Head and Neck Diseases by Alexandros G.Sfakianakis: 01/24/17

Τρίτη 24 Ιανουαρίου 2017

Childhood asthma is a risk factor for the development of chronic obstructive pulmonary disease.

Purpose of review: This review will catalog the many recent longitudinal studies that have investigated the relationship between asthma and lung function, or the persistence and trajectories of lung function deficits. Recent findings: Recent work has reported on 50-year follow-ups of some prominent population cohorts. A history of asthma confers a 10-30-fold risk of chronic obstructive pulmonary disease. Individuals reaching a reduced maximum growth of forced expiratory volume in 1 s in early adulthood are at risk for early or more severe chronic obstructive pulmonary disease (COPD). Summary: Taken together, there is a wealth of overlapping cohort studies of lung function, asthma and COPD. These show that asthma is associated with reduced lung function, which may start in infancy or prenatally, persists through childhood and adulthood and predisposes for early or more severe COPD. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Incorporating technology to advance asthma controller adherence.

Purpose of review: Technological innovations, including text messaging, smart phone applications, and electronic monitoring devices, aimed at improving asthma controller adherence are being rapidly introduced both into clinical care and directly marketed to patients. This review analyzes recent clinical trials implementing these interventions, with a focus on their benefits and shortcomings. Recent findings: Poor medication adherence continues to exert significant morbidity on patients with asthma. Objective, real-time measures to monitor adherence can overcome the limitations of prior methods, including self-report and prescription refills. Technological advances, especially those incorporating reminder systems, have demonstrated improved controller adherence. The increased adherence in these trials has not translated into consistent clinical improvement, including reducing hospitalizations, emergency department visits, and asthma exacerbations, possibly secondary to study design and poor inhalation technique. Summary: Novel monitoring and reminder technology can augment patient medication adherence and provide clues to management before escalating therapy. Further studies are needed to investigate the overarching clinical impact of this technology, especially as it grows into routine clinical practice. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Asthma guidelines: the Global Initiative for Asthma in relation to national guidelines.

Purpose of review: To compare and contrast national asthma guidelines with the Global Initiative for Asthma (GINA) strategy for asthma management and prevention. Recent findings: The common goal of GINA and national asthma guidelines is to improve asthma care using the best evidence available from published data. This evidence-based approach has evolved from an initial perspective of expert opinion but with that evolution has not always considered the breadth of asthma phenotypes. GINA and national guidelines differ in a number of ways. GINA reviews available data and updates the core document and recommendations based on the latest data on a yearly basis to offer local, regional and national guidelines materials needed for knowledge mobilization. It remains the purview of those organizations to structure and implement those locally appropriate guidelines. Summary: Both GINA and national guidelines have furthered asthma care to narrow the care gap from what is known to how asthma care is delivered, hopefully in a more directed, personalized manner. As well, both GINA and national guidelines have helped to shape the direction of research for the future benefit of children and their families. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Management of preschool recurrent wheezing and asthma: a phenotype-based approach.

Purpose of review: The purpose of this review is to summarize the recent evidence on the management of preschool children with wheezing and asthma, and to propose a phenotype-based approach to the management of these children. Recent findings: Recent studies have begun to identify populations of preschool children that are likely to benefit from inhaled corticosteroids (ICS) therapy and defined ICS regimens: daily ICS in preschool children with persistent asthma, and pre-emptive high-dose intermittent ICS among preschool children with intermittent disease reduce the risk of exacerbation. In addition, among preschool children with mild persistent asthma, the presence of aeroallergen sensitivity and/or blood eosinophil counts of 300/[mu]L or greater are predictors of good response to daily ICS therapy. Other studies identified intermittent azithromycin as a therapy to prevent, and potentially to treat, acute exacerbations. The uncertainty of the role of oral corticosteroids (OCS) as a therapy for acute exacerbations continues, as a recent meta-analysis showed that OCS did not prevent hospitalizations or urgent visits, and did not reduce the need for additional courses of OCS. Whereas previous epidemiologic studies suggested acetaminophen may increase risk of exacerbations, a clinical trial clearly demonstrated acetaminophen use, compared to ibuprofen use,does not increase exacerbation risk among preschool children with mild-persistent asthma. Summary: Recent studies have shown potential for phenotypic-driven therapies for the management of preschool children with asthma. Targeting airway bacteria has emerged as a promising therapeutic approach, but its effect on antibiotic resistance still needs to be investigated. Finally, more studies are required to evaluate if oral corticosteroids provide any benefits for acute episodic wheeze. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Effect of different wavelengths and dyes on Candida albicans: In vivo study using Galleria mellonella as an experimental model.

