The relationship between static posturography measures and specific cognitive domains in individuals with multiple sclerosis.

There are still limitations as to the understanding of the cognitive-postural control relationship in people with multiple sclerosis (PwMS). The aim of the current study' was to examine the relationship between cognition with measures of posturography in PwMS. The study was cross-sectional comprising 253 PwMS (162 women) with a mean age of 42.0 (SD=14.0). All participants completed a computerized cognitive test battery designed to evaluate multiple cognitive domains (Mindstreams; NeuroTrax) and static posturography tests (Zebris Medical GmbH). PwMS were divided into four levels of disability on the basis of their Expanded Disability Status Scale (EDSS) score: very mild (EDSS: 0-2.0), mild (EDSS: 2.5-3.5), moderate (EDSS: 4.0-5.5), and severe (EDSS: 6.0-6.5; using a walking aid). Significant correlations were observed between cognitive domains and posturography measures. However, the correlations were different between the disability subgroups. For the mild group, significant correlation scores were observed between the balance measures to the executive function and motor skills cognitive domains (Pearson's [rho]=~0.3 and ~0.4, respectively). As for the moderate group, significant correlation scores were observed in memory and verbal function (Pearson's [rho]=~0.4 and ~0.4, respectively). Attention was the only cognitive domain correlated significantly with posturography measures in the severe group (Pearson's [rho]=~0.55). Our study found that posturography measures are related to cognition in PwMS. However, the associations vary in terms of cognitive domains and disability levels. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Does neighborhood fast-food outlet exposure amplify inequalities in diet and obesity? A cross-sectional study

American Journal of Clinical Nutrition

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The use of capsule endoscopy in the emergency department as a triage of patients with GI bleeding

Gastrointestinal Endoscopy

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Association between severity of obstructive sleep apnea and blood markers of liver injury

Clinical Gastroenterology and Hepatology

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Dysphagia in patients with acute ischemic stroke: early dysphagia screening may reduce stroke-related pneumonia and improve stroke outcomes

Cerebrovascular Diseases

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Prevalence of overweight and obesity among children and adolescents with intellectual disabilities: a systematic review and meta-analysis

Obesity Reviews

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Applicability of hepatitis C virus RNA viral load thresholds for 8-week treatments in patients with chronic hepatitis C virus genotype 1 infection

Clinical Infectious Diseases

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Management and outcomes of leaks after oesophagectomy

British Journal of Surgery

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The inter-rater reliability of the International Classification of Functioning, Disability and Health set for spinal cord injury nursing.

The International Classification of Functioning, Disability and Health (ICF) has potential to be used as a clinical assessment instrument directly. However, difficulty in operationalizing the ICF qualifiers has led to unsatisfactory inter-rater reliability of ICF instruments in previous studies. The ICF set for spinal cord injury (SCI) nursing contains a group of categories that can reflect the functioning of SCI patients from the perspective of nurses. The aim of this study was to explore the inter-rater reliability of the ICF set for SCI nursing. Detailed measuring guidelines were prepared for each category of the ICF set. Two trained nurses then used the ICF set to independently rate 40 SCI patients within the first 3 days after their admission. The results showed that the percentage of the observed agreement between the nurses ranged from 42.5 to 100% (median 75%, interquartile range 62.5-87.5%). The weighted [kappa] ranged from -0.03 to 1.00 (median 0.68, interquartile range 0.45-0.84). A total of 50 categories (79.4%) showed weighted [kappa] greater than 0.4 and 39 categories (61.9%) had weighted [kappa] greater than 0.6. The medians of the weighted [kappa] for the body functions, body structures, activity and participation and environmental factors components were 0.6, 0.64, 0.84, and 0.11, respectively. This study indicated that the inter-rater reliability of the ICF set for SCI nursing was acceptable. Establishment of detailed measuring guidelines could help reduce the differences between raters. Simpler and clearer measuring guidelines are recommended and the definitions of some categories need to be clarified in future studies. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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The inter-rater reliability of the International Classification of Functioning, Disability and Health set for spinal cord injury nursing.

The International Classification of Functioning, Disability and Health (ICF) has potential to be used as a clinical assessment instrument directly. However, difficulty in operationalizing the ICF qualifiers has led to unsatisfactory inter-rater reliability of ICF instruments in previous studies. The ICF set for spinal cord injury (SCI) nursing contains a group of categories that can reflect the functioning of SCI patients from the perspective of nurses. The aim of this study was to explore the inter-rater reliability of the ICF set for SCI nursing. Detailed measuring guidelines were prepared for each category of the ICF set. Two trained nurses then used the ICF set to independently rate 40 SCI patients within the first 3 days after their admission. The results showed that the percentage of the observed agreement between the nurses ranged from 42.5 to 100% (median 75%, interquartile range 62.5-87.5%). The weighted [kappa] ranged from -0.03 to 1.00 (median 0.68, interquartile range 0.45-0.84). A total of 50 categories (79.4%) showed weighted [kappa] greater than 0.4 and 39 categories (61.9%) had weighted [kappa] greater than 0.6. The medians of the weighted [kappa] for the body functions, body structures, activity and participation and environmental factors components were 0.6, 0.64, 0.84, and 0.11, respectively. This study indicated that the inter-rater reliability of the ICF set for SCI nursing was acceptable. Establishment of detailed measuring guidelines could help reduce the differences between raters. Simpler and clearer measuring guidelines are recommended and the definitions of some categories need to be clarified in future studies. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Cognitive reserve and preinjury educational attainment: effects on outcome of community-based rehabilitation for longer-term individuals with acquired brain injury.

