Πέμπτη, 7 Ιουλίου 2016

Subclinical Thyroid Disease Is Associated with Increased Mortality in the Elderly

Clinical Thyroidology Jul 2016, Vol. 28, No. 7: 196-199.

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Off-duty Wash. medics save crash victim

By Emily Gillespie
The Columbian

VANCOUVER, Wash. — Scott Jensen was on his way home from work Tuesday evening when he saw a vehicle cross the centerline and head toward him on state Highway 503. He slammed on his brakes, but couldn't prevent the collision.

"I remember right before he hit me and the ambulance," the 29-year-old Amboy resident said.

It's what he doesn't remember that makes him tear up with gratitude. He doesn't remember other motorists stopping and running toward his burning Dodge Durango. He doesn't remember being pulled from his vehicle before it became engulfed in flames.

When he learned what happened to him, he jumped at the opportunity to meet two women who helped save his life.

From his hospital bed at PeaceHealth Southwest Medical Center, he hugged his saviors: Kim Detter and Hiedi Poulson.

"I owe you everything, thank you," he said through tears. "I don't know what else to say."

But both women knew what to say: that they were happy to help.

Detter, 36, of Battle Ground was driving in front of Jensen's Durango and saw the crash play out in her rearview mirror.

A 2015 GMC Yukon driven by 20-year-old Travis Starks of Portland was traveling south on the highway at about 5:40 p.m. when he crossed into the northbound lanes to pass traffic, according to the Washington State Patrol.

A northbound 2015 Toyota Rav 4 driven by Igor Skobkariov swerved into the right lane to try to avoid the crash. The Yukon still struck the left corner panel of the Rav 4, but Skobkariov escaped injury, State Patrol Trooper Will Finn said. The Yukon continued on and struck Jensen's Durango. Flames quickly erupted from the Durango's driver side.

Starks admitted to investigators that he smoked methamphetamine and marijuana earlier in the day and a drug recognition expert determined he was impaired, Finn said. Samples of Starks' blood were obtained and will be evaluated. The vehicle was stolen from a Portland car rental business, according to court records.

Starks made his first appearance in Clark County Superior Court on Wednesday on suspicion of vehicular assault, possession of a stolen vehicle and driving without a valid driver's license. His bail was set at $35,000.

Detter and Poulson missed becoming victims of the crash themselves by mere seconds.

"I don't know how I was missed," said Detter, who works as a medical assistant. "I just pulled over, grabbed my medic bag and ran."

Poulson, a 38-year-old combat medic with the Oregon Army National Guard, drove up to the scene and had the same reaction: help.

She pulled her car over, put the air conditioning on for her son and ran to the burning car.

"I was terrified, but I knew there was a man alive in there," she said. "I'm running up to the vehicle, and I'm absolutely afraid but I don't have a choice. … I couldn't not do it. There's no way I could not help that man."

Poulson was met by a man and the two worked to get Jensen out of the back passenger-side window. Somehow Jensen had freed himself from a safety restraint and had gotten himself in the back seat, Poulson said.

"I just reached inside and he looked at me and I just started pulling as hard as I could because the whole thing was just in flames," she said. "At one point, I had to back up because it was so hot, and then I just went back in. … It was going to go at any second and we had to get him out."

Moments after they got Jensen out of the vehicle, the Durango was consumed by fire.

"I just heard this explosion and felt the heat from it," she said. "It was intense."

Poulson began her trauma assessment and Detter stood by, handing her scissors to cut his clothes and gauze to treat his wounds.

"I'm so glad she was there," Poulson said. "Anything I needed, she gave to me. She was like my right hand."

When they saw Jensen get taken away in an ambulance, both women went home, cleaned up and worried about how he was. They didn't know the identity of the man who helped pull Jensen to safety.

Poulson said she didn't sleep well Tuesday night.

"I could still feel how stuck he was, how hard I was pulling," she said. "I remember the look on his face and the fear that this thing is going to explode and we're all going to die."

Detter called the hospital and learned through hospital staff that Jensen wanted to meet them.

Jensen winced through the pain to hug the women. He suffered three broken ribs, a lacerated liver, a gash to the face and many burns and bruises.

"I'm just a giant bruise," he quipped.

Seeing Jensen smile was enough to make the two women happy.

"He's alive and he's OK and that makes everything worth it," Poulson said. "All the training I've done, every night away from my family, everything I've gone through — it was worth it."

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Ohio health network adds EMS vehicle fleet

The network is adding 17 ambulances and 2 MICUS for interfacility transports

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Quiz: Where should you take your long-overdue vacation from the station?

Every EMT on this planet deserves a vacation. EMS is a stressful job. Whether you can actually take one is a different story.

It's OK to dream, though, and when the time comes for your long-overdue break, this quiz will show you exactly where you should take your next vacation from the station.

Related articles:

Quiz: Why do so many EMTs have a 'Type A' personality"

Paramedic uses vacation time to help disabled children

Heroes Vacation Club brings affordable vacation rentals to first responders

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Non-Certified Firefighter/EMT Trainee - Marion County Fire Rescue

MARION COUNTY FIRE RESCUE 2631 SE 3RD STREET OCALA, FLORIDA 34471 Updated: July 05, 2016 Classification: Non-Certified Firefighter/EMT Trainee Marion County Fire Rescue will be conducting a hiring process for 22 Non-Certified Firefighter/EMTs; job posting opens July 1, 2016 and will remain open until August 5, 2016. Testing is conducted through National Testing Network (NTN). Work Schedule and Starting ...

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5 costly EMS documentation mistakes

Here are the five EMS documentation mistakes that deny patients coverage they deserve and EMS agencies fair compensation for their services

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5 costly EMS documentation mistakes

By Steve Johnson

One of the most frustrating scenarios for EMS agencies is the denial of coverage for ambulance transport for far too many patients.