Publication date: Available online 24 January 2017
Source:Photodiagnosis and Photodynamic Therapy
Author(s): Elisabetta Merigo, Stefania Conti, Tecla Ciociola, Carlo Fornaini, Luciano Polonelli, Giuseppe Lagori, Maddalena Manfredi, Paolo Vescovi
BackgroundStudies on photodynamic inactivation against microorganisms had a great development in recent years. The aim of this work was to test the application of different laser wavelengths with or without different photosensitizing dyes on Candida albicans cells in vitro and in photodynamic therapy protocols in vivo in larvae of Galleria mellonella.MethodsLaser application was realized on C. albicans cells suspended in saline solution or cultured on solid medium for the in vitro study, and in a model of G. mellonella candidal infection for the in vivo study. Three wavelengths (650, 405, and 532nm) were used in continuous mode with different values of applied fluences: 10, 20 and 30J/cm² for the in vitro study and 10J/cm² for the in vivo study, without and with photosensitizing dyes.ResultsNo growth inhibition was obtained on yeast cells in saline solution without photosensitizers. The maximum inhibition of growth (100%) was obtained with 405nm diode laser and curcumin at any used fluence. No growth inhibition was observed for yeast cells cultured on solid medium after laser application without dyes. An inhibition was observed after laser application when curcumin and erythrosine were added to the medium.The survival curves of G. mellonella larvae infected with C. albicans with or without the different dyes and after laser application showed a statistically significant difference (p<0.001) in comparison with the proper control groups.ConclusionsThese results show the efficacy of photodynamic inactivation exploiting a suitable combination of light and dyes against C. albicans and the potential of photodynamic therapy for the treatment of candidal infections.

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Efficacy of photodynamic therapy in the inactivation of oral fungal colonization among cigarette smokers and non-smokers with denture stomatitis

Publication date: Available online 24 January 2017
Source:Photodiagnosis and Photodynamic Therapy
Author(s): Tariq Abduljabbar, Mansour Al-Askar, Mohammed K. Baig, Zeyad H. AlSowygh, Sergio Varela Kellesarian, Fahim Vohra
ObjectiveThe aim was to assess the efficacy of antimicrobial photodynamic therapy (aPDT) in the inactivation of oral fungal colonization among cigarette smokers and non-smokers with denture stomatitis (DS).MethodsA questionnaire was used to gather demographic information. Clinical oral examination was performed to determine location of denture in the jaws and oral erythematous lesions. Presence of fungal hyphae in smokers and non-smokers was confirmed using exfoliative cytology. In both groups, aPDT was performed and colony forming units per milliliter (CFU/ml) were assessed im both groups at 3-months follow-up. Level of significance was et at P<0.05.ResultsTwenty-two males with DS (12 smokers and 10 non-smokers) were included. The mean ages of smokers and non-smokers was 73.8±2.5 and 70.5±1.2years, respectively. The duration and daily frequency of cigarette smoking was 20.6±4.5years and 12.3±1.5 cigarettes daily, respectively. Smokers and non-smokers had been wearing complete dentures since 6.2±0.8 and 5.8±0.4years, respectively. At 3-months follow-up, there was a statistically significant decrease in the mean fungal CFU/ml among smokers (25.5±8.3 CFU/ml) compared with their respective baseline values 106.7±6.3 CFU/ml (P <0.01). Among non-smokers, the mean CFU/ml values were 12.7±0.8 CFU/ml compared with their respective baseline values (93.6±8.4 CFU/ml) (P<0.01). At 3-months follow-up, fungal CFU/ml levels were statistically significantly higher among smokers (25.5±8.3 CFU/ml) compared with non-smokers (12.7±0.8 CFU/ml) (P<0.05).ConclusionaPDT is effective in the inactivation of oral fungal colonization among cigarette smokers and non-smokers with. The role of denture is also emphasized.

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Chylopericardium with symptoms of tamponade on the grounds of extensive neck vein thrombosis

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Chylopericardium is a recognized complication of thoracic trauma, surgery or malignancy. Idiopathic or primary presentations, however, are rarely encountered in clinical practice. The severity of its presentation varies from the complete absence of symptoms to cardiac tamponade. We present the case of a 23-year-old woman with chylopericardium and extensive neck vein thrombosis that was managed surgically with a pericardial window.</span>

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Occult fracture of the lesser tuberosity in a 9-year-old female swimmer

<span class="paragraphSection"><div class="boxTitle">Abstract</div>The adolescent avulsion of the lesser tuberosity of the humerus has historically been considered as very rare. The youngest patient reported in the literature is 11 years old. We report a case of a 9-year-old girl who suffered a subscapularis tendon tear with an occult avulsion of the lesser tuberosity. Late repair restored function. Despite that late repair in this present case resulted in excellent outcome, we strongly recommend the additional axillary lateral view of the plain radiographs, as well as proper physical examination to facilitate early diagnosis.</span>

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Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery

<span class="paragraphSection"><div class="boxTitle">Abstract</div>We present a patient with sickle cell trait who suffered avascular necrosis of the maxilla as a complication of maxillary osteotomy. Understanding the blood supply of the maxilla and how possible patient related, anaesthetic and operative factors affect it, is important in understanding how the vascularity of the maxilla can become compromised in a surgical procedure. The perioperative parameters were analysed to identify any prognostic elements. Avascular necrosis of the maxilla is a rare complication of orthognathic surgery with few cases reported in the literature. There are identifiable risk factors that can influence the blood supply of the maxilla. Careful preoperative assessment is required to exclude patient factors that have the potential to affect tissue vascularity. This in conjunction with sound anaesthetic and surgical technique should all minimize the risk of avascular necrosis. Even so it is still possible for this rare complication to occur.</span>

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Preface: Studies on Understanding and Anti-Tumor Agents of Reproductive Cancer Cells

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Price variation in the most commonly prescribed ear drops in Southern California

Objectives/Hypothesis

To evaluate the variability and discrepancies among the most commonly prescribed ear drops sold at pharmacies in southern California.