The cognitive reserve hypothesis has been proposed to account for the mismatch between brain pathology and its clinical expression. The aim of the current research was to explore, in a longitudinal data set, the effects of level of educational attainment before brain injury (cognitive reserve) and clinical factors on the level of rehabilitation-induced changes in disability and community integration. Participants in receipt of postacute rehabilitation were assessed at induction to the service and again at between 14 and 18 months of follow-up while still in service on changes in aspects of their abilities, adjustment and participation (Mayo Portland Adaptability Indices) and community integration (Community Integration Questionnaire). Controlling for type and severity of injury, age at onset of injury and duration of time since injury, participants with higher previous educational attainment showed significantly greater changes over the course of rehabilitation on adjustment to their injury and participation, but not on abilities, or community integration following postacute rehabilitation. Level of education would appear to be an important element of cognitive reserve in brain injury that serves to aid responses to postacute rehabilitation in terms of an individual's adjustment to disability and participation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174

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The relationship between static posturography measures and specific cognitive domains in individuals with multiple sclerosis.

There are still limitations as to the understanding of the cognitive-postural control relationship in people with multiple sclerosis (PwMS). The aim of the current study' was to examine the relationship between cognition with measures of posturography in PwMS. The study was cross-sectional comprising 253 PwMS (162 women) with a mean age of 42.0 (SD=14.0). All participants completed a computerized cognitive test battery designed to evaluate multiple cognitive domains (Mindstreams; NeuroTrax) and static posturography tests (Zebris Medical GmbH). PwMS were divided into four levels of disability on the basis of their Expanded Disability Status Scale (EDSS) score: very mild (EDSS: 0-2.0), mild (EDSS: 2.5-3.5), moderate (EDSS: 4.0-5.5), and severe (EDSS: 6.0-6.5; using a walking aid). Significant correlations were observed between cognitive domains and posturography measures. However, the correlations were different between the disability subgroups. For the mild group, significant correlation scores were observed between the balance measures to the executive function and motor skills cognitive domains (Pearson's [rho]=~0.3 and ~0.4, respectively). As for the moderate group, significant correlation scores were observed in memory and verbal function (Pearson's [rho]=~0.4 and ~0.4, respectively). Attention was the only cognitive domain correlated significantly with posturography measures in the severe group (Pearson's [rho]=~0.55). Our study found that posturography measures are related to cognition in PwMS. However, the associations vary in terms of cognitive domains and disability levels. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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The Analgesic Effect of Obturator Nerve Block Added to a Femoral Triangle Block After Total Knee Arthroplasty: A Randomized Controlled Trial.

Background and Objectives: Total knee arthroplasty (TKA) is associated with severe pain, and effective analgesia is essential for the quality of postoperative care and ambulation. The analgesic effects of adding an obturator nerve block (ONB) to a femoral triangle block (FTB) after TKA have not been tested previously. We hypothesized that combined ONB and FTB will reduce opioid consumption and pain compared with those of a single FTB or local infiltration analgesia (LIA). Methods: Seventy-eight patients were randomized to combined ONB and FTB, single FTB, or LIA after primary unilateral TKA. The primary outcome was morphine consumption during the first 24 postoperative hours. Secondary outcomes included morphine consumption during the first 48 postoperative hours, pain at rest and passive knee flexion, nausea and vomiting, cumulated ambulation score, and Timed Up and Go test. Results: Seventy-five patients were included in the analysis. The total intravenous morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR], 0-15) in the combined ONB and FTB group, 20 mg (IQR, 10-26) in the FTB group (P = 0.0007), and 17 mg (IQR, 10-36) in the LIA group (P = 0.002). The combined ONB and FTB group displayed reduced pain, nausea, and vomiting compared with the other groups. The ambulation tests showed no statistically significant differences between the groups. Conclusions: Addition of ONB to FTB significantly reduced opioid consumption and pain after TKA compared with a single FTB or LIA, without impaired ambulation. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Cognitive reserve and preinjury educational attainment: effects on outcome of community-based rehabilitation for longer-term individuals with acquired brain injury.

The cognitive reserve hypothesis has been proposed to account for the mismatch between brain pathology and its clinical expression. The aim of the current research was to explore, in a longitudinal data set, the effects of level of educational attainment before brain injury (cognitive reserve) and clinical factors on the level of rehabilitation-induced changes in disability and community integration. Participants in receipt of postacute rehabilitation were assessed at induction to the service and again at between 14 and 18 months of follow-up while still in service on changes in aspects of their abilities, adjustment and participation (Mayo Portland Adaptability Indices) and community integration (Community Integration Questionnaire). Controlling for type and severity of injury, age at onset of injury and duration of time since injury, participants with higher previous educational attainment showed significantly greater changes over the course of rehabilitation on adjustment to their injury and participation, but not on abilities, or community integration following postacute rehabilitation. Level of education would appear to be an important element of cognitive reserve in brain injury that serves to aid responses to postacute rehabilitation in terms of an individual's adjustment to disability and participation. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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The relationship between static posturography measures and specific cognitive domains in individuals with multiple sclerosis.

There are still limitations as to the understanding of the cognitive-postural control relationship in people with multiple sclerosis (PwMS). The aim of the current study' was to examine the relationship between cognition with measures of posturography in PwMS. The study was cross-sectional comprising 253 PwMS (162 women) with a mean age of 42.0 (SD=14.0). All participants completed a computerized cognitive test battery designed to evaluate multiple cognitive domains (Mindstreams; NeuroTrax) and static posturography tests (Zebris Medical GmbH). PwMS were divided into four levels of disability on the basis of their Expanded Disability Status Scale (EDSS) score: very mild (EDSS: 0-2.0), mild (EDSS: 2.5-3.5), moderate (EDSS: 4.0-5.5), and severe (EDSS: 6.0-6.5; using a walking aid). Significant correlations were observed between cognitive domains and posturography measures. However, the correlations were different between the disability subgroups. For the mild group, significant correlation scores were observed between the balance measures to the executive function and motor skills cognitive domains (Pearson's [rho]=~0.3 and ~0.4, respectively). As for the moderate group, significant correlation scores were observed in memory and verbal function (Pearson's [rho]=~0.4 and ~0.4, respectively). Attention was the only cognitive domain correlated significantly with posturography measures in the severe group (Pearson's [rho]=~0.55). Our study found that posturography measures are related to cognition in PwMS. However, the associations vary in terms of cognitive domains and disability levels. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Kullback–Leibler divergence and the Pareto–Exponential approximation

Recent radar research interests in the Pareto distribution as a model for X-band maritime surveillance radar clutter returns have resulted in analysis of the asymptotic behaviour of this clutter model. In part...