In the vast majority of cases our clients share with us, the primary reason patients are deprived of coverage is not that ambulance transport was medically unnecessary. Rather, it's that some crew members either don't understand or simply don't care about their professional responsibility to carefully and completely document the patient's condition at the time of transport on their patient care report.

Most simply, EMS providers need to stop using vague, meaningless words, conclusory statements and phrases that do not accurately convey — in appropriate clinical terms —the true condition of the patient at the time of service.

Here are the five most common EMS documentation mistakes we see and how EMS providers can stop making these costly mistakes.

1. Facts surrounding the dispatch undocumented
Many times when an ambulance responds to a 911 call, that simple fact is missing from the PCR. And in way too many chart reviews or audits, we find no dispatch determinants or other clear indication of the patient's reported condition at the time of dispatch.

Dispatch information, including the patient's reported condition at the time of dispatch, has been a critical component of good quality patient care documentation since 2002. How is it that so many organizations still don't have this critical piece of their patient care clearly and consistently documented on the PCR some 14 years later"

Organizations, whether their dispatch is internal or external, need to ensure that they have dispatch protocols, approved by their medical director, that are clearly understood at all levels of the organization. Dispatchers then must clearly communicate to the crews the patient's reported condition, which crews must clearly document on their PCR.

2. Insufficient narrative of the patient's condition at the time of transport
Far too frequently we see PCR narratives that do little more than state where the patient was picked up from, where they were delivered to and some statement that indicates that the crew left the patient no worse off than they found them — such as, "patient transported without incident."

This is especially true in the case of non-emergency transports.

For every transport, whether emergency or non-emergency, the PCR narrative must state the facts accurately, objectively and completely so that the reader can answer the question: Was transport of this patient by means other an ambulance contraindicated"

Other questions that should never go unanswered for the reader include the patient's mobility status, as well as the patient's ability to assist with the transfer to and from the stretcher and how that transfer was accomplished-and why. The PCR narrative must also answer how the patient's ability to care for themself compares to the patient's normal condition.

Also answer, what prompted the patient to call for an ambulance" When did the patient's problems start" How have the patient's symptoms evolved"

We suggest that ambulance services obtain and crew members read, whenever possible, hospital admission summaries for the patients they transport.

That doesn't have to be all the tests that were performed and the final diagnosis, but simply the history of present illness and summary of the patient's condition upon arrival. These admission summaries will often provide concrete examples of how professional medical records are expected to be written and the information that may be missing from their PCR for that same patient.

Many times if crews had taken the time to understand their patient's presentation, and documented those findings, the ambulance service would have far less problems verifying and supporting the care they provided when seeking reimbursement.

3. Vague explanation of specific interventions and procedures performed
Too many times we find nothing more than "per protocol" to explain why a cardiac monitor was applied, an IV was initiated or some other procedure was performed. Just like the ambulance service must be medically necessary to be reimbursed by Medicare and other payers, the treatments provided must also be medically necessary.

Interventions and procedures should be performed in response to specific patient assessment findings, not simply because some protocol exists. Crew members must understand that the patient's PCR is part of that patient's medical record, not simply an internal document.

Crew members should not assume that those reading their PCR know their organization's protocols. The medical findings that suggest the need for each intervention, as well as the patient's response to that intervention, should be clearly documented.

4. No explanation for EMS-specific care and treatment
This is important with regard to two areas. First, is clearly explaining the transport itself and the service or care the patient required during the transport that could not be provided other than by trained medical professionals in an ambulance.

Second, in the case of a patient being transported from one facility to another, what specific services does the patient require that are not available at the facility of origin"

Simply stating, "Transported patient for higher level of care" tells the reader nothing. The PCR must make clear the care the patient required at the destination facility and why that care could not be provided in the facility of origin.

In addition, the PCR must show what professional medical care the patient required during transport to that facility.

5. Inadequate description of patient complaints or findings
The most common example of an inadequately described or quantified complaint or finding is with regard to a patient's pain. EMTs and paramedics should always describe a finding or complaint of pain by documenting completely the Onset, Provocation, Quality, Radiation, Severity and Time (OPQRST), as well as the patient's pain rating on a scale of zero to 10.

The word "pain" on a PCR is a trigger to remind the EMS provider to fully describe and document that pain.

Hemorrhage is another common finding that is inadequately described. Always describe the location and size of any wound, and quantify of blood loss.

Again, these are just two examples. Good PCR documentation will not just state conclusions or findings. It always describes and quantifies those findings accurately, honestly and objectively.

These five mistakes represent the most common documentation shortcomings we see on PCRs. Sadly, it is due to poor or incomplete documentation, and not an actual lack of medical necessity for an ambulance, that far too many patients are deprived of the coverage they deserve and too many ambulance services are deprived of fair compensation for the care they provide.

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How EMS chiefs can improve employee engagement

Having an engaged, committed workforce is the best way to improve patient care

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EMS leader’s 8-step guide to excellent pediatric care

Paramedic chiefs and EMS leaders can ensure pediatric patients receive the correct care with right preparation, equipment and training

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Evaluation of hypolipidemic effect of Tinospora cordifolia in cholesterol diet induced hyperlipidemia in rats