Study Design

Prospective study evaluating 11 commonly used ear drops to treat otologic disorders.

Methods

Randomly selected drug stores in three major counties in Southern California (Los Angeles, Orange, and San Diego) were included. Mean, range, minimum, and maximum prices for each drug were calculated and analyzed. The median income of pharmacy ZIP code was also cross-referenced.

Results

Data were collected from 108 pharmacies. The mean prices are noted for each of the individual drugs: Cortisporin (brand) 10 mL, $82.70; neomycin, polymyxin B sulfates, and hydrocortisone (Cortisporin–generic) 10 mL, $34.70; ofloxacin (generic) 10 mL, $99.95; sulfacetamide (generic) 15 mL, $40.18; Ciprodex (brand) 7.5 mL, $194.44; Cipro HC (brand) 10 mL, $233.32; Vosol (brand) 15 mL, $120.75; acetic acid (Vosol–generic) 10 mL, $116.55; VosolHC (brand) 10 mL, $204.14; acetic acid/aluminum acetate (Domeboro–generic) 60 mL, $22.91; and Tobradex (brand) 5 mL, $166.47.

Conclusions

There is significant variability among the prices of ear drops across Southern Californian pharmacies, which can be a financial burden to patients paying out of pocket or with high deductibles. A state-mandated, publically accessible report of drug prices may help decrease variability and cost by promoting competition among pharmacies. Price negotiations by governmental payers may assist in reducing prices. In the treatment of otologic disorders, clinicians can help reduce costs for patients by prescribing generic ear drop medications and cheaper alternatives when clinically appropriate.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2kh70rM

Price variation in the most commonly prescribed ear drops in Southern California

Objectives/Hypothesis

To evaluate the variability and discrepancies among the most commonly prescribed ear drops sold at pharmacies in southern California.

Study Design

Prospective study evaluating 11 commonly used ear drops to treat otologic disorders.

Methods

Results

Conclusions

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2kh70rM

Übergewicht und Fettleibigkeit sind Risikofaktoren für die Entwicklung einer Kardiotoxizität durch Anthrazykline oder die sequenzielle Gabe von Anthrazyklinen und Trastuzumab

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Einfluss von Dosis und Fraktionierung auf die kurativ intendierte Strahlentherapie nicht-kleinzelliger Bronchialkarzinome

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DART-bid for loco-regionally advanced NSCLC

Abstract

Background

To report acute and late toxicity with long-term follow-up, and to describe our experiences with pulmonary dose constraints.

Methods

Between 2002 and 2009, 150 patients with 155 histologically/cytologically proven non-small cell lung cancer (NSCLC; tumor stages II, IIIA, IIIB in 6, 55 and 39%, respectively) received the following median doses: primary tumors 79.2 Gy (range 72.0–90.0 Gy), lymph node metastases 59.4 Gy (54.0–73.8 Gy), nodes electively 45 Gy; with fractional doses of 1.8 Gy twice daily (bid). In all, 86% of patients received 2 cycles of chemotherapy previously.

Results

Five treatment-related deaths occurred: pneumonitis, n = 1; progressive pulmonary fibrosis in patients with pre-existing pulmonary fibrosis, n = 2; haemorrhage, n = 2. In all, 8% of patients experienced grade 3 and 1.3% grade 4 pneumonitis; 11% showed late fibrotic alterations grade 2 in lung parenchyma. Clinically relevant acute esophagitis (grade 2 and 3) was seen in 33.3% of patients, 2 patients developed late esophageal stenosis (G3). Patients with upper lobe, middle lobe and central lower lobe tumours (n = 130) were treated with V20 (total lung) up to 50% and patients with peripheral lower lobe tumours (n = 14, basal lateral tumours excluded) up to 42%, without observing acute or late pulmonary toxicity >grade 3. Only patients with basal lateral lower lobe tumours (n = 5) experienced grade 4/5 pulmonary toxicity; V20 for this latter group ranged between 30 and 53%. The mean lung dose was below the QUANTEC recommendation of 20–23 Gy in all patients. The median follow-up time of all patients is 26.3 months (range 2.9–149.4) and of patients alive 80.2 months (range 63.9–149.4.). The median overall survival time of all patients is 26.3 months; the 2-, 5- and 8‑year survival rates of 54, 21 and 15%, respectively. The local tumour control rate at 2 and 5 years is 70 and 64%, the regional control rate 90 and 88%, respectively.

Discussion and conclusion

Grade 4 or 5 toxicity occurred in 7/150 patients (4.7%), which can be partially avoided in the future (e.g. by excluding patients with pre-existing pulmonary fibrosis). Tolerance and oncologic outcome compare favourably to concomitant chemoradiation also in long-term follow-up.