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Carriage rate and methicillin resistance of Staphylococcus aureus in food handlers in Kars City, Turkey

The aim of this study was determine carriage rate and methicillin resistance of Staphylococcus aureus among food handlers. Samples were collected by swabbing the mouth, nasal cavity and hands of food workers. The...

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Expression of scavenger receptor A in rat’s liver tissue during acute obstructive cholangitis and its significance

Acute obstructive cholangitis (AOC) is a severe disease that leads to sepsis, shock and multiple organ dysfunction syndrome. Liver is the largest and the major organ for the defense mechanisms during the sepsi...

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Early Results and Description of a New Modification of Spreader Graft to Enlarge Nasal Valve Area: Modified Triangular Spreader Graft.

Objective: Nasal valve area is an important, functional part of nose and there are several different methods that have been used to enlarge that area for a better breathing function. In this study, the authors aimed to study the efficacy of a new spreader graft modification that was crafted in a triangular shape to enlarge nasal valve area. Methods: Twenty-two patients who underwent rhinoplasty operation with this new technique composed the study group. Average age of patients was 21.4 +/- 2.1, 13 of them were men (59%) and 9 of them were women (41%). Same surgeon operated all 22 patients with the same technique that included usage of modified triangular spreader graft. Surgical outcomes were assessed by visual analog scale and nasal obstruction symptom evaluation scale preoperatively and 3 months postoperatively. Results: None of the patients had complications or aesthetic deformities according to surgeon after surgery. Average of nasal obstruction symptom evaluation scale score was 64.3 before surgery which reduced to 17.9 at postoperative third month. Also average visual analog scale score was 2.6 before surgery and it was 8.1 3 months after surgery indicating a better breathing sensation (P

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The Dimensions of the Orbital Cavity Based on High-Resolution Computed Tomography of Human Cadavers.

Blow-out fractures affect the volume and surface area of the orbital cavity. Estimation of these values after the trauma may help in deciding whether or not a patient is a candidate for surgery. Recent studies have provided estimates of orbital volume and area of bone defect, and correlated them with the degree of enophthalmos. However, a large degree of biological variation between individuals may preclude such absolute values from being successful indicators for surgery. Stereological methods have been used to estimate orbital cavity volume in a few studies, but to date these have not been used for surface area. To authors' knowledge, this study is the first to have measured the entire surface area of the orbital cavity. The volume and surface area of the orbital cavity were estimated in computed tomography scans of 11 human cadavers using unbiased stereological sampling techniques. The mean (+/- SD) total volume and total surface area of the orbital cavities was 24.27 +/- 3.88 cm3 and 32.47 +/- 2.96 cm2, respectively. There was no significant difference in volume (P = 0.315) or surface area (P = 0.566) between the 2 orbital cavities. The stereological technique proved to be a robust and unbiased method that may be used as a gold standard for comparison with automated computer software. Future imaging studies in blow-out fracture patients may be based on individual and relative calculation involving both herniated volume and fractured surface area in relation to the total volume and surface area of the uninjured orbital cavity. (C) 2016 by Mutaz B. Habal, MD.

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Bone Flap Technique for Impacted Teeth Extraction and Bone Cysts Removal.

The treatment of cystic lesions and the extraction of impacted third molars are 2 of the most common procedures in oral and maxillofacial surgery. The surgical treatment of cysts of the jaws can consist of a cystectomy, a cystotomy, or a staged combination of the 2 procedures. The surgical techniques developed for the extraction of impacted third molars are: coronectomy, orthodontic extraction, and surgery using intraoral or extraoral methods. There are various complications related to both surgical treatments. With regards to these complications, authors' department has developed a new surgical technique based on a previously described technique, which provides better support to the mucoperiosteal flap and improves bone regeneration after healing. Additionally, authors' goal was to reduce the risk of nerve injury, which has been achieved thanks to a direct visualization of the inferior alveolar nerve as well as cystic lesion or the dental element. The surgical procedure described produces major advantages over the traditional alternatives, despite needing a longer operation. This technique is particularly useful in the treatment of cystic lesions that have caused considerable bone loss. It can also be utilized for cysts or impacted dental elements strictly linked to the inferior alveolar nerve. (C) 2016 by Mutaz B. Habal, MD.

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Retrieval of a Broken Dental Needle Close to the Facial Artery After Cervical Migration.

Use of imaging tools like digital C-arm, tridimensional tomography, and navigational surgery has proven its value to the surgical removal of broken needles. A 32-year-old patient was referred for evaluation of a fractured needle during inferior alveolar nerve block attempt few days before. The patient complained of a pricking sensation at the injured area while moving the neck. A contrasted computed tomography was performed for further evaluation of the needle toward the vascular network of the neck, showing a close location by the left facial artery, parallel to the styloid process of the temporal bone. The needle was then released from the underlying tissues and retrieved. Although considered a rare intercurrence, there are still reports of breaking needles during dental anesthesia. Such reports are almost always related to inferior alveolar nerve blocks, associated with the use of short, thin needles, and after multiple bending movements before the insertion of the needle in the tissues. Accurate image examinations such as contrasted computed tomography are of great importance for planning the surgical removal, especially in patients of migration next to important vessels of the neck. (C) 2016 by Mutaz B. Habal, MD.

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The Craniofacial and Upper Limb Management of Nager Syndrome.