Source: International Journal of Basic & Clinical Pharmacology
Sparshadeep E. M., Roopa P. Nayak, Kavana G. V., Mohandas Rai.
Background: There is always a need for developing novel drugs with higher efficacy and fewer side effects. Though statins are generally well-tolerated drugs for hyperlipidemia with high efficacy they are not free from adverse effects. Herbal drugs are well known for their cost-effectiveness and minimal side effects. Tinospora cordifolia (T. cordifolia) is one such plant with known hypolipidemic activity and wide availability in India. Hence this study is an attempt to verify and evaluate the extent of efficacy of T. cordifolia as a hypolipidemic agent. The objective of the study is to compare the hypolipidemic activity of aqueous root extract of T. cordifolia with that of Rosuvastatin in cholesterol diet-induced hyperlipidemia in rats. Methods: Hyperlipidemia was induced in male albino rats of wistar strain in the first 30 days of feeding period and continued in the next 30 days of treatment period. Aqueous root extract of T. cordifolia (2.5 and 5g/kg, per oral) was administered as test drug in the treatment period. Rosuvastatin (10 mg/kg, per oral) was used as the standard drug. Serum lipid profile, atherogenic index and body weights were estimated for all rats on the day before the start of the feeding period and on day 0, 15 and 30 of the treatment period. The results were analyzed statistically using students unpaired and paired t-test wherever applicable. Results: Serum lipid levels showed significant reduction (p

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How EMS chiefs can improve employee engagement

By Christine Zalar

Employees at all levels of an EMS agency must not only know what the organization's mission is, they must support it. That might seem obvious, but it's a fact that's often overlooked by EMS leaders.

The mission communicates the values and vision of the agency, which relies on its leaders and, equally, every employee to develop and implement goals, strategic initiatives and tactics to assure that mission is being achieved. After all, it's the people on the ground — from the caregivers taking care of patients to the billing office staff answering questions over the phone — who put the mission into practice.

It's important to recognize the value of an employee's emotional involvement or commitment to his or her organization. In other words, what is the level of employee engagement and how much does that engagement level impact their performance"

Research indicates that actively or highly engaged employees tend to be more productive, more customer-focused, safer and stay with the organization longer. Their engagement encourages them to give their best each day. The intensity of their bond with the organization helps them endure the ups and downs, while fueling their excitement about the organization's (and their own) successes.

Many leaders struggle with how to measure and monitor employee engagement — meaning they have no idea where the organization's relationship with its employees stands. The answer is simple; just ask. But how"

Survey says
One common approach to assessing employee engagement and dedication to the organization's mission is through employee surveys. The most beneficial surveys are those that have a standardized set of indices that support benchmarking, yet still allow for customization by the organization so it can include its most current business, leadership and work environment practices.

The following areas represent the standard subsets that are included in comprehensive survey instruments:

  • Perception of their jobs' importance to the organization.
  • Clarity of job expectations.
  • Opportunities for growth and improvement.
  • Quality of feedback from and dialog with supervisors and leaders.
  • Quality of the employees' working relationships with co-workers.
  • Perception of the organization's culture and values.
  • Perception of compensation.

The survey results may reveal specific areas for the organization to target to improve employee engagement. They often help pinpoint areas for organizational improvement as well, and allow an agency to benchmark its results against other similar organizations and share best practices with colleagues.

While the surveys help identify areas of improvement and measure progress toward goals, EMS leaders must initiate the most important piece, which is developing employees who feel strong, sustained engagement with the organization.

Talk it out
Talking to employees is sometimes more challenging in EMS organizations with numerous worksites and schedules, requiring EMS chiefs to intentionally plan to reach out and connect. But the return on time invested will be well worth it.

Sit down with staff and share the survey results. Discuss areas for improvement — both your priorities and theirs — and develop consensus. Then involve personnel in prioritizing and implementing an action plan.

Continue to seek their input, asking the key questions that arose from the survey such as what can the organization's leaders do better to ensure not only the agency's success, but also the individual employee's" Listen to their responses without defensive or posturing answers. Engage in a meaningful, shared conversation.

Open, two-way communication strengthens engagement. Push and pull communication such as emails, memos and texting are support tools, but person-to-person communication will always be the glue.

Here are a few key ways you can foster employee engagement.

  • Seek input and provide timely feedback.
  • Involve staff in projects, especially planning.
  • Anticipate employee informational needs; provide information before questions are even asked.
  • Establish a schedule and be consistent with informal, in-person communication opportunities.
  • Use written memos and emails for timely and efficient (but usually impersonal) communication.

Employee engagement contributes profoundly to the vision and mission of the organization. It improves communication, and more importantly, improves trust. Engagement leads to better EMS care for the community and each patient your organization serves.

About the author
Christine Zalar is a founding partner at Fitch & Associates. She is responsible for the firm's long-term management services contracts and leads the air medical consulting services division. Contact her directly at czalar@emprize.net.

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EMS leader’s 8-step guide to excellent pediatric care

By Sean Caffrey, NEMSMA

It is easy to find a wealth of educational material on EMS pediatric care despite the fact that most children encountered by EMS are not seriously ill or injured. How is it then that kids are a small fraction, 5 to 10 percent, of EMS patients, but command so much attention"

The reason is that effectively managing pediatric patients, including the rarely encountered critically ill pediatric patients, requires good preparation, ongoing training and comprehensive oversight by EMS services.

While the knowledge and equipment needed to take care of kids may be specialized, this should not suggest that EMS responders or response organizations are not equipped to handle sick kids.

You have likely heard "children are not small adults." While this line is certainly catchy, there is significant debate about its value within the pediatric emergency medicine community since it seems to imply that providers who take care of adults may not be skilled with children.

To the contrary, providing good care for children follows the same basic care principles as adult patients. Therefore, a more appropriate line might be "kids are patients, too," since they deserve the same level of assessment and care provided to an adult.

There are certainly some differences and special considerations, but nothing a skilled EMS practitioner can't handle. So how can leaders build these pediatric care skills for their teams"

1. Know frequent pediatric call types
The first preparatory step is knowing what to expect. The most frequent chief complaints for younger children include respiratory distress and seizures. For older children and adolescents, traumatic injury and behavioral or psychiatric complaints are the most common reasons for EMS activation.

What is most interesting, however, is that these are not the critical call types practitioners prepare for in a PALS class, nor are these the scenarios for which length-based resuscitation tapes were designed to handle.

