tumor Center was queried retrospectively for demographic and clinical information on patients seen between December 2013 and February 2014. Data also included the National Comprehensive Cancer Network’s Distress Thermometer (NCCN-DT), Functional Assessment of Cancer Therapy-Brain Cancer (FACT-Br), and Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F). 829 subjects completed questionnaires. 54% were male; 96% completed the NCCN-DT; 33.3% had a DT score ≥4 (moderate/severe distress). Women reported DT ≥ 4 more often than men (38.6 vs 29.0%; p = 0.005). Patients within 1 year of diagnosis reported DT ≥ 4 more often than those 1+ years after diagnosis (38.8 vs 30.9%; p = 0.034). 73.0% reported physical problems; the most frequent being fatigue (43.2%) and memory/concentration (40.9%). 42.0% complained of emotional problems with worry (29.4%) and nervousness (22.4%) being the most common. Patients who reported at least one practical, family, emotional or physical problem had significantly lower HRQoL scores (p < 0.001). Primary brain tumor patients experience memory dysfunction, fatigue, nervousness, worry, and financial concerns, which have a negative effect on the patient’s HRQoL. By identifying and addressing these stressors, it may be possible to improve patient HRQoL.

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What is the Role of the Oncology Nurse in Fertility Preservation Counseling and Education for Young Patients?

Abstract

Oncology nurses are uniquely positioned to offer fertility preservation counseling and education for cancer patients of reproductive age, yet there is a dearth of research that focuses on current practice and perceptions of nursing role. In 2013, the American Society of Clinical Oncology extended the duties of fertility preservation counseling among patients of reproductive age undergoing cancer treatment to include registered nurses and other allied health professionals as active partners in the counseling and education process. This study used a cross-sectional descriptive survey to assess current practices, role perceptions, and barriers to fertility preservation counseling among registered nurses working in an academic care setting with outpatient and inpatient services. There were significant gaps in current practices and perceptions of roles regarding fertility preservation counseling. Many nurses expressed the perception that fertility preservation counseling was important, but it was outside the scope of their practice to perform this education. This preliminary work defined need for an interdisciplinary fertility preservation team, communication surrounding educational practice norms, and designated oncofertility navigator.

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Restless Legs Syndrome after High Risk TIA and Minor Stroke: Association with Reduced Quality of Life

Publication date: Available online 30 June 2017
Source:Sleep Medicine
Author(s): Mark I. Boulos, Anthony Wan, Sandra E. Black, Andrew S. Lim, Richard H. Swartz, Brian J. Murray
BackgroundRestless Legs Syndrome (RLS) is a movement disorder associated with poor quality of life and depressive symptoms in the general population. Emerging evidence suggests that RLS is closely linked with cerebrovascular disease. We assessed the impact of RLS on quality of life after stroke and transient ischemic attack (TIA).MethodsIn this single-centre prospective study, we recruited patients within 14 days of high-risk TIA or minor stroke. Patients were diagnosed with RLS using a questionnaire based on the 2003 International RLS Study Group criteria and diagnoses were confirmed by a sleep neurologist. Follow-up assessments were conducted within 2-6 months of recruitment. The outcome of quality of life was measured using the Stroke-Specific Quality of Life (SS-QoL).ResultsOf the 94 patients recruited into the study, 23 (24.4%) were diagnosed with RLS; 11 had newly diagnosed RLS, while 12 endorsed RLS preceding the index stroke/TIA. There were no significant differences in baseline characteristics between those with or without RLS. Median SS-QoL in patients with RLS were lower at baseline (p=0.008) and at follow-up (p=0.002). RLS patients had more depressive symptoms at follow-up (p=0.007). Ordinal logistic regression demonstrated that RLS was negatively associated with quality of life at baseline (OR=0.28; p=0.010) and at follow-up (OR=0.14; p=0.029), independent of functional outcome and depressive symptoms.ConclusionsRLS is common after stroke or TIA and negatively impacts quality of life. Screening for RLS after cerebrovascular disease may be warranted and future research should assess whether treatment of RLS can improve post-stroke quality of life.



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Combination of docetaxel, trastuzumab and pertuzumab or treatment with trastuzumab-emtansine for metastatic salivary duct carcinoma

Dear editor,

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The use of handheld nasal spirometry to predict the presence of obstructive sleep apnea

Abstract

Objective

Nasal obstruction and oral breathing may play an important role in the pathophysiology of obstructive sleep apnea (OSA). This study aims to better understand the link between oral breathing, nasal obstruction, and the spectrum of sleep-disordered breathing.

Study Design

Prospective study.

Methods and materials

Prospective study of patients who presented to the Otolaryngology clinic and underwent polysomnogram (PSG) from 2015 to 2016. Patients were divided into two groups based on the severity of their OSA as defined by PSG results. Both apnea-hypopnea index (AHI) and supine and REM AHI (SUP-REMe AHI), a parameter that takes into account both sleep position and sleep stage, were recorded. The primary outcome was awake nasal-oral forced expiratory volume in 1-s (FEV1) ratio as measured by handheld spirometry.

Results

A total of 21 patients were included in the study. We found that nasal-oral FEV1 ratio was significantly different between patients with minimal and substantial OSA as stratified by SUP-REMe AHI, while not significant when stratified by AHI.

Conclusion

Patients with substantial OSA as determined by SUP-REMe AHI are more likely to have decreased awake nasal airflow as measured by nasal-oral FEV1. SUP-REMe AHI may represent an improved metric of OSA severity by taking into account sleep position and sleep stage. Handheld spirometers have the potential to become an important office tool by allowing for easy and reliable measurement of nasal airflow.

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What is the Role of the Oncology Nurse in Fertility Preservation Counseling and Education for Young Patients?

Abstract

Oncology nurses are uniquely positioned to offer fertility preservation counseling and education for cancer patients of reproductive age, yet there is a dearth of research that focuses on current practice and perceptions of nursing role. In 2013, the American Society of Clinical Oncology extended the duties of fertility preservation counseling among patients of reproductive age undergoing cancer treatment to include registered nurses and other allied health professionals as active partners in the counseling and education process. This study used a cross-sectional descriptive survey to assess current practices, role perceptions, and barriers to fertility preservation counseling among registered nurses working in an academic care setting with outpatient and inpatient services. There were significant gaps in current practices and perceptions of roles regarding fertility preservation counseling. Many nurses expressed the perception that fertility preservation counseling was important, but it was outside the scope of their practice to perform this education. This preliminary work defined need for an interdisciplinary fertility preservation team, communication surrounding educational practice norms, and designated oncofertility navigator.

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The single-center experience with the standardization of single-site laparoscopic colectomy for right-sided colon cancer

Abstract

Purpose

Complete mesocolic excision (CME) with central vascular ligation (CVL) has been widely accepted as a surgical treatment for right-sided colon cancer. Single-site laparoscopic colectomy (SLC) is associated with reduced pain and improved cosmesis, in comparison to the multi-site laparoscopic colectomy (MCL). Although the feasibility of CME + CVL under MCL has been reported, SLC for right-sided colon cancer is generally challenging. The purpose of this study is to demonstrate our efforts to standardize the SLC for right-sided colon cancer.

Methods

This retrospective study enrolled 202 consecutive patients with right-sided colon cancer who underwent laparoscopic colectomy for right-sided colon cancer, using an inferior approach and intraoperative navigation surgery, between 2008 and 2014. The patients were divided into 3 groups, based on the period of treatment, as follows: Period I (2008–2009, n = 56), Period II (2010–2011, n = 70), and Period III (2012–2014, n = 76).

Results

The patient’s baseline characteristics did not differ among the three periods. The ratio of SLC significantly increased with the passage of the time. The short-term outcomes were similar among the three periods. As for oncological clearance, there was a significant increase in the number of resected lymph nodes with the passage of the time (P < 0.05).

Conclusions

We successfully standardized SLC for right-sided colon cancer.