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Prepregnancy Dietary Patterns Are Associated with Blood Lipid Level Changes During Pregnancy: A Prospective Cohort Study inRio de Janeiro, Brazil

Publication date: Available online 24 January 2017
Source:Journal of the Academy of Nutrition and Dietetics
Author(s): Ilana Eshriqui, Ana Beatriz Franco-Sena, Dayana Rodrigues Farias, Ana Amélia Freitas-Vilela, Diana Barbosa Cunha, Erica Guimarães Barros, Pauline M. Emmett, Gilberto Kac
BackgroundPhysiologic adaptations lead to an increase in blood lipid levels during pregnancy, yet little is known about the influence of prepregnancy dietary patterns.AimTo identify whether prepregnancy dietary patterns that explain the consumption of fiber, energy, and saturated fat are associated with blood lipid levels throughout pregnancy.DesignProspective cohort study, with data collection at gestational weeks 5 to 13, 20 to 26, and 30 to 36. A food frequency questionnaire was administered at baseline (gestational week 5 to 13).Participants/settingWomen with singleton pregnancy (N=299) aged 20 to 40 years, without infectious/chronic disease (except obesity) were enrolled in the study. One hundred ninety-nine women were included in the final analysis. The study took place at a prenatal service of a public health care center in Rio de Janeiro, Brazil, during the period from 2009 to 2012.Main outcome measuresTotal cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, and triglyceride levels, measured at all trimesters.Statistical analyses performedDietary patterns were derived by reduced rank regression. Fiber density, dietary energy density, and percent energy from saturated fat were response variables. Crude and adjusted longitudinal linear mixed-effects regression models were performed to account for confounders and mediators. Interaction terms between dietary pattern and gestational week were tested.ResultsFast Food and Candies; Vegetables and Dairy; and Beans, Bread, and Fat patterns were derived. Our Fast Food and Candies pattern was positively associated with triglyceride level (β=4.961, 95% CI 0.945 to 8.977; P=0.015). In the HDL-C rate of change prediction, significant interactions were observed between both the Fast Food and Candies and Vegetables and Dairy patterns and gestational week (β=–.053, 95% CI –0.101 to –0.004; P=0.035 and β=.055, 95% CI –0.002 to 0.112; P=0.060, respectively). The Beans, Bread, and Fat pattern was not associated with blood lipid levels.ConclusionsPrepregnancy dietary patterns were associated with gestational blood lipid levels; that is, higher scores for the Fast Food and Candies pattern were associated with higher triglyceride and slower HDL-C rates of change during pregnancy, whereas higher scores for the Vegetables and Dairy dietary patterns were associated with faster HDL-C rates of change over gestational weeks.

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Childhood asthma is a risk factor for the development of chronic obstructive pulmonary disease.

Incorporating technology to advance asthma controller adherence.

Childhood asthma is a risk factor for the development of chronic obstructive pulmonary disease.

Asthma guidelines: the Global Initiative for Asthma in relation to national guidelines.

Incorporating technology to advance asthma controller adherence.

Management of preschool recurrent wheezing and asthma: a phenotype-based approach.

Asthma guidelines: the Global Initiative for Asthma in relation to national guidelines.

Management of preschool recurrent wheezing and asthma: a phenotype-based approach.

French updated recommendations in Stage I to III melanoma treatment and management

Abstract

As knowledge continues to develop, regular updates are necessary concerning recommendations for practice. The recommendations for the management of melanoma stages I to III were drawn up in 2005. At the request of the Société Française de Dermatologie, they have now been updated using the methodology for recommendations proposed by the Haute Autorité de Santé in France. In practice, the principal recommendations are as follows: for staging, it is recommended that the 7th edition of AJCC be used. The maximum excision margins have been reduced to 2 cm. Regarding adjuvant therapy, the place of interferon has been reduced and no validated emerging medication has yet been identified. Radiotherapy may be considered for patients in Stage III at high risk of relapse. The sentinel lymph node technique remains an option. Initial examination includes routine ultrasound as of Stage II, with other examinations being optional in stages IIC and III. A shorter strict follow-up period (3 years) is recommended for patients, but with greater emphasis on imaging.

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Molecular diversity of corticotropin-releasing hormone mRNA-containing neurons in the hypothalamus

Hormonal responses to acute stress rely on the rapid induction of corticotropin-releasing hormone (CRH) production in the mammalian hypothalamus, with subsequent instructive steps culminating in corticosterone release at the periphery. Hypothalamic CRH neurons in the paraventricular nucleus of the hypothalamus are therefore considered as 'stress neurons'. However, significant morphological and functional diversity among neurons that can transiently produce CRH in other hypothalamic nuclei has been proposed, particularly as histochemical and molecular biology evidence associates CRH to both GABA and glutamate neurotransmission. Here, we review recent advances through single-cell RNA sequencing and circuit mapping to suggest that CRH production reflects a state switch in hypothalamic neurons and thus confers functional competence rather than being an identity mark of phenotypically segregated neurons. We show that CRH mRNA transcripts can therefore be seen in GABAergic, glutamatergic and dopaminergic neuronal contingents in the hypothalamus. We then distinguish 'stress neurons' of the paraventricular nucleus that constitutively express secretagogin, a Ca²⁺ sensor critical for the stimulus-driven assembly of the molecular machinery underpinning the fast regulated exocytosis of CRH at the median eminence. Cumulatively, we infer that CRH neurons are functionally and molecularly more diverse than previously thought.