As such, the forward-thinking EMS leader should examine their agency-specific call data to ensure that providers have the appropriate supplemental training to be well prepared for what likely constitutes the vast majority of their pediatric call volume.

2. Offline medical direction from evidence-based guidelines
Another important preparatory step is securing offline medical direction based on protocols reflecting current standards of pediatric care. Within the last few years, a number of evidenced-based guidelines have been published to assist medical directors and administrators in this area.

These pediatric EBGs represent a methodical approach to evaluating existing evidence in order to build the most effective care guidelines. While not protocols themselves, EBGs are great tools to use when building protocols and have already been implemented in a number of states.

Currently published guidelines include pediatric seizure management, as well as pain control for traumatic injuries. A respiratory distress guideline is also expected soon. Share these links and resources with your EMS medical director.

3. Medical direction from a pediatric specialist
A number of progressive services across the country, as well as a couple of states, have begun to add associate EMS medical directors for pediatric care. This trend primarily occurs in EMS services with ready access to children's hospitals. However, it may be worth contacting your regional children's hospital to see if their pediatric emergency medicine specialists are willing to participate in your medical direction system, or at least review your department's pediatric protocols.

I work closely with pediatric emergency medicine physicians and can assure you that it is great to have that level of expertise available as a resource to EMS practitioners. It is equally valuable to introduce these specialists, who often have a limited opportunity to interact outside their institutions, to EMS services throughout their region.

While it may take some effort to make this connection, you might be amazed what happens if you ask.

4. Providers need pediatric-specific tools
A final step in offline medical direction is making sure your practitioners have good tools available to implement their protocols. The most important tool is a product or method to estimate patient weight and determine drug dosages.

A pediatric drug quick-reference guide to determine fluid and drug dosage calculations needs to include information for commonly used respiratory, anti-seizure and pain medications. Many systems use pocket cards, quick-reference books, charts or apps in addition to length-based tapes that focus on resuscitation.

Last, a frequently overlooked tool is one to measure pain. As many younger children cannot use a standard zero-to-10 pain scale. Having access to a Faces, Legs, Activity, Cry and Consolability and a Wong-Baker Faces Scale are important to be able to treat pediatric pain or traumatic injuries effectively.

5. Essential pediatric equipment
Most states have minimum requirements for pediatric equipment based on nationally recommended equipment lists. As part of the work of the National EMS for Children program, your service has likely been surveyed regarding the availability of this equipment.

EMS leaders should strongly consider adding the following items:

  • A set-up for pull-push fluid administration. According to the most recent sepsis and shock guidelines, children in shock should receive 20 mL/kg in the first 5 to 10 minutes. Fluid resuscitation goals are to achieve normal vital signs within the first hour of shock presentation. Infusions at this rate are simply not possible using the unregulated administration of fluid through an intravenous bag alone or through a burette system. Services should consider carrying a three-way stopcock device and 60-cc Luer lock tip syringes that can be used to quickly and accurately administer fluid during resuscitation.
  • Diagnostic equipment to assess blood pressure and pulse oximetry. This includes appropriately sized blood pressure cuffs and pulse oximetry probes. In addition, automatic blood pressure cuffs, which are essential in obtaining a blood pressure on infants and toddlers, should be strongly considered. Previous teaching that blood pressure measurement is unimportant in children should be disregarded, as this vital sign is as critical to effective assessment and care of children as it is in adults.
  • Mushroom-tip or BBG type suction catheters are significantly more effective than bulb syringes or traditional Yankauer rigid suction tips at removing nasal secretions, especially in young children unable to blow their noses to alleviate respiratory distress. Such a device is easier to use and less traumatic, and does not risk stimulation of a vagal response.
  • Appropriate distraction and trust-building tools such as stuffed animals or search-and-find distraction books can assist children in coping with the EMS encounter.

6. Delivering pediatric care
When delivering pediatric care, it is important to consider that the most common problem with the care of children is the failure to deliver appropriate care when indicated. In some instances, practitioners may talk themselves out of essential interventions due to inadequate assessment or fear of agitating a child.

Examples of this include not obtaining vital signs and withholding essential respiratory, fluid resuscitation, glucose, pain control or spinal motion restriction. The best method to address these issues is to ensure a complete assessment, including a blood pressure, pulse oximetry, glucose measurement, pain measurement and capnography on all seriously ill children.

Simulation training improves care through practice with your service's protocols, reference materials, diagnostic tools and pediatric equipment. This is especially important considering the low volume of pediatric EMS encounters.

7. Assign a pediatric care champion
Make someone at your service responsible for preparation, equipment and training issues. In the most recent national Pediatric Readiness Assessment, over 4,000 hospital emergency department representatives across the United States were asked if they assigned a nurse or physician to the role of a pediatric care coordinator or champion to oversee pediatric readiness at their facilities.

The facilities that indicated such a role existed were found to score significantly higher on their overall readiness scores [1]. Assigning this role to an aspiring and motivated practitioner or supervisor in your organization could be just as helpful to your overall pediatric readiness.

8. Measure success
Children are a specialized patient population that require additional effort. Comprehensive review of your organization's pediatric calls is critical. Use your own electronic records, which do a great job of describing what types of patients you encounter and how well care is delivered to them.

Since critically ill children are a rare occurrence in any EMS system, the ability to evaluate and communicate findings about the care delivered on these calls, if done in an effective and non-punitive manner, will provide the opportunity for all of your practitioners to learn from these rare experiences. As such, quality improvement personnel should be sure to develop guidelines to regularly review both high-acuity and a subset of low-acuity pediatric calls.

Set up for future performance measurement success
The National EMS for Children program is in the process of approving new EMS performance measures for EMS for Children state partnerships to implement. Those measures will likely include electronic patient care reporting to the states on the NEMSIS version 3 standard, establishment of pediatric care coordinators in EMS services and competency testing of providers.