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Neoadjuvant chemotherapy for gastric adenocarcinoma in Japan

Abstract

Surgery had been and remains a mainstay in the treatment of gastric cancer. The Japanese surgical oncologists employed surgery-first approach to treat gastric cancer because of the widespread use of D2 lymph node dissection and the high incidence of oncologically resectable cancer, and early attempts at the multimodality treatment strategy featured surgery followed by postoperative chemotherapy. Although evidence to treat Stage II/III gastric cancer with this strategy is now abundant in the Far East, poor compliance of the post-gastrectomy patients to intense combination chemotherapies has been a limitation associated with this strategy. Evidence in support of neoadjuvant chemotherapy in the West and in various other types of cancer prompted the Japan Clinical Oncology Group (JCOG) researchers to explore this strategy, primarily for a selected population of locally advanced cancer that could either be unresectable by the surgery-first approach or is known to suffer from a poor prognosis; cancers with bulky lymph node metastases or those with a scirrhous phenotype. Encouraged by some promising results from these neoadjuvant trials and taking into account the aforementioned limitations associated with postoperative chemotherapy, the JCOG researchers decided to embark on a phase III trial to explore neoadjuvant chemotherapy among patients with clinically Stage III cancer. This review describes the development of the neoadjuvant strategy for gastric cancer in Japan, mainly by going through a series of clinical trials conducted by the JCOG.

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A decrease in the prognostic nutritional index is associated with a worse long-term outcome in gastric cancer patients undergoing neoadjuvant chemotherapy

Abstract

Purpose

The aim of this study was to evaluate the prognostic impact of the prognostic nutritional index (PNI) in gastric cancer patients undergoing neoadjuvant chemotherapy (NAC).

Methods

This study reviewed 54 patients with gastric cancer who underwent NAC and a subsequent R0 gastrectomy. The PNI before starting NAC and before gastrectomy were calculated using the following formula: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). A multivariate analysis was performed to identify the predictors of overall survival (OS).

Results

The mean pre-NAC and preoperative PNI were 48.3 ± 5.1 and 48.2 ± 4.7, respectively (p = 0.934). The PNI decreased after NAC in 31 patients (57.4%). The pre-NAC PNI and preoperative PNI were not significantly associated with the OS rate. The 3-year OS rate in patients with the decreased PNI values was significantly lower than that in the patients whose PNI values were either maintained or increased (41 vs. 76.4%, p = 0.003). A multivariate analysis revealed that a decreased PNI value was an independent predictor of a poor OS (p = 0.006).

Conclusions

Decreased PNI values were associated with worse long-term outcomes in gastric cancer patients undergoing NAC.

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Timing and outcome of stoma closure in very low birth weight infants with surgical intestinal disorders

Abstract

Purpose

Very low birth weight infants (VLBWIs) are at risk of surgical intestinal disorders including necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI). We conducted this study to verify whether the timing of stoma closure and that of enteral nutrition establishment after stoma closure in VLBWIs differ among the most common disorders.

Methods

A retrospective multicenter study was conducted at 11 institutes. We reviewed the timing of stoma closure and enteral nutrition establishment in VLBWIs who underwent stoma creation for intestinal disorders.

Results

We reviewed the medical records of 73 infants: 21 with NEC, 24 with FIP, and 25 with MRI. The postnatal age at stoma closure was 107 (28–359) days for NEC, 97 (25–302) days for FIP, and 101 (15–264) days for MRI (p = 0.793), and the postnatal age at establishment of enteral nutrition was 129 (42–381) days for NEC, 117 (41–325) days for FIP, and 128 (25–308) days for MRI (p = 0.855). The body weights at stoma closure were 1768 (620–3869) g for NEC, 1669 (1100–3040) g for FIP, and 1632 (940–3776) g (p = 0.614) for MRI. There were no significant differences among the three groups.

Conclusions

The present study revealed that the time and body weights at stoma closure and the postoperative restoration of bowel function in VLBWIs did not differ among the three diseases.

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The optimal cut-off value of the preoperative prognostic nutritional index for the survival differs according to the TNM stage in hepatocellular carcinoma

Abstract

Purpose

To establish the optimal cut-off value of the preoperative prognostic nutritional index (PNI) for prognosis according to the Tumor Node Metastasis (TNM) stage of hepatocellular carcinoma (HCC) after curative resection.

Methods

This retrospective study reviewed the records of 375 patients. The optimal cut-off value of the PNI was established according to the TNM stage, and overall survival was compared between the low and high PNI groups.

Results

The optimal cut-off value of the PNI decreased with increasing TNM stage, with 52, 47, and 43 patients having stage I, II, and III HCC, respectively. A low preoperative PNI predicted a poorer overall survival than did a high PNI for stage I (P < 0.001) and II (P = 0.002), but not stage III disease (P = 0.052). Multivariate analysis revealed that the preoperative PNI was an independent predictor of overall survival for stage I and II HCC (hazard ratios: 6.96 and 3.57, P = 0.001 and P = 0.001, respectively).

Conclusions

The findings of this study show that the optimal cut-off value for the PNI for prognosis differs among the TNM stages and that the preoperative PNI is a favorable prognostic factor for stage I HCC.

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The influence of specific technical maneuvers utilized in the creation of diverting loop-ileostomies on stoma-related morbidity

Abstract

Purpose

The association between technical maneuvers in fashioning a diverting loop-ileostomy and stoma-related complications remains unclear. Thus, this study aimed to evaluate their relevance to stoma-related morbidity.

Methods

This retrospective multicenter study was designed to collect data from 37 institutions. We evaluated the perioperative outcomes of consecutive patients who underwent surgery to create a diverting loop-ileostomy in 2013.

Results

A total of 4137 patients with colorectal disease underwent colorectomy, 279 of whom received an ileostomy. The results of these 279 patients were analyzed. The most common complications were parastomal dermatitis (n = 132) followed by ileus (n = 36), mucocutaneous separation (n = 24), parastomal hernia (n = 16), stoma retraction (n = 15), and stoma prolapse (n = 9). The technical maneuvers used in the creation of ileostomies were heterogeneous and some had a great deal of relevance to the complications. A long distance from the ileocecal valve to the ileostomy was associated with a low risk of stoma retraction and a high risk of ileus. Additionally, the height of the distal limb of the ileostomy significantly affected the incidence of parastomal dermatitis and mucocutaneous separation.

Conclusions

Specific technical maneuvers that are utilized in the creation of diverting loop-ileostomies had a significant influence on the incidence of stoma-related morbidities. Our findings emphasize the possibility of minimizing stoma-related complications with appropriate surgical techniques.

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Omitting perioperative urinary catheterization in laparoscopic cholecystectomy: a single-institution experience

Abstract

Purpose

In 2009, the Centers for Disease Control and Prevention published Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections, which limited the indications for perioperative urinary catheter use. We conducted this study to evaluate the safety of elective laparoscopic cholecystectomy (LC) without urinary catheter placement and to investigate whether it reduces the incidence of urinary complications.

Methods

Of 244 patients who underwent elective LC between March, 2010 and April 2011, 192 patients fulfilled the eligibility criteria and underwent surgery without urinary catheterization (non-catheterized group). We compared the clinical features and surgical outcomes of the non-catheterized group with those of an historical control of 90 patients who underwent LC with routine urinary catheterization.

Results

The operating times were similar in the two groups and there was no case of conversion to open surgery. The postoperative hospital stay was slightly shorter and the incidence of urinary complications was significantly lower in the non-catheterized group. Three patients in the non-catheterized group suffered urinary retention, which resolved after temporary catheterization.

Conclusion

Our study demonstrated that elective LC without urinary catheter placement is feasible for most patients and might reduce the incidence of perioperative urinary complications.

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Onabotulinumtoxin A for the management of chronic migraine in current clinical practice: results of a survey of sixty-three Italian headache centers

Chronic migraine is a complex clinical condition often undertreated. Onabotulinumtoxin A (OBT-A) was approved in Italy in 2013 for symptom relief in patients with chronic migraine who have failed, or do not to...

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The use of handheld nasal spirometry to predict the presence of obstructive sleep apnea

Abstract

Objective

Nasal obstruction and oral breathing may play an important role in the pathophysiology of obstructive sleep apnea (OSA). This study aims to better understand the link between oral breathing, nasal obstruction, and the spectrum of sleep-disordered breathing.

Study Design

Prospective study.

Methods and materials

Prospective study of patients who presented to the Otolaryngology clinic and underwent polysomnogram (PSG) from 2015 to 2016. Patients were divided into two groups based on the severity of their OSA as defined by PSG results. Both apnea-hypopnea index (AHI) and supine and REM AHI (SUP-REMe AHI), a parameter that takes into account both sleep position and sleep stage, were recorded. The primary outcome was awake nasal-oral forced expiratory volume in 1-s (FEV1) ratio as measured by handheld spirometry.

Results

A total of 21 patients were included in the study. We found that nasal-oral FEV1 ratio was significantly different between patients with minimal and substantial OSA as stratified by SUP-REMe AHI, while not significant when stratified by AHI.