Introduction: Nager syndrome is a rare condition characterized by craniofacial and upper limb abnormalities. It is commonly mistaken for Treacher Collins syndrome, with which it shares the same craniofacial phenotype. However, patients with Treacher Collins do not exhibit hand anomalies, which are seen in patients with Nager syndrome. This paper reviews the multidisciplinary management of patients with Nager syndrome who were treated at the Australian Craniofacial Unit, Adelaide and the Erasmus Medical Centre, Rotterdam. Methods: The database of both units was scrutinized and the case-notes of the patients with Nager syndrome were reviewed. Data was collected on patient demographics, surgical management, complications, and outcome. Results: Nine patients (6 M:3 F) were identified with Nager syndrome, with a mean age at presentation of 3.7 years (range 8 days to 11.8 years). The mean follow-up time was 2.2 years (2 months to 19 years). SF3B4 mutation was noted in 2 patients and 1 patient had an X:9 translocation. Seven (77.8%) had obstructive sleep apnoea, with 5 patients diagnosed as severe obstructive sleep apnoea. Four patients had pollicization of their index, 2 patients had excision of extra radial digits and 1 patient underwent thumb duplication correction. Craniofacial surgery included mandibular advancement in 5 patients, temporo-mandibular joint reconstruction in 2 patients, and a genioplasty in 1 patient. Conclusion: Nager syndrome is a rare acrofacial dysostosis syndrome that is best managed within the realms of a multidisciplinary team. The authors would advocate early pollicization in patients with thumb anomalies to prevent any impairment in manual dexterity. (C) 2016 by Mutaz B. Habal, MD.

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Multilevel Combined Surgery With Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome.

Objective: To evaluate the results of combined multilevel surgery with transoral robotic surgery (TORS) in patients with obstructive sleep apnea/hypopnea syndrome for multilevel upper airway obstruction. Methods: Subjects who underwent combined sleep surgery via TORS were evaluated. The drug-induced sleep endoscopy was used in diagnosing the presence of level-specific upper airway collapse and to detect the type of surgery. Pre- and postoperative Apnea-hypopnea index, Epworth sleepiness scale lowest oxygen saturation, total operation time, robotic set-up time and robotic surgery time, blood loss value, and complications were recorded. Results: Twenty five subjects were identified. All subjects underwent base of tongue (BOT) + epiglottoplasty. The tracheotomy was not performed for any patient. Overall, 72% of patients met the criteria for cure, 8% met the criteria for cure, and 20% of patients met the criteria for failure. There was a significant decrease between preoperative and postoperative Apnea-hypopnea index scores (28.7 +/- 17.8 SD versus 9.4 +/- 12.4, P = 0.000) and Epworth sleepiness scale scores (13.5 +/- 2.8 versus 3.4 +/- 1.6, P = 0.000). There was a significant increase between preoperative and postoperative ED SPO2 levels (80.7 +/- 7.6 versus 82.6 +/- 18.1, P = 0.001). Conclusion: TORS BOT, epiglottoplasty, and multilevel procedures in patients with obstructive sleep apnea/hypopnea syndrome can be regarded as feasible, safe, and effective technique. (C) 2016 by Mutaz B. Habal, MD.

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Mucocele After Orbital Fracture Repair Masquerading as Optic Neuritis.

The authors report a patient of mucocele formation after orbital wall fracture repair masquerading as optic neuritis. A 38-year-old man with a history of medial orbital wall fracture repair with an alloplastic implant 10 years previously, presented with left visual disturbance and mild ocular pain with movement of the left eye of 3-day duration, and a relative afferent papillary defect in his left eye. He reported having cold symptoms 2 weeks before presentation. His symptoms were typical of retrobulbar optic neuritis. Under suspicion of optic neuritis, computed tomography and magnetic resonance imaging were performed and revealed a large cyst in the sphenoid sinus and ethmoid sinus, just behind the alloplastic implant, that was compressing the medial rectus muscle and optic nerve of the left eye. The patient underwent endoscopic marsupialization of the cyst. Subsequent histologic examinations revealed a cyst lined with ciliated pseudostratified columnar epithelium. The patient had an uncomplicated postoperative course and the visual disturbance resolved. For patients who present solely with optic neuropathy after orbital fracture repair, it is important to be vigilant of potentially rare cause, mucocele formation. (C) 2016 by Mutaz B. Habal, MD.

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Anatomy and Histology of an Epicanthal Fold.

The aim of this study is to elucidate the precise anatomical and histological detail of the epicanthal fold. Thirty-two hemifaces of 16 Korean adult cadavers were used in this study (30 hemifaces with an epicanthal fold, 2 without an epicanthal fold). In 2 patients who had an epicanthoplasty, the epicanthal folds were sampled. In a dissection, the periorbital skin and subcutaneous tissues were removed and the epicanthal fold was observed in relation to each part of the orbicularis oculi muscle. Specimens including the epicanthal fold were embeddedin in paraffin, sectioned at 10 um, and stained with Hematoxylin-Eosin. The horizontal section in the level of the paplebral fissure was made and the prepared slides were observed under a light microscope. In the specimens without an epicanthal fold, no connection between the upper preseptal muscle and the lower preseptal muscle was found. In the specimens with an epicanthal fold, a connection of the upper preseptal muscle to the lower preseptal muscle was observed. It was present in all 15 hemifaces (100%). There was no connection between the pretarsal muscles. In a horizontal section, the epicanthal fold was composed of 3 compartments: an outer skin lining, a core structure, and an innerskin lining. The core structure was mainly composed of muscular fibers and fibrotic tissue and they were intermingled. Surgeons should be aware of the anatomical details of an epicanthal fold. In removing or reconstructing an epicanthal fold, the fibromuscular core band should also be removed or reconstructed. (C) 2016 by Mutaz B. Habal, MD.

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Cholesteatoma of Maxillary Sinus: What Is the Best Surgical Approach?.

Cholesteatoma is a relatively common disease entity within the middle ear or mastoid cavity but cholesteatoma of the paranasal sinuses is a rare diseases entity, especially in the maxillary sinus. As the authors recently experienced a patient of maxillary sinus cholesteatoma, the authors tried to review all the literatures previously reported on the "Cholesteatoma of the maxillary sinus." The aim of this study was to describe authors' recent experience and review previously reported patients of cholesteatoma of the maxillary sinus. Additionally, it is to describe the clinical features focusing on the computed tomography findings and to elucidate which approach may be best for complete excision. The authors thoroughly reviewed 10 patient reports written in English regarding the cholesteatoma of maxillary sinus which have been published since the 1980s. Based on authors' review, the authors suggest some conclusions. First, the diagnosis of cholesteatoma, although rare, should be considered for any slowly expansile lesion of the maxillary sinus. Second, there was no specific computed tomography finding that was helpful for the diagnosis of maxillary sinus cholesteatoma. Last, the surgical approach to cholesteatoma of the maxillary sinus should be chosen to allow visibility and complete removal according to the size, location, and extent of diseases. (C) 2016 by Mutaz B. Habal, MD.