If your service implements these eight steps, your department will be well positioned to meet or exceed the expectations of these performance measures and provide great care for kids in the process.

About the author:
Sean Caffrey, MBA, CEMSO, NRP currently serves at the EMS Programs Manager for the University of Colorado School of Medicine, Pediatric Emergency Medicine Section. Sean has been certified as a paramedic since 1991and has worked in volunteer, private, hospital-based, fire-based and 3rd service EMS systems in roles from provider through department head. He currently works in conjunction with the state EMS office in Colorado, is the vice president of the EMS Association of Colorado, is a board member of the National EMS Management Association, and a member of NAEMT, NASEMSO and NAEMSP. Sean's interests include EMS system design, pediatrics, public policy, professional development and research.


1. Gausche-Hill M, Ely M, Schmuhl P, et al. A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatr. 2015;169(6):527-534. doi:10.1001/jamapediatrics.2015.138.

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CRISPR: a versatile tool for both forward and reverse genetics research


Human genetics research employs the two opposing approaches of forward and reverse genetics. While forward genetics identifies and links a mutation to an observed disease etiology, reverse genetics induces mutations in model organisms to study their role in disease. In most cases, causality for mutations identified by forward genetics is confirmed by reverse genetics through the development of genetically engineered animal models and an assessment of whether the model can recapitulate the disease. While many technological advances have helped improve these approaches, some gaps still remain. CRISPR/Cas (clustered regularly interspaced short palindromic repeats/CRISPR-associated), which has emerged as a revolutionary genetic engineering tool, holds great promise for closing such gaps. By combining the benefits of forward and reverse genetics, it has dramatically expedited human genetics research. We provide a perspective on the power of CRISPR-based forward and reverse genetics tools in human genetics and discuss its applications using some disease examples.

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Prospective study of physical, clinical and radiological profile of patients with pancreatic diabetes

Source: International Journal of Advances in Medicine
H. S. Patel, Ambrish Singh.
Background: Pancreatic diabetes (PD) is the unique kind of diabetes which is secondary to tropical pancreatitis. The present study was performed to elucidate the prevalence, clinical profile and underlying nutritional factors of secondary or pancreatic diabetes (PD) mellitus along with the role of exocrine failure in the absence of radiological evidence of calcification. Methods: A total 891 diabetes mellitus patients who were attending the diabetes education and care clinic, Jabalpur from October 2013 to April 2015 were studied. Diagnosis of pancreatic diabetes was done on the basis of history of recurrent abdominal pain from an early age, history of chronic alcoholism, the presence of pancreatic calculi seen on plain abdominal X-ray, absence of gall stone or hyperparathyroidism and diabetes mellitus. A detailed history, glycemic and lipid parameters along with micro and macrovascular complications were studied in all the patients with pancreatic diabetes. Results: Out of 891 diabetes patients, 3 (0.34%) were having pancreatic diabetes. Most of them belong to age group of 36-45 years. BMI was 200 mg/dl, PPG >320 mg/dl and HbA1c > 8.5%). All three patients had retinopathy and peripheral neuropathy problem. Macrovascular complications were less present. Conclusions: The prevalence of pancreatic diabetes was 0.34%, usually occurs in men with 3rd decade of age, low BMI and low socioeconomic status. Patients usually have uncontrolled diabetes (high FPG, PPG and HbA1c). Abdominal pain was the most common presenting symptom in patients. Microvascular complication was present in all the patients with pancreatic diabetes.

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Etiological profile of pancytopenia in a tertiary care hospital

Source: International Journal of Advances in Medicine
Nikhil Goli, Srikanth Koguru, Rustom S. Wadia, Sanjay Agarwal, Pradeep Patel, Pradeep Reddy, Karthik Nallam, Datta Kharwade.
Background: As the severity of pancytopenia and the underlying pathology determines the management and prognosis of these patients, identifying the correct etiopathology in a given case is crucial and helps in implementing timely and appropriate treatment.The objective of the study was to determine the etiological profile of pancytopenia. Methods: The present study included 44 patients with pancytopenia comprising of all ages and both sex. All cases were analyzed with respect to age, sex, clinical features at presentation, hemogram, peripheral smear, serum B12, plasma Folate, serum ferritin and bone marrow aspiration and etiological profile of pancytopenia was ascertained. Whether critical analysis of peripheral smear provides clue to the underlying pathology and how frequently bone marrow aspiration yields the diagnosis were also studied. Results: Megaloblastic anemia was the most common cause of pancytopenia in this study (54.5%). Malignant and premalignant conditions (20.5%) were the second commonest cause of pancytopenia. Among 24 patients of megaloblastic anemia, 13 patients (54.16%) had macrocytic picture on peripheral smear suggestive of uncomplicated megaloblastic anemia. Of the 24 patients of megaloblastic anemia, 22 patients (91.66%) had low serum B12 levels. The distribution of cellularity, megakaryopoiesis, erythropoiesis, granulopoiesis on bone marrow aspiration differed significantly across various causes of pancytopenia (p-value

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Clinical study of myoclonic epileptic syndromes