Conclusion

Patients with substantial OSA as determined by SUP-REMe AHI are more likely to have decreased awake nasal airflow as measured by nasal-oral FEV1. SUP-REMe AHI may represent an improved metric of OSA severity by taking into account sleep position and sleep stage. Handheld spirometers have the potential to become an important office tool by allowing for easy and reliable measurement of nasal airflow.

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Phase I clinical trial of olprinone in liver surgery

Abstract

Purpose

Post-hepatectomy liver failure is one of the most serious complications liver surgeons must overcome. We previously examined olprinone, a selective phosphodiesterase III inhibitor, and demonstrated its hepatoprotective effects in rats and pigs. We herein report the results of a phase I clinical trial of olprinone in liver surgery (UMIN000004975).

Methods

Twenty-three patients who underwent hepatectomy between 2011 and 2015 were prospectively registered. In the first 6 cases, olprinone (0.1 μg/kg/min) was administered for 24 h from the start of surgery. In the remaining 17 cases, olprinone (0.05 μg/kg/min) was administered from the start of surgery until just before the transection of the liver parenchyma. The primary endpoint was safety, and the secondary endpoint was efficacy. For the evaluation of efficacy, the incidence of post-hepatectomy liver failure in 20 hepatocellular carcinoma patients was externally compared with 20 propensity score-matched patients.

Results

No intraoperative side effects were observed, and the morbidity rates in the analyzed cohorts were acceptable. The rate of post-hepatectomy liver failure frequency tended to be lower in the olprinone group.

Conclusions

The safety of olprinone in liver surgery was confirmed. The efficacy of olprinone will be re-evaluated in clinical trials.

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The single-center experience with the standardization of single-site laparoscopic colectomy for right-sided colon cancer

Abstract

Purpose

Complete mesocolic excision (CME) with central vascular ligation (CVL) has been widely accepted as a surgical treatment for right-sided colon cancer. Single-site laparoscopic colectomy (SLC) is associated with reduced pain and improved cosmesis, in comparison to the multi-site laparoscopic colectomy (MCL). Although the feasibility of CME + CVL under MCL has been reported, SLC for right-sided colon cancer is generally challenging. The purpose of this study is to demonstrate our efforts to standardize the SLC for right-sided colon cancer.

Methods

This retrospective study enrolled 202 consecutive patients with right-sided colon cancer who underwent laparoscopic colectomy for right-sided colon cancer, using an inferior approach and intraoperative navigation surgery, between 2008 and 2014. The patients were divided into 3 groups, based on the period of treatment, as follows: Period I (2008–2009, n = 56), Period II (2010–2011, n = 70), and Period III (2012–2014, n = 76).

Results

The patient’s baseline characteristics did not differ among the three periods. The ratio of SLC significantly increased with the passage of the time. The short-term outcomes were similar among the three periods. As for oncological clearance, there was a significant increase in the number of resected lymph nodes with the passage of the time (P < 0.05).

Conclusions

We successfully standardized SLC for right-sided colon cancer.

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The influence of specific technical maneuvers utilized in the creation of diverting loop-ileostomies on stoma-related morbidity

Abstract

Purpose

The association between technical maneuvers in fashioning a diverting loop-ileostomy and stoma-related complications remains unclear. Thus, this study aimed to evaluate their relevance to stoma-related morbidity.

Methods

This retrospective multicenter study was designed to collect data from 37 institutions. We evaluated the perioperative outcomes of consecutive patients who underwent surgery to create a diverting loop-ileostomy in 2013.

Results

A total of 4137 patients with colorectal disease underwent colorectomy, 279 of whom received an ileostomy. The results of these 279 patients were analyzed. The most common complications were parastomal dermatitis (n = 132) followed by ileus (n = 36), mucocutaneous separation (n = 24), parastomal hernia (n = 16), stoma retraction (n = 15), and stoma prolapse (n = 9). The technical maneuvers used in the creation of ileostomies were heterogeneous and some had a great deal of relevance to the complications. A long distance from the ileocecal valve to the ileostomy was associated with a low risk of stoma retraction and a high risk of ileus. Additionally, the height of the distal limb of the ileostomy significantly affected the incidence of parastomal dermatitis and mucocutaneous separation.

Conclusions

Specific technical maneuvers that are utilized in the creation of diverting loop-ileostomies had a significant influence on the incidence of stoma-related morbidities. Our findings emphasize the possibility of minimizing stoma-related complications with appropriate surgical techniques.

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Increased Antimicrobial Resistance in a Novel CMY-54 AmpC-Type Enzyme with a GluLeu217–218 Insertion in the Ω-Loop

Microbial Drug Resistance , Vol. 0, No. 0.


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Omitting perioperative urinary catheterization in laparoscopic cholecystectomy: a single-institution experience

Abstract

Purpose

In 2009, the Centers for Disease Control and Prevention published Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections, which limited the indications for perioperative urinary catheter use. We conducted this study to evaluate the safety of elective laparoscopic cholecystectomy (LC) without urinary catheter placement and to investigate whether it reduces the incidence of urinary complications.

Methods

Of 244 patients who underwent elective LC between March, 2010 and April 2011, 192 patients fulfilled the eligibility criteria and underwent surgery without urinary catheterization (non-catheterized group). We compared the clinical features and surgical outcomes of the non-catheterized group with those of an historical control of 90 patients who underwent LC with routine urinary catheterization.

Results

The operating times were similar in the two groups and there was no case of conversion to open surgery. The postoperative hospital stay was slightly shorter and the incidence of urinary complications was significantly lower in the non-catheterized group. Three patients in the non-catheterized group suffered urinary retention, which resolved after temporary catheterization.

Conclusion

Our study demonstrated that elective LC without urinary catheter placement is feasible for most patients and might reduce the incidence of perioperative urinary complications.

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Review of "Mastery of Care-Toward Communitarian Regulation" by Pronovost P and Higgins RS in Ann Surg 265: 271-272, 2017.

No abstract available

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The Effect of Anterior Palatoplasty Plus Modified Expansion Sphincter Pharyngoplasty on Voice Performance in Obstructive Sleep Apnea Syndrome.

Objective: We aimed to investigate the effect of anterior palatoplasty (AP) plus modified expansion sphincter pharyngoplasty (MESP) on voice performance in patients with obstructive sleep apnea syndrome (OSAS). Methods: Fourteen OSAS patients who had AP + MESP procedure were included in the study. Voice performances of the patients were analyzed with acoustic voice analysis before surgery, and 6 months after surgery. Results: Preoperative and postoperative F0, jitter percentage, and shimmer percentage were compared. Mean preoperative F0 was 129.85 Hz, and mean postoperative F0 was 138.07 Hz, with a significant difference in between (P = 0.017). Mean preoperative jitter percentage was 0.65, and mean shimmer percentage was 0.88, while those values were 0.67 and 0.84, respectively, in the postoperative period. The differences were not statistically significant (P = 0.801 and 0.652). Conclusion: The AP + MESP procedure performed for OSAS results in improvement of F0 in the long term; however, there were no differences in jitter percentage and shimmer percentage. (C) 2017 by Mutaz B. Habal, MD.

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Three-Dimensional Anthropometric Evaluation of Facial Morphology.

Objectives: The objectives of this study were to evaluate sexual dimorphism for facial features within Colombian and Mexican-American populations and to compare the facial morphology by sex between these 2 populations. Materials and Methods: Three-dimensional facial images were acquired by using the portable 3dMDface system, which captured 223 subjects from 2 population groups of Colombians (n = 131) and Mexican-Americans (n = 92). Each population was categorized into male and female groups for evaluation. All subjects in the groups were aged between 18 and 30 years and had no apparent facial anomalies. A total of 21 anthropometric landmarks were identified on the 3-dimensional faces of each subject. The independent t test was used to analyze each data set obtained within each subgroup. Results: The Colombian males showed significantly greater width of the outercanthal width, eye fissure length, and orbitale than the Colombian females. The Colombian females had significantly smaller lip and mouth measurements for all distances except upper vermillion height than Colombian males. The Mexican-American females had significantly smaller measurements with regard to the nose than Mexican-American males. Meanwhile, the heights of the face, the upper face, the lower face, and the mandible were all significantly less in the Mexican-American females. The intercanthal and outercanthal widths were significantly greater in the Mexican-American males and females. Meanwhile, the orbitale distance of Mexican-American sexes was significantly smaller than those of the Colombian males and females. The Mexican-American group had significantly larger nose width and length of alare than the Colombian group regarding both sexes. With respect to the nasal tip protrusion and nose height, they were significantly smaller in the Colombian females than in the Mexican-American females. The face width was significantly greater in the Colombian males and females. Conclusions: Sexual dimorphism for facial features was presented in both the Colombian and Mexican-American populations. In addition, there were significant differences in facial morphology between these 2 populations. (C) 2017 by Mutaz B. Habal, MD.