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Chronic Rhinosinusitis With Massive Polyposis Causing Proptosis Requiring Craniofacial Resection.

Chronic rhinosinusitis (CRS) is a common health problem in the Western world. CRS is classified as CRS with (CRSwNP) and without (CRSsNP) nasal polyps. A less common third type is allergic fungal sinusitis, which often presents with polyps and, not infrequently, skull base erosion. Most patients are successfully managed with maximal medical therapy or endoscopic approaches. There are currently no reports of CRSwNPs resulting in fibro-osseous thickening and proptosis in the English literature. As such, the authors report a case of a 33-year-old man who underwent a craniofacial resection with drilling of the hyperostosed bone, which led to resolution of the proptosis and nasal symptoms. In an era where endoscopic surgery is the standard surgical approach for CRSwNP, this case highlights the need for open skullbase approaches for this condition due to the extensive and recalcitrant nature of the disease. While the majority of patients can be dealt with endoscopically, the authors highlight the importance of having the open approach in the otolaryngologists' armamentarium for patients of recalcitrant and extensive CRSwNP. (C) 2016 by Mutaz B. Habal, MD.

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Technique for Management of Aplasia Cutis Congenita of the Scalp With a Skin Allograft.

Aplasia cutis congenital is a rare condition presenting with localized or widespread congenital absence of skin, most commonly affecting the scalp. Its management remains controversial due to risks associated with both conservative and surgical approaches. The authors report a new technique to manage a large area of aplasia cutis congenital on a newborn's scalp, initially 5.5 cm x 6 cm, with a single skin allograft application. This is a simple procedure, which can be performed on a ward without need for anaesthetic and led to complete epithelialization of the skin defect. (C) 2016 by Mutaz B. Habal, MD.

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Long-Term Incisal Relationships After Palatoplasty in Patients With Isolated Cleft Palate.

Purpose: Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate. Methods: Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist. Results: Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P

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Microsurgical Replantation of a Two-Segment Total Scalp Avulsion.

Total scalp avulsion is a rare and severe injury that may be life threatening and can result in devastating disfigurement and psychological trauma. Microsurgical hair-bearing scalp replantation is considered the procedure of choice and should be performed by a skilled surgical team. Replantation of a multifragmented scalp is even rarer and shows random results. Only 2 patients have been reported, resulting in partial or total necrosis of implanted fragments. The authors describe the successful replantation of a totally avulsed 2-segment scalp in a 63-year-old woman whose hair was entrapped in the propeller shaft of a ship. The avulsed scalp involved both eyebrows, the frontal region, the upper part of both ears, and most of the occipital portion. After initial management including correction of hemorrhagic shock, the patient underwent emergency scalp replantation by microsurgical anastomosis of 3 arteries and 4 veins and the use of 2 vein grafts. According to authors' experience, multifragmented scalp avulsion imposes emergency relocation using as many microsurgical sutures as possible and implementation of vein grafts to ensure optimal revascularization of the avulsed scalp. (C) 2016 by Mutaz B. Habal, MD.

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The Causes of Persistent and Recurrent Nasal Obstruction After Primary Septoplasty.

Objectives: Septoplasty is the most frequently performed surgical procedure in patients with nasal obstruction. However, nasal obstruction may persist or recur after septoplasty in some patients. In this study, the authors aimed to determine the causes of nasal obstruction after septoplasty. Methods: Fifty consecutive patients who admitted to our clinic with the complaints of persistent or recurrent nasal obstruction after primary septoplasty and had revision surgery between 2011 and 2015 were included in this study. Demographic data and physical examination findings of the patients were recorded. Results: There were 33 men (66%) and 17 women (34%) with a mean age of 37.3 +/- 10.5 (range, 21-57) years. Deviation of perpendicular plate of ethmoid bone (44%), inferior turbinate hypertrophy (36%), concha bullosa (26%), caudal septal deviation-nostril asymmetry (20%), and alar collapse (6%) were the pathologies that were unaddressed during primary surgery. The iatrogenic causes of nasal obstruction after septoplasty were collumellar retraction-nasal tip ptosis (46%), nasal synechiae (20%), nasal septal perforation (10%), and saddle-nose/flat nose deformity (10%). Conclusions: Iatrogenic deformities due to surgery and pathologies ignored during primary surgery may cause persistent/recurrent nasal obstruction after primary septoplasty. A detailed physical examination and objective tests showing the site of nasal obstruction, an extensive surgical plan that covers all diagnosed pathologies, and a careful postoperative care must be undertaken to prevent undesired postoperative results. (C) 2016 by Mutaz B. Habal, MD.

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Clinical Use of Deferoxamine in Distraction Osteogenesis of Irradiated Bone.

The deleterious effects of radiotherapy, including hypovascularity and hypocellularity, have made distraction of irradiated bones challenging. Animal studies, however, have demonstrated adjunctive measures such as the administration of deferoxamine to significantly improve bone regeneration across irradiated distraction gaps. In this report, the authors demonstrate, for the first time, enhanced bone formation following deferoxamine application in a patient following distraction of a previously irradiated maxilla. Computed tomography imaging of the pterygomaxillary buttress on the side of administration revealed significantly increased bone area and density relative to the contralateral buttress. This is the first presentation of clinical deferoxamine use to promote bone formation following irradiated bone distraction and highlights the promise for this adjunctive measure to make outcomes after distraction of irradiated bone more reliable. (C) 2016 by Mutaz B. Habal, MD.

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Microscopic Transnasal Approach: A New Technique for the Reconstruction of Frontoethmoidal Meningoencephalocele.