Source: International Journal of Advances in Medicine
Nikhil Goli, Srikanth Koguru, Rustom S. Wadia, Sanjay Agarwal, Pradeep Patel, Pradeep Reddy, Karthik Nallam, Datta Kharwade.
Background: Incidence of different myoclonic epileptic syndromes is variable in different regions. Here in as there is very few literature available internationally being inclusive of all myoclonic epilepsies together. Very few studies are available which describe all characteristics in a given study population. The aim of the study was to find incidence of different types of myoclonic epilepsies among patients presenting with myoclonic seizures their characteristics and to study all myoclonic epilepsies and juvenile myoclonic epilepsy in the study population. Methods: In this study conducted in neurological unit at Ruby hall clinic, a total of 188 case of epileptic disorder were enrolled irrespective of age and sex, among 136 were new case of epileptic disorder were classified based on seizure pattern, 23 were new cases of myoclonic epilepsy, these 23 new case of myoclonic epilepsy along with 52 old cases of myoclonic epilepsy attending to neurological unit were clubbed, a total of 75 cases myoclonic epilepsy were studied. All cases of myoclonic epilepsy and juvenile myoclonic epilepsy were studied with respect to age of onset different seizures, relation with family history, response to treatment, EEG findings. Results: Out of 136 cases 23 were new cases of myoclonic epilepsy, these 23 newly diagnosed cases of myoclonic epilepsies along with 52 already diagnosed myoclonic epilepsy are clubbed together, total of 75 cases were further studied. Incidence of myoclonic epilepsy among epileptic patients found to be 16.9%. Incidence of JME among myoclonic epilepsies is 75-80%, in all myoclonic epilepsies and JME association with GTCS, family history, EEG abnormalities were common finding, valproate and leviteracetam are good therapeutic options, carbamazepine aggravated myoclonus. Conclusions: For diagnosis of myoclonic epilepsy proper clinical history stress laid to ask history of myoclonic jerk in case of all seizure disorder, diagnosis basically depends on proper knowledge of myoclonic epileptic syndrome, eliciting history, EEG as an ancillary testing when in doubt always expert opinion is required as misdiagnosis of the myoclonus as partial seizure leads to wrong prescription of carbamazepine which exacerbates the myoclonus.

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A profile of adverse drug reactions in a rural tertiary care hospital

Source: National Journal of Physiology, Pharmacy and Pharmacology
Shivaraj Basavaraj Patil, Shrinivas R Raikar, Marupaka Janardhan, Y Venkata rao, Bhaskar H N, Nallavelly Vahila.
Background: Adverse drug reactions (ADRs) are a great concern in therapeutics. ADRs were ranked between the fourth and sixth leading causes of death in the USA. Aims and Objectives: The present study was conducted with the aim of identifying, analyzing the causality, pattern, and severity of ADRs occurring in our institution. Materials and Methods: A non-interventional observational study was conducted over 1 year from January to December 2015. The yellow forms dropped in the red ADR boxes are collected and analyzed for demographic data, causality, severity, drugs implicated, and organ system affected. The data were presented as numbers and percentages. Results: Antimicrobials are the most common drug class implicated in ADRs, and the dermatological system was the most common system affected by ADRs. All the reactions either belonged to the probable or possible category. Majority of reactions were nonserious. Conclusion: 175 ADRs were reported, which shows reporting was adequate. Awareness should be increased among health-care professionals regarding polypharmacy, which helps in reducing the ADR incidence.

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Role of proximal tibial osteotomy in knee osteoarthritis

Source: International Journal of Research in Medical Sciences
Farid Mohammed, Afzal Ansari, Sanjiv Kumar, Yasir Ali Khan, Vikas Verma.
Background: Osteoarthritis is an inevitable consequence of aging and second only to cardiovascular diseases in producing severe chronic disability. Osteoarthritis is characterized by degenerative changes in articular cartilage of diarthrodial joints and subsequent new bone formation at the articular margin. It is the result of excessive aging that primarily produces an alteration in the ratio of total glycosaminoglycans to that of fiber content in the matrix. The aim was to evaluate the results of proximal tibial osteotomy in medial compartment osteoarthritis (OA) of knee in terms of relief of pain, range of movement, correction of deformity and functional outcome Methods: This prospective observational study was conducted on 24 patients in the age range 54 to 70 years at the department of orthopedics, Eras Lucknow Medical College from July 2014 to May 2016. The femorotibial angle was assessed radiologically. A written informed consent was obtained. A closed wedge osteotomy was done followed by rehabilitation programme. Results: It was concluded that proximal tibial osteotomy is a satisfactory alternative to joint replacement surgery in osteoarthritis limited to medial compartment of the knee in developing countries like India. Conclusions: The study concluded that proximal tibial osteotomy is a satisfactory alternative to joint replacement surgery when the disease is restricted to medial compartment of the knee.

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Cis retinol oxidation regulates photoreceptor access to the retina visual cycle and cone pigment regeneration


Chromophore supply by the retinal Müller cells (retina visual cycle) supports the efficient pigment regeneration required for cone photoreceptor function in bright light. Surprisingly, a large fraction of the chromophore produced by dihydroceramide desaturase-1 (DES1), the putative all-trans retinol isomerase in Müller cells, appears to be 9-cis retinol. In contrast, the canonical retinal pigment epithelium (RPE) visual cycle produces exclusively 11-cis retinal. Here, we used the different absorption spectra of 9-cis and 11-cis pigments to identify the isoform of the chromophore produced by the visual cycle of the intact retina. We found that the spectral sensitivity of salamander and mouse cones dark-adapted in the isolated retina (with only the retina visual cycle) was similar to that of cones dark-adapted in the intact eye (with both the RPE and retina visual cycles) and consistent with pure 11-cis pigment composition. However, in mice lacking the cellular retinaldehyde binding protein (CRALBP), cone spectral sensitivity contained a substantial 9-cis component. Thus, the retina visual cycle provides cones exclusively with 11-cis chromophore and this process is mediated by the 11-cis selective CRALBP in Müller cells. Finally, despite sharing the same pigment, salamander blue cones, but not green rods, recovered their sensitivity in the isolated retina. Exogenous 9-cis retinol produced robust sensitivity recovery in bleached red and blue cones but not in red and green rods suggesting that cis retinol oxidation restricts access to the retina visual cycle to cones.

This article is protected by copyright. All rights reserved

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Erratum to: The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study

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The use of patient factors to improve the prediction of operative duration using laparoscopic cholecystectomy



Reliable prediction of operative duration is essential for improving patient and care team satisfaction, optimizing resource utilization and reducing cost. Current operative scheduling systems are unreliable and contribute to costly over- and underestimation of operative time. We hypothesized that the inclusion of patient-specific factors would improve the accuracy in predicting operative duration.