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Double Vision After Minimally Invasive Orbital Decompression.

Introduction: New onset Diplopia following orbital decompression in thyroid eye disease patients is estimated to occur in up to 30% to 40% of decompression patients, mostly related to deep lateral and medial wall decompressions. Methods: A retrospective chart review of all minimally invasive (fat and minimal bone orbital decompression performed at the UCLA Stein Eye Institute between 2005 and 2015. Inclusion criteria were thyroid eye disease patients older than 18 years undergoing fat only orbital decompression with no previous muscle surgery. Results: The chart review revealed only 5 patients with new onset diplopia after this surgery. The cases are discussed and a possible mechanism for the diplopia is proposed. Discussion: Double vision following minimally invasive orbital decompression is rare and the mechanisms are poorly understood. (C) 2017 by Mutaz B. Habal, MD.

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Change in Posterior Pharyngeal Space After Counterclockwise Rotational Orthognathic Surgery for Class II Dentofacial Deformity Diagnosed With Obstructive Sleep Apnea Based on Cephalometric Analysis.

Although maxillomandibular advancement (MMA) is an orthognathic surgical procedure used to manage obstructive sleep apnea (OSA) in individuals who are noncompliant with continuous positive airway pressure therapy, simple MMA encounters problems in terms of aesthetic outcomes in Asian populations with preexisting dentoalveolar protrusion. Our current prospective investigation describes changes in posterior pharyngeal space and aesthetic outcomes after counterclockwise rotational orthognathic surgery, which is known to be quite difficult in terms of the maintenance of the skeletal stability in skeletal class II patients with OSA. This prospective study investigated the surgical outcome of patients who suffered from OSA following counterclockwise rotational orthognathic surgery. The patients were skeletal class II patients who underwent orthognathic surgery between March 2013 and December 2014. Cephalometric posterior airway analysis and a questionnaire for facial perception were used to assess pharyngeal airway and patient perception of facial appearance. A total of 14 patients were included. Satisfactory results were achieved without complications in all OSA patients. The airway parameters for anteroposterior length significantly increased. Thirteen patients answered a questionnaire on their facial appearance, and the visual analog scale averaged 7.31 points, indicating a favorable facial appearance. Counterclockwise rotational orthognathic surgery without maxilla advancement for the correction of OSA can effectively increase the posterior pharyngeal space, with favorable aesthetic results. With thoughtful application, this novel approach may be an alternative to standard approaches for the correction of OSA using orthognathic surgery. (C) 2017 by Mutaz B. Habal, MD.

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Aesthetic Lateral Canthoplasty: a Gray Line Split Approach.

Background: Many women in Asian countries chase larger and brighter eyes, but to most Asian people only double eye plasty and epicanthoplasty is not enough. As a result, aesthetic lateral canthoplasty, another procedure to lengthen the palpebral fissure, is becoming more and more popular. However, the current procedure of aesthetic lateral canthoplasty has many potential complications, restricting the wide application of this procedure. Methods: Here, the authors developed a minimally invasive method through gray line split and canthopexy to achieve lateral canthoplasty. Eighty-seven patients from February 2013 to January 2016 were included and had the procedure. The lengthen of the palpebral fissure was measured and photographs were also taken before the surgery and in the follow-up periods. Besides, the complications related to this procedure were also investigated. Results: The authors have performed aesthetic lateral canthoplasty in 87 patients, almost all of the follow-up patients have satisfactory results with a lengthen of palpebral fissure ranging from 2.3 to 4.2 mm. Through the long-term follow-up the authors found the lengthen of the palpebral fissure is stable. No serious complications like lacrimal system fistula or hypertrophic scars emerged except 1 patient with conjunctival exposure. Conclusions: Through this gray line split method, the authors can acquire larger and brighter eyes without serious complications. The authors think that this is a good method and worthy of promotion. (C) 2017 by Mutaz B. Habal, MD.

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Displacement of a Broken Dental Injection Needle Into the Perivertebral Space.

Dental injection needle breakage is an uncommon problem in dental practice. Displacement of the broken fragment into anatomical spaces is, on the other hand, a serious complication that occurs most commonly during inferior alveolar nerve blocks as a result of material wear, incorrect application of the anesthesia technique, or sudden movement of the patient during injection. Further complications such as infection, trismus, and nerve paralysis may exacerbate the condition and, if not treated adequately, life-threatening conditions may develop over time as the fragment dislodges deeper in soft tissues. Clinical symptoms of the patient, as well as the findings gathered from detailed physical examination and radiographic evaluation, are important factors to consider before performing an exploratory surgery. Removal of a broken needle may be troublesome due to its proximity to vital anatomic structures. Multislice computed tomography is a reliable imaging modality that provides accurate information to pinpoint the exact location of the needle fragment. This report describes a case of needle breakage occurred during inferior alveolar nerve block which was performed to extract a third molar tooth and the migration of the broken fragment from the right mandibular ramus area into the perivertebral space, with special emphasis on the surgical retrieval technique with multiplanar computed tomography imaging guidance. (C) 2017 by Mutaz B. Habal, MD.

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Retrotransposons Are the Major Contributors to the Expansion of the Drosophila ananassae Muller F Element

The discordance between genome size and the complexity of eukaryotes can partly be attributed to differences in repeat density. The Muller F element (~5.2 Mb) is the smallest chromosome in Drosophila melanogaster, but it is substantially larger (>18.7 Mb) in Drosophila ananassae. To identify the major contributors to the expansion of the F element and to assess their impact, we improved the genome sequence and annotated the genes in a 1.4 Mb region of the D. ananassae F element, and a 1.7 Mb region from the D element for comparison. We find that transposons (particularly LTR and LINE retrotransposons) are major contributors to this expansion (78.6%), while Wolbachia sequences integrated into the D. ananassae genome are minor contributors (0.02%). Both D. melanogaster and D. ananassae F element genes exhibit distinct characteristics compared to D element genes (e.g., larger coding spans, larger introns, more coding exons, lower codon bias), but these differences are exaggerated in D. ananassae. Compared to D. melanogaster, the codon bias observed in D. ananassae F element genes can primarily be attributed to mutational biases instead of selection. The 5' ends of F element genes in both species are enriched in H3K4me2 while the coding spans are enriched in H3K9me2. Despite differences in repeat density and gene characteristics, D. ananassae F element genes show a similar range of expression levels compared to genes in euchromatic domains. This study improves our understanding of how transposons can affect genome size and how genes can function within highly repetitive domains.

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A High Density Linkage Map Reveals Sexual Dimorphism in Recombination Landscapes in Red Deer (Cervus elaphus)

High density linkage maps are an important tool to gain insight into the genetic architecture of traits of evolutionary and economic interest, and provide a resource to characterise variation in recombination landscapes. Here, we used information from the cattle genome and the 50K Cervine Illumina BeadChip to inform and refine a high density linkage map in a wild population of red deer (Cervus elaphus). We constructed a predicted linkage map of 38,038 SNPs and a skeleton map of 10,835 SNPs across 34 linkage groups. We identified several chromosomal rearrangements in the deer lineage relative to sheep and cattle, including six chromosome fissions, one fusion and two large inversions. Otherwise, our findings showed strong concordance with map orders in the cattle genome. The sex-averaged linkage map length was 2739.7cM and the genome-wide autosomal recombination rate was 1.04cM per Mb. The female autosomal map length was 1.21 longer than that of males (2767.4cM vs 2280.8cM, respectively). Sex differences in map length were driven by high female recombination rates in peri-centromeric regions, a pattern that is unusual relative to other mammal species. This effect was more pronounced in fission chromosomes that would have had to produce new centromeres. We propose two hypotheses to explain this effect: (1) that this mechanism may have evolved to counteract centromeric drive associated with meiotic asymmetry in oocyte production; and/or (2) that sequence and structural characteristics suppressing recombination in close proximity to the centromere may not have yet evolved at neo-centromeres. Our study provides insight into how recombination landscapes vary and evolve in mammals, and will provide a valuable resource for studies of evolution, genetic improvement and population management in red deer and related species.