Frontoethmoidal meningoencephalocele is a rare congenital malformation, which occurs due to a deficiency in neural tube closure. It may present as an external mass over the nose, nasal obstruction, rhinorrhea and attacks of central nervous system infections. Herein, the authors present a 3-month-old infant with naso-ethmoidal form of frontoethmoidal meningoencephalocele, who was operated on using a newly described approach that was performed under microscope. (C) 2016 by Mutaz B. Habal, MD.

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Early Results and Description of a New Modification of Spreader Graft to Enlarge Nasal Valve Area: Modified Triangular Spreader Graft.

Objective: Nasal valve area is an important, functional part of nose and there are several different methods that have been used to enlarge that area for a better breathing function. In this study, the authors aimed to study the efficacy of a new spreader graft modification that was crafted in a triangular shape to enlarge nasal valve area. Methods: Twenty-two patients who underwent rhinoplasty operation with this new technique composed the study group. Average age of patients was 21.4 +/- 2.1, 13 of them were men (59%) and 9 of them were women (41%). Same surgeon operated all 22 patients with the same technique that included usage of modified triangular spreader graft. Surgical outcomes were assessed by visual analog scale and nasal obstruction symptom evaluation scale preoperatively and 3 months postoperatively. Results: None of the patients had complications or aesthetic deformities according to surgeon after surgery. Average of nasal obstruction symptom evaluation scale score was 64.3 before surgery which reduced to 17.9 at postoperative third month. Also average visual analog scale score was 2.6 before surgery and it was 8.1 3 months after surgery indicating a better breathing sensation (P

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The Dimensions of the Orbital Cavity Based on High-Resolution Computed Tomography of Human Cadavers.

Blow-out fractures affect the volume and surface area of the orbital cavity. Estimation of these values after the trauma may help in deciding whether or not a patient is a candidate for surgery. Recent studies have provided estimates of orbital volume and area of bone defect, and correlated them with the degree of enophthalmos. However, a large degree of biological variation between individuals may preclude such absolute values from being successful indicators for surgery. Stereological methods have been used to estimate orbital cavity volume in a few studies, but to date these have not been used for surface area. To authors' knowledge, this study is the first to have measured the entire surface area of the orbital cavity. The volume and surface area of the orbital cavity were estimated in computed tomography scans of 11 human cadavers using unbiased stereological sampling techniques. The mean (+/- SD) total volume and total surface area of the orbital cavities was 24.27 +/- 3.88 cm3 and 32.47 +/- 2.96 cm2, respectively. There was no significant difference in volume (P = 0.315) or surface area (P = 0.566) between the 2 orbital cavities. The stereological technique proved to be a robust and unbiased method that may be used as a gold standard for comparison with automated computer software. Future imaging studies in blow-out fracture patients may be based on individual and relative calculation involving both herniated volume and fractured surface area in relation to the total volume and surface area of the uninjured orbital cavity. (C) 2016 by Mutaz B. Habal, MD.

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Bone Flap Technique for Impacted Teeth Extraction and Bone Cysts Removal.

The treatment of cystic lesions and the extraction of impacted third molars are 2 of the most common procedures in oral and maxillofacial surgery. The surgical treatment of cysts of the jaws can consist of a cystectomy, a cystotomy, or a staged combination of the 2 procedures. The surgical techniques developed for the extraction of impacted third molars are: coronectomy, orthodontic extraction, and surgery using intraoral or extraoral methods. There are various complications related to both surgical treatments. With regards to these complications, authors' department has developed a new surgical technique based on a previously described technique, which provides better support to the mucoperiosteal flap and improves bone regeneration after healing. Additionally, authors' goal was to reduce the risk of nerve injury, which has been achieved thanks to a direct visualization of the inferior alveolar nerve as well as cystic lesion or the dental element. The surgical procedure described produces major advantages over the traditional alternatives, despite needing a longer operation. This technique is particularly useful in the treatment of cystic lesions that have caused considerable bone loss. It can also be utilized for cysts or impacted dental elements strictly linked to the inferior alveolar nerve. (C) 2016 by Mutaz B. Habal, MD.

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Retrieval of a Broken Dental Needle Close to the Facial Artery After Cervical Migration.

Use of imaging tools like digital C-arm, tridimensional tomography, and navigational surgery has proven its value to the surgical removal of broken needles. A 32-year-old patient was referred for evaluation of a fractured needle during inferior alveolar nerve block attempt few days before. The patient complained of a pricking sensation at the injured area while moving the neck. A contrasted computed tomography was performed for further evaluation of the needle toward the vascular network of the neck, showing a close location by the left facial artery, parallel to the styloid process of the temporal bone. The needle was then released from the underlying tissues and retrieved. Although considered a rare intercurrence, there are still reports of breaking needles during dental anesthesia. Such reports are almost always related to inferior alveolar nerve blocks, associated with the use of short, thin needles, and after multiple bending movements before the insertion of the needle in the tissues. Accurate image examinations such as contrasted computed tomography are of great importance for planning the surgical removal, especially in patients of migration next to important vessels of the neck. (C) 2016 by Mutaz B. Habal, MD.

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The Craniofacial and Upper Limb Management of Nager Syndrome.

Introduction: Nager syndrome is a rare condition characterized by craniofacial and upper limb abnormalities. It is commonly mistaken for Treacher Collins syndrome, with which it shares the same craniofacial phenotype. However, patients with Treacher Collins do not exhibit hand anomalies, which are seen in patients with Nager syndrome. This paper reviews the multidisciplinary management of patients with Nager syndrome who were treated at the Australian Craniofacial Unit, Adelaide and the Erasmus Medical Centre, Rotterdam. Methods: The database of both units was scrutinized and the case-notes of the patients with Nager syndrome were reviewed. Data was collected on patient demographics, surgical management, complications, and outcome. Results: Nine patients (6 M:3 F) were identified with Nager syndrome, with a mean age at presentation of 3.7 years (range 8 days to 11.8 years). The mean follow-up time was 2.2 years (2 months to 19 years). SF3B4 mutation was noted in 2 patients and 1 patient had an X:9 translocation. Seven (77.8%) had obstructive sleep apnoea, with 5 patients diagnosed as severe obstructive sleep apnoea. Four patients had pollicization of their index, 2 patients had excision of extra radial digits and 1 patient underwent thumb duplication correction. Craniofacial surgery included mandibular advancement in 5 patients, temporo-mandibular joint reconstruction in 2 patients, and a genioplasty in 1 patient. Conclusion: Nager syndrome is a rare acrofacial dysostosis syndrome that is best managed within the realms of a multidisciplinary team. The authors would advocate early pollicization in patients with thumb anomalies to prevent any impairment in manual dexterity. (C) 2016 by Mutaz B. Habal, MD.