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Leptin stimulates bone formation in ob/ob mice at doses having minimal impact on energy metabolism

Leptin, the protein product of the ob gene, is essential for normal bone growth, maturation and turnover. Peripheral actions of leptin occur at lower serum levels of the hormone than central actions because entry of leptin into the central nervous system (CNS) is limited due to its saturable transport across the blood–brain barrier (BBB). We performed a study in mice to model the impact of leptin production associated with different levels of adiposity on bone formation and compared the response with well-established centrally mediated actions of the hormone on energy metabolism. Leptin was infused (0, 4, 12, 40, 140 or 400 ng/h) for 12 days into 6-week-old female ob/ob mice (n = 8/group) using sc-implanted osmotic pumps. Treatment resulted in a dose-associated increase in serum leptin. Bone formation parameters were increased at EC₅₀ infusion rates of 7–17 ng/h, whereas higher levels (EC₅₀, 40–80 ng/h) were required to similarly influence indices of energy metabolism. We then analyzed gene expression in tibia and hypothalamus at dose rates of 0, 12 and 140 ng/h; the latter dose resulted in serum leptin levels similar to WT mice. Infusion with 12 ng/h leptin increased the expression of genes associated with Jak/Stat signaling and bone formation in tibia with minimal effect on Jak/Stat signaling and neurotransmitters in hypothalamus. The results suggest that leptin acts peripherally to couple bone acquisition to energy availability and that limited transport across the BBB insures that the growth-promoting actions of peripheral leptin are not curtailed by the hormone's CNS-mediated anorexigenic actions.

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Dissociating the Neural Basis of Conceptual Self-Awareness from Perceptual Awareness and Unaware Self-Processing

Conceptual self-awareness is a mental state in which the content of one's consciousness refers to a particular aspect of semantic knowledge about oneself. This form of consciousness plays a crucial role in shaping human behavior; however, little is known about its neural basis. Here, we use functional magnetic resonance imaging (fMRI) and a visual masked priming paradigm to dissociate the neural responses related to the awareness of semantic autobiographical information (one's own name, surname, etc.) from the awareness of information related to any visual stimulus (perceptual awareness), as well as from the unaware processing of self-relevant stimuli. To detect brain activity that is highly selective for self-relevant information, we used the blood-oxygen-level-dependent (BOLD) adaptation approach, which goes beyond the spatial limitations of conventional fMRI. We found that self-awareness was associated with BOLD adaptation in the medial frontopolar-retrosplenial areas, whereas perceptual awareness and unaware self-processing were associated with BOLD adaptation in the lateral fronto-parietal areas and the inferior temporal cortex, respectively. Thus, using a direct manipulation of conscious awareness we demonstrate for the first time that the neural basis of conceptual self-awareness is neuroanatomically distinct from the network mediating perceptual awareness of the sensory environment or unaware processing of self-related stimuli.

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Heparan Sulfates Support Pyramidal Cell Excitability, Synaptic Plasticity, and Context Discrimination

Heparan sulfate (HS) proteoglycans represent a major component of the extracellular matrix and are critical for brain development. However, their function in the mature brain remains to be characterized. Here, acute enzymatic digestion of HS side chains was used to uncover how HSs support hippocampal function in vitro and in vivo. We found that long-term potentiation (LTP) of synaptic transmission at CA3–CA1 Schaffer collateral synapses was impaired after removal of highly sulfated HSs with heparinase 1. This reduction was associated with decreased Ca²⁺ influx during LTP induction, which was the consequence of a reduced excitability of CA1 pyramidal neurons. At the subcellular level, heparinase treatment resulted in reorganization of the distal axon initial segment, as detected by a reduction in ankyrin G expression. In vivo, digestion of HSs impaired context discrimination in a fear conditioning paradigm and oscillatory network activity in the low theta band after fear conditioning. Thus, HSs maintain neuronal excitability and, as a consequence, support synaptic plasticity and learning.

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Dermatomal Organization of SI Leg Representation in Humans: Revising the Somatosensory Homunculus

Penfield and Rasmussen's homunculus is the valid map of the neural body representation of nearly each textbook of biology, physiology, and neuroscience. The somatosensory homunculus places the foot representation on the mesial surface of the postcentral gyrus followed by the representations of the lower leg and the thigh in superio-lateral direction. However, this strong homuncular organization contradicts the "dermatomal" organization of spinal nerves. We used somatosensory-evoked magnetic fields and source analysis to study the leg's neural representation in the primary somatosensory cortex (SI). We show that the representation of the back of the thigh is located inferior to the foot's representation in SI whereas the front of the thigh is located laterally to the foot's representation. This observation indicates that the localization of the leg in SI rather follows the dermatomal organization of spinal nerves than the typical map of neighboring body parts as depicted in Penfield and Rasmussen's illustration of the somatosensory homunculus.

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Elevated Body Mass Index is Associated with Increased Integration and Reduced Cohesion of Sensory-Driven and Internally Guided Resting-State Functional Brain Networks

Elevated body mass index (BMI) is associated with increased multi-morbidity and mortality. The investigation of the relationship between BMI and brain organization has the potential to provide new insights relevant to clinical and policy strategies for weight control. Here, we quantified the association between increasing BMI and the functional organization of resting-state brain networks in a sample of 496 healthy individuals that were studied as part of the Human Connectome Project. We demonstrated that higher BMI was associated with changes in the functional connectivity of the default-mode network (DMN), central executive network (CEN), sensorimotor network (SMN), visual network (VN), and their constituent modules. In siblings discordant for obesity, we showed that person-specific factors contributing to obesity are linked to reduced cohesiveness of the sensory networks (SMN and VN). We conclude that higher BMI is associated with widespread alterations in brain networks that balance sensory-driven (SMN, VN) and internally guided (DMN, CEN) states which may augment sensory-driven behavior leading to overeating and subsequent weight gain. Our results provide a neurobiological context for understanding the association between BMI and brain functional organization while accounting for familial and person-specific influences.