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FlyExpress 7: An Integrated Discovery Platform To Study Co-expressed Genes Using In Situ Hybridization Images in Drosophila

Gene expression patterns assayed across development can offer key clues about a gene's function and regulatory role. Drosophila melanogaster is ideal for such investigations as multiple individual and high-throughput efforts have captured the spatiotemporal patterns of thousands of embryonic expressed genes in the form of in situ images. FlyExpress (www.flyexpress.net), a knowledgebase based on a massive and unique digital library of standardized images and a simple search engine to find co-expressed genes, was created to facilitate the analytical and visual mining of these patterns. Here, we introduce the next generation of FlyExpress resources to facilitate the integrative analysis of sequence data and spatiotemporal patterns of expression from images. FlyExpress 7 now includes over 100,000 standardized in situ images and implements a more efficient, user-defined search algorithm to identify co-expressed genes via Genomewide Expression Maps (GEMs). Shared motifs found in the upstream 5' regions of any pair of co-expressed genes can be visualized in an interactive dotplot. Additional webtools and linkouts to assist in the downstream validation of candidate motifs are also provided. Together, FlyExpress 7 represents our largest effort yet to accelerate discovery via the development and dispersal of new webtools that allow researchers to perform data-driven analyses of co-expression (image) and genomic (sequence) data.

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An RNA Recognition Motif-Containing Protein Functions in Meiotic Silencing by Unpaired DNA

Meiotic silencing by unpaired DNA (MSUD) is a biological process that searches pairs of homologous chromosomes (homologs) for segments of DNA that are unpaired. Genes found within unpaired segments are silenced for the duration of meiosis. In this report, we describe the identification and characterization of Neurospora crassa sad-7, a gene that encodes a protein with an RNA recognition motif. Orthologs of sad-7 are found in a wide range of ascomycete fungi. In N. crassa, sad-7 is required for a fully-efficient MSUD response to unpaired genes. Additionally, at least one parent must have a functional sad-7 allele for a cross to produce ascospores. Although sad-7-null crosses are barren, sad-7 strains grow at a wild-type rate and appear normal under vegetative growth conditions. With respect to expression, sad-7 is transcribed at baseline levels in early vegetative cultures, at slightly higher levels in mating-competent cultures, and at its highest level during mating. These findings suggest that SAD-7 is specific to mating-competent and sexual cultures. Although the role of SAD-7 in MSUD remains elusive, green fluorescent protein (GFP)-based tagging studies place SAD-7 within nuclei, perinuclear regions, and cytoplasmic foci of meiotic cells. This localization pattern is unique among known MSUD proteins and raises the possibility that SAD-7 coordinates nuclear, perinuclear, and cytoplasmic aspects of MSUD.

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Demarcative Necrosis Along Previous Laceration Line After Filler Injection.

In recent years, fillers have been widely used for soft tissue augmentation. Although they are generally considered to be safe, many complications have been reported to date. Nose and nasolabial fold augmentations with fillers can lead to an implementation of nasal skin necrosis, possibly caused by intravascular embolism and/or extravascular compression. Herein, we present a case of a successfully treated patient who experienced skin necrosis after an injection of dermal fillers into the nasolabial fold. Interestingly, we discovered that the patient had experienced a laceration 8 years ago around the area in which the filler was injected. (C) 2017 by Mutaz B. Habal, MD.

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Mozart Ear Deformity: a Rare Diagnosis in the Ear Reconstruction Clinic.

Mozart ear is a rare auricular deformity; clinically the auricle is characterized by the bulging appearance of the anterosuperior portion of the auricle due to fusion of the crura of the antihelix, an inversion in the normal form of the cavum conchae resulting in its convexity and a slit-like narrowing of the orifice of the external auditory meatus. A retrospective review of clinical and photographic records of patients attended at the ear reconstruction clinic of our hospital between June of 2010 and May 2016 was performed; out of 576 consecutive patients only 3 fulfilled the inclusion criteria, with a prevalence of 0.5%. The authors present these patients. Surgical interventions mainly focus on the correction of the convex concha; however, the procedure should be tailored to the severity of the deformity and the wishes of the patient. (C) 2017 by Mutaz B. Habal, MD.

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Review of "Surgical Education and Health Care Reform, Defining the Role and Value of Trainees in an Evolving Medical Landscape" by Fayanju OM, Aggarwal R, Baucom RB, Ferrone CR, Massaro D, Terhune KP in Ann Surg 265: 459-460, 2017.

No abstract available

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Morphometric Analysis of the Posterior Cranial Fossa in Syndromic and Nonsyndromic Craniosynostosis.

Posterior cranial fossa (PCF) anatomy can be abnormal in craniosynostosis, and hindbrain herniation may occur. This study analyzed PCF anatomy in single suture and complex craniosynostosis. Children with craniosynostosis and age-matched controls were identified. Cephalic index (CI) for cranial vault and PCF as well as tentorial (TA) and occipital angles (OA) were measured on preoperative imaging. Children with syndromic (N = 6), bicoronal (N = 4), sagittal (N = 12), and metopic synostosis (N = 4) as well as controls (N = 10) were enrolled. Mean CI for cranial vault was 0.89, 0.93, 0.65, 0.74, and 0.78, respectively. Corresponding CI for PCF was 0.81, 0.93, 0.62, 0.74, and 0.78. Mean TA and OA were 45.4[degrees] and 96.6[degrees] in syndromic, 39.7[degrees] and 87.0[degrees] in bicoronal, 34.0 and 75.0[degrees] in sagittal, 39.7[degrees] and 87.0[degrees] in metopic synostosis, and 42.9[degrees] and 88.3[degrees] in controls. While CI, TA, and OA in metopic synostosis were similar to controls, abnormalities were found in syndromic, bicoronal, and sagittal synostosis. Syndromic and bicoronal craniosynostosis patients had a higher CI for both cranial vault and PFC as well as larger TA and OA, indicating a brachycephalic skull with steep tentorium and narrow PCF. In sagittal synostosis, CI for cranial vault and PCF were lower and TA and OA smaller, reflecting scaphocephalic deformity also at PCF, with a flat tentorium. This study provides basic PCF morphometry in craniofacial conditions. (C) 2017 by Mutaz B. Habal, MD.

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Lower Eyelid Reconstruction After Ablation of Skin Malignancies: How Far Can We Get in a Single-Stage Procedure?.

: Reconstruction of full-thickness lower eyelid defects tends to be a devastating procedure, especially when big amount of tissue has to be removed because of oncological reasons. The applied techniques are mostly difficult to execute and multistaged, often require extensive dissection, and result in scarring and facial disfigurement. The aim of the present study is to demonstrate the authors' experience in single-staged reconstructions of full-thickness defects of the lower eyelid with local tissue only. Material and Methods: A retrospective analysis was conducted identifying patients with postexcisional defects after skin cancer occurring in the lower eyelid, reconstructed in 1 stage. Appropriate demographic, pathological, preoperative, and postoperative clinical data and photo documentation were collected and analyzed. Results: After excluding patients with partial thickness defects (n=5), a total of 13 patients with lower eyelid full-thickness defects were studied, including 9 women and 4 men with mean age 66.5 years (age range 53-79 years). The most common malignancy was basal cell carcinoma (n = 11). In one of the patients 2 synchronous neoplasms were excised simultaneously from the same lower eyelid. The reconstruction was successfully performed in 1 stage in all the patients by recruiting the same eyelid tissue and/or temporal tissue. No additional surgery was needed at a minimal follow-up of 9 months. Conclusion: Local tissue flaps have proven to be a reliable option for a single-stage reconstruction of large full-thickness defects. Tenzel flap technique seems to be a reliable option for repair of defects as large as 60% of the total eyelid length. (C) 2017 by Mutaz B. Habal, MD.

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Nasal Septal Deformity in Relation to the Mode of Delivery.

Objective: The aim of this study was to find the relation between mode of delivery and the types of septal deviation. Materials and Methods: Records of patients treated for a deviated nasal septum from March 2003 to October 2015 were reviewed. Those with previous facial trauma were excluded. Information retrieved included basic demographic data, mode of delivery, sibling birthing order, type and date of surgery, and postoperational outcomes. Results: A total of 130 records were recovered. According to Guyuron's classification of nasal septal deviation, we found that type 5 was the most common type for patients delivered normally, whereas type 2 was the most common type for those who were delivered by cesarean section. Conclusion: Mode of delivery may be related to a certain type of deviation. However, studies with larger samples are required to support the finding in our study. (C) 2017 by Mutaz B. Habal, MD.