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Multilevel Combined Surgery With Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome.

Objective: To evaluate the results of combined multilevel surgery with transoral robotic surgery (TORS) in patients with obstructive sleep apnea/hypopnea syndrome for multilevel upper airway obstruction. Methods: Subjects who underwent combined sleep surgery via TORS were evaluated. The drug-induced sleep endoscopy was used in diagnosing the presence of level-specific upper airway collapse and to detect the type of surgery. Pre- and postoperative Apnea-hypopnea index, Epworth sleepiness scale lowest oxygen saturation, total operation time, robotic set-up time and robotic surgery time, blood loss value, and complications were recorded. Results: Twenty five subjects were identified. All subjects underwent base of tongue (BOT) + epiglottoplasty. The tracheotomy was not performed for any patient. Overall, 72% of patients met the criteria for cure, 8% met the criteria for cure, and 20% of patients met the criteria for failure. There was a significant decrease between preoperative and postoperative Apnea-hypopnea index scores (28.7 +/- 17.8 SD versus 9.4 +/- 12.4, P = 0.000) and Epworth sleepiness scale scores (13.5 +/- 2.8 versus 3.4 +/- 1.6, P = 0.000). There was a significant increase between preoperative and postoperative ED SPO2 levels (80.7 +/- 7.6 versus 82.6 +/- 18.1, P = 0.001). Conclusion: TORS BOT, epiglottoplasty, and multilevel procedures in patients with obstructive sleep apnea/hypopnea syndrome can be regarded as feasible, safe, and effective technique. (C) 2016 by Mutaz B. Habal, MD.

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Mucocele After Orbital Fracture Repair Masquerading as Optic Neuritis.

The authors report a patient of mucocele formation after orbital wall fracture repair masquerading as optic neuritis. A 38-year-old man with a history of medial orbital wall fracture repair with an alloplastic implant 10 years previously, presented with left visual disturbance and mild ocular pain with movement of the left eye of 3-day duration, and a relative afferent papillary defect in his left eye. He reported having cold symptoms 2 weeks before presentation. His symptoms were typical of retrobulbar optic neuritis. Under suspicion of optic neuritis, computed tomography and magnetic resonance imaging were performed and revealed a large cyst in the sphenoid sinus and ethmoid sinus, just behind the alloplastic implant, that was compressing the medial rectus muscle and optic nerve of the left eye. The patient underwent endoscopic marsupialization of the cyst. Subsequent histologic examinations revealed a cyst lined with ciliated pseudostratified columnar epithelium. The patient had an uncomplicated postoperative course and the visual disturbance resolved. For patients who present solely with optic neuropathy after orbital fracture repair, it is important to be vigilant of potentially rare cause, mucocele formation. (C) 2016 by Mutaz B. Habal, MD.

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Anatomy and Histology of an Epicanthal Fold.

The aim of this study is to elucidate the precise anatomical and histological detail of the epicanthal fold. Thirty-two hemifaces of 16 Korean adult cadavers were used in this study (30 hemifaces with an epicanthal fold, 2 without an epicanthal fold). In 2 patients who had an epicanthoplasty, the epicanthal folds were sampled. In a dissection, the periorbital skin and subcutaneous tissues were removed and the epicanthal fold was observed in relation to each part of the orbicularis oculi muscle. Specimens including the epicanthal fold were embeddedin in paraffin, sectioned at 10 um, and stained with Hematoxylin-Eosin. The horizontal section in the level of the paplebral fissure was made and the prepared slides were observed under a light microscope. In the specimens without an epicanthal fold, no connection between the upper preseptal muscle and the lower preseptal muscle was found. In the specimens with an epicanthal fold, a connection of the upper preseptal muscle to the lower preseptal muscle was observed. It was present in all 15 hemifaces (100%). There was no connection between the pretarsal muscles. In a horizontal section, the epicanthal fold was composed of 3 compartments: an outer skin lining, a core structure, and an innerskin lining. The core structure was mainly composed of muscular fibers and fibrotic tissue and they were intermingled. Surgeons should be aware of the anatomical details of an epicanthal fold. In removing or reconstructing an epicanthal fold, the fibromuscular core band should also be removed or reconstructed. (C) 2016 by Mutaz B. Habal, MD.

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Cholesteatoma of Maxillary Sinus: What Is the Best Surgical Approach?.

Cholesteatoma is a relatively common disease entity within the middle ear or mastoid cavity but cholesteatoma of the paranasal sinuses is a rare diseases entity, especially in the maxillary sinus. As the authors recently experienced a patient of maxillary sinus cholesteatoma, the authors tried to review all the literatures previously reported on the "Cholesteatoma of the maxillary sinus." The aim of this study was to describe authors' recent experience and review previously reported patients of cholesteatoma of the maxillary sinus. Additionally, it is to describe the clinical features focusing on the computed tomography findings and to elucidate which approach may be best for complete excision. The authors thoroughly reviewed 10 patient reports written in English regarding the cholesteatoma of maxillary sinus which have been published since the 1980s. Based on authors' review, the authors suggest some conclusions. First, the diagnosis of cholesteatoma, although rare, should be considered for any slowly expansile lesion of the maxillary sinus. Second, there was no specific computed tomography finding that was helpful for the diagnosis of maxillary sinus cholesteatoma. Last, the surgical approach to cholesteatoma of the maxillary sinus should be chosen to allow visibility and complete removal according to the size, location, and extent of diseases. (C) 2016 by Mutaz B. Habal, MD.

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Chronic Rhinosinusitis With Massive Polyposis Causing Proptosis Requiring Craniofacial Resection.