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Longitudinal Evidence for Increased Functional Response in Frontal Cortex for Older Adults with Hippocampal Atrophy and Memory Decline

The functional organization of the frontal cortex is dynamic. Age-related increases in frontal functional responses have been shown during various cognitive tasks, but the cross-sectional nature of most past studies makes it unclear whether these increases reflect reorganization or stable individual differences. Here, we followed 130 older individuals' cognitive trajectories over 20–25 years with repeated neuropsychological assessments every 5th year, and identified individuals with stable or declining episodic memory. Both groups displayed significant gray matter atrophy over 2 successive magnetic resonance imaging sessions 4 years apart, but the decline group also had a smaller volume of the right hippocampus. Only individuals with declining memory demonstrated increased prefrontal functional responses during memory encoding and retrieval over the 4-year interval. Regions with increased functional recruitment were located outside, or on the borders of core task-related networks, indicating an expansion of these over time. These longitudinal findings offer novel insight into the mechanisms behind age-associated memory loss, and are consistent with a theoretical model in which hippocampus atrophy, past a critical threshold, induces episodic-memory decline and altered prefrontal functional organization.

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Spontaneous eye blink rate (EBR) predicts poor performance in high-stakes situations

Publication date: Available online 24 January 2017
Source:International Journal of Psychophysiology
Author(s): Ilse H. van de Groep, Lucas M. de Haas, Iris Schutte, Erik Bijleveld
Although the existence of 'choking under pressure' is well-supported by research, its biological underpinnings are less clear. In this research, we examined two individual difference variables that may predict whether people are likely to perform poorly in high-incentive conditions: baseline eye blink rate (EBR; reflecting dopamine system functioning) and baseline anterior hemispheric asymmetry (an indicator of goal-directed vs. stimulus driven processing). Participants conducted a switch task under control vs. incentive conditions. People low in EBR were generally capable of improving their performance when incentives were at stake, whereas people high in EBR were not. Hemispheric asymmetry did not predict performance. These findings are consistent with the idea that suboptimal performance in high-stakes conditions may stem from the neuromodulatory effects of dopamine.

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Blunted cardiovascular reactivity during social reward anticipation in subclinical depression

Publication date: Available online 24 January 2017
Source:International Journal of Psychophysiology
Author(s): Kerstin Brinkmann, Jessica Franzen
The present study extends past research about reduced reward responsiveness in depression by assessing effort-related cardiovascular responses during anticipation of a social reward. Dysphoric (i.e., subclinically depressed) and nondysphoric participants worked on a cognitive task. Half the participants in each group expected the possibility to subscribe to a social exchange internet site. Effort mobilization during task performance was assessed by participants' cardiovascular reactivity. Confirming the predictions, nondysphoric participants in the social-reward condition had higher reactivity of pre-ejection period, systolic blood pressure, and heart rate, compared to the other three cells. In contrast, dysphoric participants' cardiovascular reactivity was generally low. These findings indicate that social-reward function is indeed impaired in subclinical depression. Implications for social punishment are discussed.

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Cold flow of three-dimensional confined polymer systems

Publication date: 24 February 2017
Source:Polymer, Volume 111
Author(s): Xiang Li, Chen Zhang, Ye Sha, Linling Li, Dongshan Zhou, Zexin Zhang, Gi Xue, Xiaoliang Wang
Increasing temperature has been widely considered as a primary and effective way to improve the segmental mobility of polymer chains and subsequently cause polymer chains to flow. Here, by confining the morphology of polymers into nanospheres and combining this process with external stress, we present an important new approach to achieve the cold flow of glassy polymers at room temperature, under which the mobility of chain segments are enhanced significantly. The interparticle fusion and the flow of polymer chains under pressure were monitored by utilizing a non-radiative energy transfer (NRET) method. Additionally, we showed that low-temperature processing based on cold flow retains the biological activity of bio-additives.

Graphical abstract

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Thymic origins of T cell receptor alloreactivity.

MHC restriction is a unique feature of T cell antigen recognition. Mature T cells respond to antigenic nonself peptides bound to self-MHC molecules, but a sizeable fraction of peripheral T cells can also respond to nonself peptide-MHC (pMHC) complexes in the context of transplantation. MHC specificity of the T cell receptor repertoire is shaped during thymic development. Two hypotheses have been proposed to explain MHC specificity of T cells. It has been suggested that MHC specificity is an intrinsic feature of TCR structure, mediated by the germline-encoded regions of the TCR sequence. In support of this model, an estimated 15-30% of preselection TCR repertoire is estimated to be MHC-specific. Moreover, structural studies have shown some degree of conserved binding topology for TCR-peptide MHC complexes. However, there is also evidence that MHC restriction can be imposed on the TCR repertoire during thymic development, and it has been proposed that the interaction of the Lck kinase with CD4 or CD8 coreceptors is critical for generation of MHC specificity. This review will discuss recent work on assessment of the preselection of TCR repertoire, molecular evidence for the germline encoded TCR bias for MHC and for the coreceptor sequestration model in the context of alloreactivity and transplantation. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Impact of Antibodies that React with Liver Tissue and Donor-specific anti-HLA Antibodies in Pediatric Idiopathic Posttransplantation Hepatitis.