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Open Craniosynostosis Surgery: Effect of Early Intraoperative Blood Transfusion on Postoperative Course.

Correction of craniosynostosis can result in blood loss when the patient already has physiologic anemia. The aim of this study was to determine whether patients benefit from early blood transfusion and whether the timing of blood transfusion affects metabolic disturbances and the postoperative course. In this retrospective review, 71 patients who underwent open calvarial vault remodeling for correction of craniosynostosis were separated into 2 groups according to whether they received blood transfusions early (within the first 30 minutes of surgery) or later (after the first 30 minutes of surgery). Patients were further separated into nonsyndromic and syndromic cohorts. Tracked variables included hemoglobin, hematocrit, arterial blood gas values, lactate level, length of stay, estimated blood loss, and amount of blood transfused in the operating room, amount transfused postoperatively, and total amount transfused. Among all patients, the early transfusion group had a higher hemoglobin nadir overall and received less postoperative blood. Within the nonsyndromic cohort, the early transfusion group had a higher estimated blood loss and received more transfused blood. In the syndromic cohort, the early transfusion group had a hemoglobin nadir that was significantly higher than in the late transfusion group and a lower estimated blood loss, shorter pediatric intensive care unit stay, and less postoperative blood transfused. Syndromic patients also received significantly more blood overall. For syndromic patients undergoing open calvarial vault remodeling, transfusion within the first 30 minutes of surgery should be considered. (C) 2017 by Mutaz B. Habal, MD.

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Craniofacial features affecting mandibular asymmetries in skeletal Class II patients

Abstract

Objectives

The aim of this study was to evaluate the characteristics affecting different intensities of mandibular asymmetry in skeletal Class II adults using three-dimensional images. This study is clinically relevant since it allows professionals to evaluate the morphological components related to these deformities and more carefully obtain correct diagnosis and treatment plan for such patients.

Methods

Cone-beam computed tomography data of 120 Class II patients (40 with relative symmetry, 40 with moderate asymmetry, and 40 with severe asymmetry) were imported to SimPlant Ortho Pro^® 2.0 software (Dental Materialise, Leuven, Belgium). Three reference planes were established and linear measurements were performed from specific landmarks to these planes, comparing the deviated side and the contralateral side in each group, as well as the differences between groups. The correlation between midline mandibular asymmetry and other variables was also evaluated. Statistical analyses considered a significance level of 5%.

Results

Comparing the values obtained on the deviated side and on the contralateral side, there were significant differences for patients with moderate asymmetry and severe asymmetry. However, differences were seen more often in severe mandibular asymmetries. In those patients, there was a significant correlation of the gnathion deviation with lower dental midline deviation, difference in the lateral gonion positions, difference in the mandibular rami heights, and difference in the jugale vertical displacements.

Conclusions

For skeletal Class II patients with mandibular asymmetry, some craniofacial features are related to chin deviation and require proper evaluation, including the bilateral differences in the ramus height, mandibular body length, transverse and vertical positioning of the gonion and jugale points.

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Letter to the editor

Publication date: Available online 30 June 2017
Source:American Journal of Otolaryngology
Author(s): Satvinder Singh Bakshi




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Letter to Editors: Detection of endolymphatic hydrops using traditional MR imaging sequences

Publication date: Available online 30 June 2017
Source:American Journal of Otolaryngology
Author(s): Shinji Naganawa, Michihiko Sone




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Separation, Aspiration, and Fat Equalization: SAFE Liposuction Concepts for Comprehensive Body Contouring

No abstract available

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Angel Armor - Home of the Brave 2017

Let freedom ring as we celebrate independence and those who defend it in our third annual Fourth of July tribute. We live in the greatest country on Earth — rock on.

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Angel Armor - Home of the Brave 2017

Let freedom ring as we celebrate independence and those who defend it in our third annual Fourth of July tribute. We live in the greatest country on Earth — rock on.

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Evidence-Based Medicine: Mandible Fractures

Learning Objectives: After reading this article, the participant should be able to: 1. Explain the epidemiology of mandible fractures. 2. Discuss preoperative evaluation of the patient with a mandible fracture. 3. Compare the various modalities of fracture fixation. 4. Identify common complications after fracture repair. Summary: In this Maintenance of Certification/Continuing Medical Education article, the reader is provided with a review of the epidemiology, preoperative evaluation, perioperative management, and surgical outcomes of mandible fractures. The objective of this series is to present a review of the literature so that the practicing physician can remain up-to-date on key evidence-based guidelines to enhance management and improve outcomes. The physician can also seek further in-depth study of the topic through the references provided.

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Predictors, Classification, and Management of Umbilical Complications in DIEP Flap Breast Reconstruction

Background: In recent years, the deep inferior epigastric perforator (DIEP) flap has become the workhorse flap for autologous breast reconstruction. Despite increased reports on DIEP flaps, umbilical complications have not been previously studied. The aesthetics of the umbilicus dictates the beauty of the abdomen, and it is critical for plastic surgeons to minimize the scarring of the umbilicus. In this study, we retrospectively reviewed patients who underwent DIEP flaps to determine the predictors of umbilical complications, and created a classification system of these wounds. Methods: Retrospective review of 323 patients who underwent DIEP flap surgery from 2009 to 2016 was performed. Umbilical stalk heights, widths of fascial diastasis, and abdominal wall thicknesses were measured from computed tomographic scans. Data regarding demographic and patient characteristics were collected. Results: Of the 323 patients, there were 58 patients that had umbilical complications (18 percent). These patients had statistically higher body mass indexes, heavier flaps, and thicker abdominal walls (p

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Evidence-Based Medicine: Alloplastic Breast Reconstruction

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. Summary: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

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Vertical Midface Lifting with Periorbital Anchoring in the Management of Lower Eyelid Retraction: A 10-Year Clinical Retrospective Study

Background: Lower eyelid retraction can be the unfortunate result of aesthetic surgery, trauma, disease, or the aging processes. The purpose of this article is to assess whether midface lifting based on purely vertical repositioning constitutes an effective procedure for its correction. Methods: A retrospective study was carried out on 199 patients (311 eyelids) operated on between January of 2004 and January of 2014. The various causes of eyelid retraction in this population included cosmetic blepharoplasty (56.8 percent), involutional ectropion (23.1 percent), tumor resection (9.5 percent), facial nerve paralysis (8.5 percent), and trauma and related surgery (2 percent). The study was restricted exclusively to cases of moderate and severe lower eyelid retraction addressed by means of midface lifting. The mean follow-up time was 16.8 months. All of the patients were subjected to midface lifting with strengthening of the lateral canthus. A spacer graft was also used in 37.7 percent of the cases. Results: One hundred ninety-five patients (97.9 percent) displayed objective improvement of the eyelid retraction and a marked degree of improvement both in aesthetic terms and as regards the functional disorders reported. Only four patients (2 percent) presented complications such as needing another operation. Conclusion: Midface lifting based on purely vertical repositioning makes it possible to recruit a considerable amount of “new” skin at the lower eyelid, thus ensuring a decrease in vertical distraction and correct recovery of the height of the external lamellar plane. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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Reconstructive Plastic Surgery of the Head and Neck: Current Techniques and Flap Atlas

No abstract available

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Discussion: Vertical Midface Lifting with Periorbital Anchoring in the Management of Lower Eyelid Retraction: A 10-Year Clinical Retrospective Study

No abstract available

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Cohort Study to Assess the Impact of Breast Implants on Breastfeeding

No abstract available

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Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection

Background: The “Nefertiti lift” consists of injecting the platysmal bands and the inferior border of the mandible with botulinum toxin. No clinical trial has evaluated its effect on the different lower face and neck aging components, and little is known about the clinical characteristics that predict treatment success. Methods: Patients were injected with abobotulinumtoxinA along the inferior border of the mandible and into the platysmal bands. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. Results: Thirty patients were injected with a mean dose of 124.9 U of abobotulinumtoxinA per patient. Platysmal bands at rest and with maximal tension reached a statistically significant improvement. The other components showed a tendency for improvement but did not reach statistical significance; 93.3 percent of investigators and patients rated the overall results as improved, and 96.6 percent of patients were satisfied with their results. When comparing the patients who improved the most to all the other patients, they had lower preinjection region-specific scores. Conclusions: The Nefertiti lift can be used on its own or in conjunction with other rejuvenating procedures. It is particularly helpful in younger patients with platysma muscle hyperactivity and retained skin elasticity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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Reply: Effects of Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study

No abstract available

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Discussion: Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection

No abstract available

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Single-Injection Versus Multiple-Injection Technique of Ultrasound-Guided Paravertebral Blocks: A Randomized Controlled Study Comparing Dermatomal Spread.