We reviewed all elective laparoscopic cholecystectomies performed at a single institution between 01/2007 and 06/2013. Concurrent procedures were excluded. Univariate analysis evaluated the effect of age, gender, BMI, ASA, laboratory values, smoking, and comorbidities on operative duration. Multivariable linear regression models were constructed using the significant factors (p < 0.05). The patient factors model was compared to the traditional surgical scheduling system estimates, which uses historical surgeon-specific and procedure-specific operative duration. External validation was done using the ACS-NSQIP database (n = 11,842).


A total of 1801 laparoscopic cholecystectomy patients met inclusion criteria. Female sex was associated with reduced operative duration (−7.5 min, p < 0.001 vs. male sex) while increasing BMI (+5.1 min BMI 25–29.9, +6.9 min BMI 30–34.9, +10.4 min BMI 35–39.9, +17.0 min BMI 40 + , all p < 0.05 vs. normal BMI), increasing ASA (+7.4 min ASA III, +38.3 min ASA IV, all p < 0.01 vs. ASA I), and elevated liver function tests (+7.9 min, p < 0.01 vs. normal) were predictive of increased operative duration on univariate analysis. A model was then constructed using these predictive factors. The traditional surgical scheduling system was poorly predictive of actual operative duration (R 2 = 0.001) compared to the patient factors model (R 2 = 0.08). The model remained predictive on external validation (R 2 = 0.14).The addition of surgeon as a variable in the institutional model further improved predictive ability of the model (R 2 = 0.18).


The use of routinely available pre-operative patient factors improves the prediction of operative duration during cholecystectomy.

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5th Anniversary International Fluid Academy Days

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A cross sectional study on awareness about injectable polio vaccine among pregnant women and mothers of children under 14 weeks in a rural area of Kannur, North Kerala, India

Source: International Journal of Community Medicine and Public Health
Sarada A. K., Thilak S. A., Sushrit A. Neloopant.
Background: Poliomyelitis, a highly infectious disease which can cause irreversible total paralysis which mainly affects the children under five years of age. As the Government was introducing the injectable polio vaccine (IPV) from April 2016 in Kerala as a part of polio end game strategy, the study was conducted to assess the awareness about IPV. The aim was to assess the level of knowledge about IPV and attitude towards IPV introduction in the national immunisation schedule among pregnant mothers and mothers having children

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Assessment of treatment adherence among hypertensive patients in a coastal area of Karnataka, India

Source: International Journal of Community Medicine and Public Health
Sneha D. Mallya, Ashwini Kumar, Asha Kamath, Avinash Shetty, Sravan K. Reddy T., Surabhi Mishra.
Background: Hypertension is the most prevalent non communicable disease. With the rising burden of hypertension, prevention of complications such as cardiovascular events or stroke resulting due to uncontrolled blood pressure is of paramount significance. Strict adherence to prescribed antihypertensive medications is the key to blood pressure control and prevention of its complications and mortality. Hence, the present study was conducted with the objective of assessing the medication adherence among hypertensive patients on treatment. Methods: A community based cross sectional study was conducted among 200 hypertensive patients on treatment for at least a year. Results: The study included 200 hypertensive patients on medication, 69% of them being females. More than two third (79.5%) were literate and 37% of study population were classified as under below poverty line. Most (39.5%) of the patients were 60-69 years of age and 55% of the patients were on treatment for over 5years. Majority (96%) of the hypertensive subjects in the study population were having an adherence rate of ≥85%. About 13% of the individuals had an interrupted treatment in the last one month. The most common reasons for missing the medications were being forgetful and not having any symptoms. Conclusions: The adherence rate in the current study is high, this needs to be maintained and further optimised.

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Prevalence and factors associated with depression among the elderly in rural areas of Kannur, North Kerala, India: a cross sectional study

Source: International Journal of Community Medicine and Public Health
Thilak S. A., Sarada A. K., Sushrit A. Neloopant.
Background: The proportion of elderly people aged 60 years and above is increasing in India alarmingly and they are at higher risk of developing neuropsychiatric problems if any associated comorbidities exist. The commonest neuropsychiatric problem is depression and if not diagnosed and treated early will lead to serious psychiatric illnesses, so this study was conducted to know the prevalence and factors associated with geriatric depression in rural Kannur. The aim was to determine the prevalence and the factors associated with depression among elderly in rural areas of Kannur, North Kerala, India. Methods: A cross sectional study was conducted at two Grama Panchayaths under the rural field practice area of Community Medicine department, Kannur Medical College, Kannur, Kerala, India. Convenient sampling method was used for the sampling. Data was collected using Geriatric Depression Scale (GDS) by visiting homes and rural health centre, descriptive statistics and associations were analysed. Results: Out of 250 elderly persons, 51.6% were males and 48.4% were females and prevalence of geriatric depression was 72.4%. The independent predictors of depression were elderly persons aged >70 years, financial dependency and with one or more comorbidities (p 70 years, financial dependency and having one or more comorbidities. There is a need to strengthen the mental health programme in the primary health centres. Giving health education to family members to spend time with elderly, creating awareness about the availability of social security schemes, family support to the elderly may help in preventing depression.