Background: The cause of late graft dysfunction has not been elucidated. Although an antibody-mediated reaction is suspected as a potential mechanism, the target antigens have not been clarified. Methods: To clarify the etiology of idiopathic posttransplantation hepatitis (IPTH), we simultaneously examined the presence of antibodies that react with liver tissue (ARLT) by means of indirect immunofluorescence staining, as well as the presence of donor-specific anti-human leukocyte antigen antibodies (HLA-DSA). A subanalysis of the IPTH group was also performed. Within the IPTH group, the correlation between ARLT titer and clinical data were analyzed. Results: In the sera of patients with IPTH (30 patients), ARLT were found at a significantly higher frequency than in patients without IPTH (42 patients; p

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Auditing access to outpatient rehabilitation services for children with traumatic brain injury and public insurance in Washington State

Publication date: Available online 23 January 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Molly M. Fuentes, Leah Thompson, D. Alex Quistberg, Wren L. Haaland, Karin Rhodes, Deborah Kartin, Cheryl Kerfeld, Susan Apkon, Ali Rowhani-Rahbar, Frederick P. Rivara
ObjectiveIdentify insurance-based disparities in access to outpatient pediatric neurorehabilitation services.DesignAudit study, with paired calls where callers posed as a mother seeking services for a simulated child with history of severe traumatic brain injury (TBI) and public or private insurance.SettingOutpatient rehabilitation clinics in Washington StateParticipants195 physical therapy clinics (PTc), 109 occupational therapy clinics (OTc), 102 speech therapy clinics (STc) and 11 rehabilitation medicine clinicsInterventionsNoneMain outcome measuresAcceptance of public insurance, business days until the next available appointment.ResultsTherapy clinics were more likely to accept private versus public insurance (relative risk (RR) for PTc 1.33 (95% confidence interval (CI) 1.22-1.44), OTc 1.40 (95% CI 1.24-1.57), and STc 1.42 (95% CI 1.25-1.62), with no significant difference for rehabilitation medicine (RR 1.10, 95% CI 0.90-1.34). The difference in median wait time between clinics that accepted public versus only private insurance was 4 business days for PTc and 15 days for STc (p ≤ .001) but not significantly different for OTc or rehabilitation medicine. When adjusting for urban and multidisciplinary clinic status, the wait at clinics accepting public insurance was 59% longer for PT (95% CI 39-81%), 18% longer for OT (95% CI 7-30%) and 107% longer for ST (95% CI 87-130%) than at clinics accepting only private insurance. Distance to clinics varied by discipline and area within the state.ConclusionTherapy clinics were less likely to accept public versus private insurance. Therapy clinics accepting public insurance had longer wait times than clinics that accepted only private insurance. Rehabilitation professionals should attempt to implement policy and practice changes to promote equitable access to care.

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Body Image in Patients With Spinal Cord Injury During Inpatient Rehabilitation

Publication date: Available online 24 January 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Tijn van Diemen, Christel van Leeuwen, Ilse van Nes, Jan Geertzen, Marcel Post
Objectives(1) To investigate the course of body image in patients with spinal cord injury (SCI) during their first inpatient rehabilitation stay; and (2) to explore the association between demographic and injury-related variables and body image and the association between body image and psychological distress.DesignLongitudinal inception cohort study.SettingRehabilitation center.ParticipantsOf the 210 people admitted for their first inpatient SCI rehabilitation program (between March 2011 and April 2015), 188 met the inclusion criteria. Of these, N=150 (80%) agreed to participate.InterventionsNot applicable.Main Outcome MeasureThe Body Experience Questionnaire was used to measure 2 dimensions of body image: alienation and harmony.ResultsMean scores on the Body Experience Questionnaire alienation subscale decreased significantly during the rehabilitation program. Mean scores on the Body Experience Questionnaire harmony subscale did not increase significantly but showed a trend in the hypothesized direction. The 2 subscales showed weak correlations with demographic and injury-related variables. The 2 subscales together explained 16% and 14% of the variance of depression and anxiety, respectively, after correction for demographic and injury-related variables.ConclusionsDuring participants' first inpatient rehabilitation stay after SCI, body image progressed toward a healthier state. Body image explains part of the variance in depression and anxiety, and the entire rehabilitation team should be targeting interventions to improve body image.

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Tissue engineering the mechanosensory circuit of the stretch reflex arc with human stem cells: Sensory neuron innervation of intrafusal muscle fibers

Publication date: April 2017
Source:Biomaterials, Volume 122
Author(s): Xiufang Guo, Alisha Colon, Nesar Akanda, Severo Spradling, Maria Stancescu, Candace Martin, James J. Hickman
Muscle spindles are sensory organs embedded in the belly of skeletal muscles that serve as mechanoreceptors detecting static and dynamic information about muscle length and stretch. Through their connection with proprioceptive sensory neurons, sensation of axial body position and muscle movement are transmitted to the central nervous system. Impairment of this sensory circuit causes motor deficits and has been linked to a wide range of diseases. To date, no defined human-based in vitro model of the proprioceptive sensory circuit has been developed. The goal of this study was to develop a human-based in vitro muscle sensory circuit utilizing human stem cells. A serum-free medium was developed to drive the induction of intrafusal fibers from human satellite cells by actuation of a neuregulin signaling pathway. Both bag and chain intrafusal fibers were generated and subsequently validated by phase microscopy and immunocytochemistry. When co-cultured with proprioceptive sensory neurons derived from human neuroprogenitors, mechanosensory nerve terminal structural features with intrafusal fibers were demonstrated. Most importantly, patch-clamp electrophysiological analysis of the intrafusal fibers indicated repetitive firing of human intrafusal fibers, which has not been observed in human extrafusal fibers.