Background and Objectives: The objective of this study was to investigate the extent of dermatomal spread following an ultrasound-guided thoracic paravertebral block (PVB) when equal volumes of local anesthetic are injected at 1 versus 5 vertebral levels. Methods: Seventy patients undergoing a unilateral mastectomy were randomized to receive either single or multiple injections of a PVB under real-time ultrasound guidance using a parasagittal approach. The patients in the single-injection group received a PVB at T3-T4 level with 25 mL of 0.5% ropivacaine and 4 subcutaneous sham injections. Patients in the multiple-injection group received 5 injections of a PVB from T1 to T5 level. Five milliliters of 0.5% ropivacaine was injected at each level. Evaluation of the sensory block was carried out 20 minutes following the completion of the PVB. Results: The median (interquartile range) dermatomal spread was not significantly different for the single-injection group (5 [4-6]) compared with the multiple-injection group (5 [5-6]), with a median difference of 0 segments (95% confidence interval, -1 to 0 segments; P = 0.22). The median time to performance of the single-injection PVB was shorter compared with the multiple-injection group (10 minutes), with a mean difference of -4 minutes (95% confidence interval, -6 to -3 minutes; P

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Neuralgic Amyotrophy Attributed Incorrectly to Block-Related Injury: Understanding Errors in Clinical Reasoning.

Objective: We report a case of misdiagnosed neuralgic amyotrophy (brachial plexus neuritis, Parsonage-Turner syndrome). Our primary objective is to review the scientific basis for errors in clinical reasoning. Case Report: We herein report a patient in whom signs and symptoms compatible with neuralgic amyotrophy presented after shoulder surgery. The patient's brachial plexopathy was attributed incorrectly as a complication of interscalene brachial plexus block. The true diagnosis was made only after the patient developed neuralgic amyotrophy in the contralateral upper extremity after a subsequent shoulder surgery on that side, this time without a brachial plexus block. Conclusions: Cognitive bias may lead to errors in clinical reasoning and consequent misdiagnosis. Temporal proximity may falsely implicate regional anesthesia as the causative agent. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Assessment of the Efficacy of Cryolipolysis on Saddlebags: A Prospective Study of 53 Patients

Background: Cryolipolysis is a noninvasive subcutaneous fat removal technique. Its efficacy has been demonstrated on various fatty areas but not yet on saddlebags. The main objective of this study was to demonstrate the efficacy, patient tolerance, and safety of cryolipolysis on the saddlebags. Methods: This prospective study enrolled 53 patients with saddlebags. Patients with a history of liposuction or other surgical procedure on the saddlebag area and those on diet pills were excluded. The primary endpoint was a decrease in fat thickness at 3 and 6 months, as assessed by thigh circumference measurement and by ultrasound evaluation of subcutaneous fat. Pain associated with cryolipolysis was assessed using a visual analogue scale. Body mass index at the different time points and adverse events were recorded. All patients completed a satisfaction questionnaire at the end of the study. Results: At 6 months, there was a mean decrease of 5.63 cm in thigh circumference; the mean decrease in fat layer thickness measured by ultrasound was 1.31 cm. The satisfaction questionnaire showed that 93.75 percent of patients were satisfied with the results. The mean visual analogue scale score was 1.66 of 10 after the session. Reversible skin changes such as postprocedure postinflammatory hyperpigmentation were observed in 8.33 percent of patients. Conclusions: Cryolipolysis is an effective technique for reducing saddlebag fat and is well tolerated by patients. A substantial risk of skin lesions, including postinflammatory hyperpigmentation that resolved after a few months, was observed. Cryolipolysis is a good alternative to liposuction in women with moderate, well-localized saddlebags. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome

Learning Objectives: After studying this article, the participant should be able to: 1. Create a safe and effective plan for management of carpal tunnel syndrome. 2. Support his or her rationale for the use of diagnostic tests. 3. Discuss elements of management that have been controversial, including anesthesia, the use of a tourniquet, postoperative pain control, and cost of care. Summary: This is the fourth MOC-PS CME article on carpal tunnel syndrome. Each of the prior three has had a slightly different focus, and the reader is invited to review all to generate a comprehensive view of the management of this common, and often controversial, topic. The operative goal—to release the transverse carpal ligament—is straightforward: diagnosis, cause, and technique have generated more vibrant discussions.

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Post-Surgical Relapse in Metopic Synostosis and Limitations of the Interfrontal Angle as an Outcome Measure.

Background: The interfrontal angle (IFA) has been utilized as a surrogate for morphologic assessment of the anterior cranial region in metopic synostosis with success in characterizing presenting severity. Its utility as an outcome measure has not been assessed similarly. In this study, we aimed to determine whether meaningful information relative to shape, and relapse in particular, could be assessed using the IFA. Methods: Patients with operatively treated isolated metopic synostosis were identified and included based on the availability of "previously obtained" low-dose computerized tomography (CT) scans at (1) preoperative and 2 postoperative (2) postoperative day-3 and (3) 1 year time points. Relapse was calculated as the percentage of the operatively induced change in IFA that was retained after the first postoperative year. Results: After exclusionary criteria, 19 patients were identified. The mean IFA values at the 3 time points were 119.3[degrees] (+/-9.8), 139.6[degrees] (+/-6.3), and 135.3[degrees] (+/-7.1), chronologically. Of the 19 patients, 14 (73.7%) experienced relapse, with this subgroup averaging 62.4% retention of their surgical change after 1 year. Increased preoperative severity and delayed age at surgical intervention were concurrently associated with an increased occurrence of relapse (P = 0.011). Another model utilizes preoperative IFA to predict the change in IFA that would accompany surgery on a case-by-case basis (P

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Surgical Outcomes of Endonasal Conjunctivodacryocystorhinostomy According to Jones Tube Location.

Purpose: The aim of this study was to compare surgical outcomes and complications of endonasal conjunctivodacryocystorhinostomy (CDCR) according to Jones tube location. Methods: Patients who underwent endonasal CDCR owing to proximal obstruction of the lacrimal drainage system between 2009 and 2016 were retrospectively reviewed. Patients were divided into 2 groups according to the location of the proximal end of the Jones tube. The canthal-based group included patients in which the proximal end of the Jones tube was located in the medial canthal angle, and the fornix-based group included patients in which the proximal end of the Jones tube was located in the inferomedial conjunctival fornix. Success rates were evaluated at 3 months and 6 months after surgery. Causes of failure, incidence of tube migration, and incidence of canthal deformity were also evaluated. Results: The success rate at 3 months postoperative was 95% in the canthal-based group and 78.6% in the fornix-based group (P = 0.283). Success rates at 6 months postoperative were 85% in the canthal-based group and 71.4% in the fornix-based group, respectively (P = 0.410). The main cause of failure was granuloma in the canthal-based group (2/20) and medial migration in the fornix-based group (3/14). Medial canthal deformity occurred in 12 of 20 cases in the canthal-based group, but none occurred in the fornix-based group. Conclusion: The canthal-based group had a lower migration rate and slightly better surgical success rate than the fornix based group, but canthal deformity was more prevalent. (C) 2017 by Mutaz B. Habal, MD.

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Our Surgical Past: An Aid to Understanding the Present and a Guide to the Future.

No abstract available

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Reconstruction of a Marjolin Ulcer Defect of the Scalp Invading Brain and Causing Brain Abscess Formation Using Free Latissimus Dorsi Flap.

Marjolin ulcers are known as aggressive malignant tumors that mostly arise over chronic wounds and cutaneous scars. Brain abscess is a serious medical condition that requires surgical drainage along with antibiotic treatment. Here, we report a case with a Marjolin ulcer located over the right parietal bone with intracranial abscess formation along with tumor invasion into brain parenchyma. This patient was a 64-year-old man and had a 4 x 4 cm open wound on his scalp from which a purulent discharge was coming. This wound required surgical excision with security margins, resection of bone, evacuation of the cystic cavity, and excision of the walls of the cystic cavity, which were invaded by the tumor. Duraplasty and reconstruction of the defect with a free lattisimus dorsi flap are performed. To the best of our knowledge, the case reported here is unique because of the formation of brain abscess in the background of a long-lasting Marjolin ulcer invading brain parenchyma. It must be remembered that on the background of cutaneous scars located over the scalp, a Marjolin ulcer may develop, and if left untreated, tumor cells may invade even the brain parenchyma. Long-term asymptomatic brain infections may also accompany the given scenario, and complicate differential diagnosis. (C) 2017 by Mutaz B. Habal, MD.