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Perioperative complications of obese patients

Current Opinion in Critical Care

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Outcomes after successful direct acting antiviral therapy for patients with chronic hepatitis C and decompensated cirrhosis

Journal of Hepatology

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'Bad guy' cells blamed in asthma, allergies prove life-saving in deadly C. difficile

University of Virginia Health System News

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Gastroesophageal reflux and sleep disturbances: A bidirectional association in a population-based cohort study, the HUNT study


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Association of preference-based health-related quality of life with weight loss in obese adults

Value in Health

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Desirable characteristics of hepatitis C treatment regimens: A review of what we have and what we need

Infectious Diseases and Therapy

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Impact of biliary stent-related events in patients diagnosed with advanced pancreatobiliary tumours receiving palliative chemotherapy

World Journal of Gastroenterology

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Efficacy and safety of cTACE versus DEB-TACE in patients with hepatocellular carcinoma: A meta-analysis

Journal of Digestive Diseases

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Optimal contrast enhancement liquid for dynamic MRI of swallowing

Journal of Oral Rehabilitation

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The effect of body mass index on surgical outcomes in patients undergoing pancreatic resection: A systematic review and meta-analysis


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Blood test to detect DNA fragments shed from colon cancers accurately predicts disease's recurrence

Johns Hopkins Medicine

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Extra-intestinal findings on magnetic resonance enterography in children with inflammatory bowel disease

Clinical Radiology

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Systematic review of tumour necrosis factor antagonists in extraintestinal manifestations in inflammatory bowel disease

Clinical Gastroenterology and Hepatology

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CD4 and CD4/CD8 ratio progression in HIV-HCV infected patients after achievement of SVR

Journal of Clinical Virology

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Development and validation of a risk score for advanced colorectal adenoma recurrence after endoscopic resection

World Journal of Gastroenterology

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Risk-Taking Behavior and Impulsivity among HCV-infected Patients

Psychiatry Research

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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: The radiologists perspective

Abdominal Imaging

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Intravenous and oral contrast vs intravenous contrast alone computed tomography for the visualization of appendix and diagnosis of appendicitis in adult emergency department patients

Canadian Association of Radiologists Journal

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Health-specific information and communication technology use and its relationship to obesity in high-poverty, urban communities: analysis of a population-based biosocial survey

Journal of Medical Internet Research

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Visualizing the hepatic vascular architecture using superb microvascular imaging in patients with hepatitis C virus: A novel technique

World Journal of Gastroenterology

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A Comparison of Measurements of Change in Respiratory Status in Spontaneously Breathing Volunteers by the ExSpiron Noninvasive Respiratory Volume Monitor Versus the Capnostream Capnometer.


BACKGROUND: Current respiratory monitoring technologies such as pulse oximetry and capnography have been insufficient to identify early signs of respiratory compromise in nonintubated patients. Pulse oximetry, when used appropriately, will alert the caregiver to an episode of dangerous hypoxemia. However, desaturation lags significantly behind hypoventilation and alarm fatigue due to false alarms poses an additional problem. Capnography, which measures end-tidal CO2 (EtCO2) and respiratory rate (RR), has not been universally used for nonintubated patients for multiple reasons, including the inability to reliably relate EtCO2 to the level of impending respiratory compromise and lack of patient compliance. Serious complications related to respiratory compromise continue to occur as evidenced by the Anesthesiology 2015 Closed Claims Report. The Anesthesia Patient Safety Foundation has stressed the need to improve monitoring modalities so that "no patient will be harmed by opioid-induced respiratory depression." A recently available, Food and Drug Administration-approved noninvasive respiratory volume monitor (RVM) can continuously and accurately monitor actual ventilation metrics: tidal volume, RR, and minute ventilation (MV). We designed this study to compare the capabilities of capnography versus the RVM to detect changes in respiratory metrics. METHODS: Forty-eight volunteer subjects completed the study. RVM measurements (MV and RR) were collected simultaneously with capnography (EtCO2 and RR) using 2 sampling methods (nasal scoop cannula and snorkel mouthpiece with in-line EtCO2 sensor). For each sampling method, each subject performed 6 breathing trials at 3 different prescribed RRs (slow [5 min-1], normal [12.6 +/- 0.6 min-1], and fast [25 min-1]). All data are presented as mean +/- SEM unless otherwise indicated. RESULTS: Following transitions in prescribed RRs, the RVM reached a new steady state value of MV in 37.7 +/- 1.4 seconds while EtCO2 changes were notably slower, often failing to reach a new asymptote before a 2.5-minute threshold. RRs as measured by RVM and capnography during steady breathing were strongly correlated (R = 0.98 +/- 0.01, bias = Capnograph-based RR - RVM-based RR = 0.21 +/- 1.24 [SD] min-1). As expected, changes in MV were negatively correlated with changes in EtCO2. However, large changes in MV following transitions in prescribed RR resulted in relatively small changes in EtCO2 (instrument sensitivity = [DELTA]EtCO2/[DELTA]MV = -0.71 +/- 0.11 and -0.55 +/- 0.11 mm Hg per 1 L/min for nasal and in-line sampling, respectively). Nasal cannula EtCO2 measurements were on average 4 mm Hg lower than in-line measurements. CONCLUSIONS: RVM measurements of MV change more rapidly and by a greater degree than capnography in response to respiratory changes in nonintubated patients. Earlier detection could enable earlier intervention that could potentially reduce frequency and severity of complications due to respiratory depression. (C) 2016 International Anesthesia Research Society

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In Response.


No abstract available

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In Response.


No abstract available

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Anesthesia Emergencies.


No abstract available

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Ectopic lymphocytic thyroiditis: A case report and treatment options

Source: Archives of Clinical and Experimental Surgery (ACES)
Irami Araújo-Filho, Amália Cínthia Meneses Rêgo, Francisco Irochima Pinheiro.
The presence of ectopic thyroid tissue is a rare entity. Non-gland migration occurs during the early stages of embryogenesis to the normal cervical location. Thus, ectopic tissue is lodged, in general, in the path of the thyroglossal duct in the middle line of the neck. The most common location is in the lingual zone, being the lingual thyroid. This, in most cases, will be asymptomatic. However, it is able to manifest itself with symptoms of dysphagia, dysphonia, obstruction of the upper airways or hemorrhage at any moment between childhood and adulthood. This article is a review of this disease, targeting mainly conduct, still very controversial in the literature.

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