Chronic rhinosinusitis (CRS) is a common health problem in the Western world. CRS is classified as CRS with (CRSwNP) and without (CRSsNP) nasal polyps. A less common third type is allergic fungal sinusitis, which often presents with polyps and, not infrequently, skull base erosion. Most patients are successfully managed with maximal medical therapy or endoscopic approaches. There are currently no reports of CRSwNPs resulting in fibro-osseous thickening and proptosis in the English literature. As such, the authors report a case of a 33-year-old man who underwent a craniofacial resection with drilling of the hyperostosed bone, which led to resolution of the proptosis and nasal symptoms. In an era where endoscopic surgery is the standard surgical approach for CRSwNP, this case highlights the need for open skullbase approaches for this condition due to the extensive and recalcitrant nature of the disease. While the majority of patients can be dealt with endoscopically, the authors highlight the importance of having the open approach in the otolaryngologists' armamentarium for patients of recalcitrant and extensive CRSwNP. (C) 2016 by Mutaz B. Habal, MD.

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Technique for Management of Aplasia Cutis Congenita of the Scalp With a Skin Allograft.

Aplasia cutis congenital is a rare condition presenting with localized or widespread congenital absence of skin, most commonly affecting the scalp. Its management remains controversial due to risks associated with both conservative and surgical approaches. The authors report a new technique to manage a large area of aplasia cutis congenital on a newborn's scalp, initially 5.5 cm x 6 cm, with a single skin allograft application. This is a simple procedure, which can be performed on a ward without need for anaesthetic and led to complete epithelialization of the skin defect. (C) 2016 by Mutaz B. Habal, MD.

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Long-Term Incisal Relationships After Palatoplasty in Patients With Isolated Cleft Palate.

Purpose: Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate. Methods: Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist. Results: Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P

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Property of Human Bone Marrow Stromal Cells Derived From Bone Fragments Removed in Sagittal Split Ramus Osteotomy.

Bone tissue engineering is in the process of making the shift from bench to bed. Organ as a cell source is important for tissue engineering. The appropriate cells should be harvested without invasiveness and ethical problems. The authors focused on mandibular cortex bone fragments removed in sagittal split ramus osteotomy as a cell source for bone tissue engineering. These bone fragments were discarded after surgery until now. Bone marrow stromal cells (BMSCs) were harvested from inside of bone fragments, which is an endosteal region. Endosteal region is known to be a hematopoietic stem cell niche and harbors osteoblasts, preosteoblasts, and mesenchymal stem cells (MSCs). Bone marrow stromal cells could be cultured easily, and grew rapidly in vitro under ordinary serum-supplemented culture condition. The expression pattern of surface markers of BMSCs was the same as that of MSCs. Bone marrow stromal cells could differentiated into multiple mesenchymal lineages (osteoblasts, adipocytes, chondrocytes, and smooth muscle cells). These results indicated the existence of MSCs in BMSCs. The osteoblastic characters of BMSCs were examined more closely. Bone marrow stromal cells showed a high alkaline phosphatase activity, and expressed osteoblastic markers (PTHr, bone sialoprotein, Type I collagen, Rnut-related transcription factor 2, and osteocalcin). In transplantation experiments, BMSCs generated ectopic bone tissues on the border of hydroxyapatite scaffold without osteogenic differentiation-inducing agents such as dexamethasone (Dex) or bone morphogenetic protein. The results of this study suggest that mandibular cortex bone fragments removed in sagittal split ramus osteotomy are a good cell source for bone tissue engineering. (C) 2016 by Mutaz B. Habal, MD.

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Commenting on Early Paper Patching Versus Observation in Patients With Traumatic Eardrum Perforations.

No abstract available

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The Risks to Patient Privacy from Publishing Data from Clinical Anesthesia Studies.

In this article, we consider the privacy implications of posting data from small, randomized trials, observational studies, or case series in anesthesia from a few (e.g., 1-3) hospitals. Prior to publishing such data as supplemental digital content, the authors remove attributes that could be used to re-identify individuals, a process known as "anonymization." Posting health information that has been properly "de-identified" is assumed to pose no risks to patient privacy. Yet, computer scientists have demonstrated that this assumption is flawed. We consider various realistic scenarios of how the publication of such data could lead to breaches of patient privacy. Several examples of successful privacy attacks are reviewed, as well as the methods used. We survey the latest models and methods from computer science for protecting health information and their application to posting data from small anesthesia studies. To illustrate the vulnerability of such published data, we calculate the "population uniqueness" for patients undergoing one or more surgical procedures using data from the State of Texas. For a patient selected uniformly at random, the probability that an adversary could match this patient's record to a unique record in the state external database was 42.8% (SE

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Toxins, Vol. 8, Pages 150: Sensitive, Rapid, Quantitative and in Vitro Method for the Detection of Biologically Active Staphylococcal Enterotoxin Type E

Staphylococcus aureus is a major bacterial cause of clinical infections and foodborne illnesses through its production of a group of enterotoxins (SEs) which cause gastroenteritis and also function as superantigens to massively activate T cells. In the present study, we tested Staphylococcal enterotoxin type E (SEE), which was detected in 17 of the 38 suspected staphylococcal food poisoning incidents in a British study and was the causative agent in outbreaks in France, UK and USA. The current method for detection of enterotoxin activity is an in vivo monkey or kitten bioassay; however, this expensive procedure has low sensitivity and poor reproducibility, requires many animals, is impractical to test on a large number of samples, and raises ethical concerns with regard to the use of experimental animals. The purpose of this study is to develop rapid sensitive and quantitative bioassays for detection of active SEE. We apply a genetically engineered T cell-line expressing the luciferase reporter gene under the regulation of nuclear factor of activated T-cells response element (NFAT-RE), combined with a Raji B-cell line that presents the SEE-MHC (major histocompatibility complex) class II to the engineered T cell line. Exposure of the above mixed culture to SEE induces differential expression of the luciferase gene and bioluminescence is read out in a dose dependent manner over a 6-log range. The limit of detection of biologically active SEE is 1 fg/mL which is 109 times more sensitive than the monkey and kitten bioassay.

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