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Alternative treatments for chronic spontaneous urticaria beyond the guideline algorithm

Purpose of review: The international EAACI/GA2LEN/EDF/WAO guideline suggests a stepwise approach for the therapeutic management of chronic spontaneous urticaria (CSU), outlined in an algorithm. The aim of this article is to summarize and review the evidence available on alternative treatment options for CSU outside of this algorithm. Recent findings: Although CSU is a common disease, there are a limited number of high-quality studies, and only antihistamines and omalizumab are licensed for its treatment. Most studies regarding alternative therapies for CSU show methodological limitations and a high risk of bias. For many therapies, only case reports and uncontrolled studies exist. Recent publications on alternative treatments for chronic urticaria/CSU include reports on the use of adalimumab, rituximab, vitamin D, probiotics, histaglobulin, injection of autologous whole blood or serum, and phototherapy. Summary: Numerous treatments beyond the guideline algorithm have been evaluated in patients with refractory CSU. The global level of evidence to support their efficacy in CSU is low or very low. Further research is needed to assess the efficacy and safety of alternative therapies of CSU to manage adequately those patients who do not respond to the treatments included in the algorithm.

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Physiatric Patient Care, Graduate Medical Education Training, and Graduate Medical Education Funding: A Call for Alignment.

No abstract available

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Effects of Light-Emitting Diode Therapy on Muscle Hypertrophy, Gene Expression, Performance, Damage, and Delayed-Onset Muscle Soreness: A Case-Control Study With a Pair of Identical Twins.

No abstract available

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Ultrasound-Guided Injection to the Fifth Cervical Spinal Nerve Root Level.

No abstract available

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Skin allergy

No abstract available

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Pharmacotherapy of mast cell disorders

Purpose of review: Mast cell disorders (MCDs) comprise mastocytosis and disorders referred to as mast cell activation syndrome and are caused by abnormal accumulation and/or activation of mast cells in tissues. Clinical signs and symptoms are protean; therefore, finding suitable treatment options for individual patients entails a challenge for clinicians. The purpose of this manuscript is to review the literature on the available therapeutic interventions in patients with MCD. Recent findings: Pharmacotherapy is mainly directed against the effects of mast cells and their mediators. The current recommendations are exclusively based on expert opinions due to the lack of controlled clinical trials. The targeted therapies aiming at blocking mutant KIT variants and/or downstream signaling pathways are currently being developed and may be considered in severely affected, therapy-refractory patients. Summary: There is currently no method for predicting the best available approach to control symptoms in individual patients with MCD. Therefore, a stepwise, individual-based approach in pharmacotherapy options appears to be most successful strategy and is recommended in all patients. The core component of the treatment in most patients is to control symptoms caused by mast cell mediator release, whereas cytoreductive therapies are mainly reserved for patients with advanced/aggressive systemic mastocytosis.

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Allergic contact dermatitis in preservatives: current standing and future options

Purpose of review: Preservatives are well known skin sensitizers and represent one of the main causes of contact allergy. The purpose of this article is to review the current state of contact sensitization induced by preservatives and point future alternatives for products’ preservation. Recent findings: Isothiazolinones currently are the most common preservatives responsible of contact allergy in Europe and in the United States, and although some regulatory interventions have been taken place, the current contact allergy outbreak is not yet under control. Despite the ban of methyldibromo glutaronitrile from cosmetics in Europe, sensitized patients are still diagnosed, suggesting other nonregulated sources of exposure. Sensitization rates to formaldehyde and formaldehyde-releasers are lower in Europe in comparison with the United States due to stricter regulations regarding their use. Prevalence of contact allergy to parabens has remained stable over the last decades, whereas iodopropynyl butylcarbamate is an emerging allergen with an increasing prevalence. Future alternatives for products’ preservation look for a broad antimicrobial spectrum, but with a better safety profile (in terms of sensitization) than the currently available compounds. Summary: Given the high rates of sensitization reported over the last years, timely regulatory actions are urgently required for some preservatives that currently represent a concern for public health.

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Single-Injection Versus Multiple-Injection Technique of Ultrasound-Guided Paravertebral Blocks: A Randomized Controlled Study Comparing Dermatomal Spread.

Background and Objectives: The objective of this study was to investigate the extent of dermatomal spread following an ultrasound-guided thoracic paravertebral block (PVB) when equal volumes of local anesthetic are injected at 1 versus 5 vertebral levels. Methods: Seventy patients undergoing a unilateral mastectomy were randomized to receive either single or multiple injections of a PVB under real-time ultrasound guidance using a parasagittal approach. The patients in the single-injection group received a PVB at T3-T4 level with 25 mL of 0.5% ropivacaine and 4 subcutaneous sham injections. Patients in the multiple-injection group received 5 injections of a PVB from T1 to T5 level. Five milliliters of 0.5% ropivacaine was injected at each level. Evaluation of the sensory block was carried out 20 minutes following the completion of the PVB. Results: The median (interquartile range) dermatomal spread was not significantly different for the single-injection group (5 [4-6]) compared with the multiple-injection group (5 [5-6]), with a median difference of 0 segments (95% confidence interval, -1 to 0 segments; P = 0.22). The median time to performance of the single-injection PVB was shorter compared with the multiple-injection group (10 minutes), with a mean difference of -4 minutes (95% confidence interval, -6 to -3 minutes; P

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Angel Armor - Home of the Brave 2017

Let freedom ring as we celebrate independence and those who defend it in our third annual Fourth of July tribute. We live in the greatest country on Earth — rock on.

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Angel Armor - Home of the Brave 2017

Let freedom ring as we celebrate independence and those who defend it in our third annual Fourth of July tribute. We live in the greatest country on Earth — rock on.

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Perioperative Retinal Artery Occlusion: Incidence and Risk Factors in Spinal Fusion Surgery From the US National Inpatient Sample 1998-2013.

Background: Retinal artery occlusion (RAO) is a rare but devastating complication of spinal fusion surgery. We aimed to determine its incidence and associated risk factors. Methods: Hospitalizations involving spinal fusion surgery were identified by searching the National Inpatient Sample, a database of hospital discharges, from 1998 to 2013. RAO cases were identified using ICD-9-CM codes. Using the STROBE guidelines, postulated risk factors were chosen based on literature review and identified using ICD-9-CM codes. Multivariate logistic models with RAO as outcome, and risk factors, race, age, admission, and surgery type evaluated associations. Results: Of an estimated 4,784,275 spine fusions in the United States from 1998 to 2013, there were 363 (CI: 291-460) instances of RAO (0.76/10,000 spine fusions, CI: 0.61-0.96). Incidence ranged from 0.35/10,000 (CI: 0.11-1.73) in 2001-2002 to 1.29 (CI: 0.85-2.08) in 2012-2013, with no significant trend over time (P = 0.39). Most strongly associated with RAO were stroke, unidentified type (odds ratio, OR: 14.33, CI: 4.54-45.28, P

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Intracranial Aneurysms of Neuro-Ophthalmologic Relevance.

Background: Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. Evidence Acquisition: A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. Results: Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. Conclusions: Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity. (C) 2017 by North American Neuro-Ophthalmology Society

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History of Neuro-Ophthalmology in Argentina.

No abstract available

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Disparities in access to pediatric hearing health care.

Purpose of review: There are significant disparities in care facing children with hearing loss. The objective of this review is to assess the current disparities in pediatric hearing healthcare delivery, describe the barriers of efficient and effective pediatric hearing health care, and explore the innovations to improve pediatric hearing healthcare delivery. Recent findings: Children with hearing loss from certain geographic regions or ethnic background are significantly delayed in diagnosis and treatment. Multiple patient characteristics (presentation of hearing loss), parental factors (insurance status, socioeconomic status, educational status, and travel distance to providers), and provider barriers (specialist shortage and primary care provider challenges) prevent the delivery of timely hearing health care. Advances, such as improved screening programs and the expansion of care through remote services, may help to ameliorate these disparities. Summary: Timely identification and treatment of pediatric hearing loss is critical to prevent lifelong language complications. Children from vulnerable populations, such as rural residents, face significant disparities in care. Careful assessment of these barriers and implementation of culturally acceptable interventions are paramount to maximize communication outcomes of children with hearing loss. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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