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Broad spectrum antibiotic enrofloxacin modulates contact sensitivity through gut microbiota in a murine model

Publication date: Available online 24 January 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Anna Strzępa, Monika Majewska-Szczepanik, Francis M. Lobo, Li Wen, Marian Szczepanik
BackgroundMedical advances in the field of infection therapy has led to an increasing use of antibiotics, which, apart from eliminating pathogens, also partially eliminate naturally existing commensal bacteria. It has become increasingly clear that less exposure to microbiota early in life may contribute to the observed rise in "immune-mediated" diseases including autoimmunity and allergy.ObjectiveWe sought to test whether the change of gut microbiota with the broad spectrum antibiotic enrofloxacin will modulate contact sensitivity (CS) in mice.MethodsNatural gut microbiota were modified by oral treatment with enrofloxacin prior to sensitization with TNP-Cl followed by CS testing. Finally, adoptive cell transfers were performed to characterize the regulatory cells that are induced by microbiota modification.ResultsOral treatment with enrofloxacin suppresses CS and production of anti-TNP IgG1 antibodies. Adoptive transfer experiments show that antibiotic administration favors induction of regulatory cells that suppress CS. Flow cytometry and adoptive transfer of purified cells show that antibiotic-induced suppression of CS is mediated by TCRαβ⁺CD4⁺CD25⁺FoxP3⁺ Treg, CD19⁺B220⁺CD5⁺IL-10⁺, IL-10⁺ Tr1, and IL-10⁺TCRγδ⁺ cells. Treatment with the antibiotic induces dysbiosis characterised by increased proportion of Clostridium coccoides (cluster XIVa), Clostridium coccoides – E. rectale (cluster XIVab), Bacteroidetes and Bifidobacterium spp., but decreased segmented filamentous bacteria. Transfer of antibiotic-modified gut microbiota inhibits CS, but this response can be restored through oral transfer of control gut bacteria to antibiotic-treated animals.ConclusionOral treatment with a broad spectrum antibiotic modifies gut microbiota composition and promotes anti-inflammatory response, suggesting that manipulation of gut microbiota can be a powerful tool to modulate the course of CS.

Teaser

Antibiotic-induced dysbiosis, characterized by increased levels of Bacteroidetes, Bifidobacterium spp., Clostridium cluster XIVa and XIVab, but decreased proportions of segmented filamentous bacteria, effectively inhibits contact sensitivity by inducing a variety of regulatory cells.

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Traumatologie der Nase

Zusammenfassung

Die Nase als prominentestes Element des Gesichtes wird überdurchschnittlich oft traumatisiert. Eine exakte Beurteilung einer traumatisierten Nase, eine angemessene Diagnostik und die Entscheidung zu einer adäquaten Frühbehandlung tragen dazu bei, bleibende Formstörungen zu verhindern. Die gesamte Palette der bekannten Techniken der Rhinoplastik ermöglicht weitreichende Korrekturmaßnahmen. In die Planung intensiver Korrekturmaßnahmen sollten technische Varianten wie mehrfache Osteotomien und die Abtragung überschüssiger Knochensequester oder Narben einbezogen werden. Außerdem ist die Auswahl eines geeigneten Materials zur Auffüllung von Defekten wichtig.

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Traumatologie der Nase

Zusammenfassung

http://ift.tt/2kpWkKr

Body weight changes in early onset Narcolepsy: implying compensatory mechanisms

We thank Dr Kovalská et al. for their special interest in our paper, and we thank the editors for giving us the opportunity to interpret our work. The findings of Dr Kovalská contribute to the understanding of the long-term status and outcome of patients with narcolepsy with cataplexy [1]. Their observations on characteristics of BMI were consistent with our findings in body mass index (BMI) [2]. However, they may have misunderstood our findings on BMI and BMI growth [3]. Our data showed significant interaction in time and BMI growth, but not in time and BMI, between patients and controls.

http://ift.tt/2juVKXG

Copyright

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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Contributors

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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CME Accreditation Page

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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Forthcoming Issues

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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Genitourinary Imaging

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2
Author(s): Andrew B. Rosenkrantz

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Dual-Energy Computed Tomography in Genitourinary Imaging

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2
Author(s): Achille Mileto, Daniele Marin

Teaser

Reignited by innovations in scanner engineering and software design, dual-energy computed tomography (CT) has come back into the clinical radiology arena in the last decade. Possibilities for noninvasive in vivo characterization of genitourinary disease, especially for renal stones and renal masses, have become the pinnacle offerings of dual-energy CT for body imaging in clinical practice. This article renders a state-of-the-art review on clinical applications of dual-energy CT in genitourinary imaging.

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The Evidence for and Against Corticosteroid Prophylaxis in At-Risk Patients

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2
Author(s): Matthew S. Davenport, Richard H. Cohan

Teaser

Corticosteroid prophylaxis is commonly used for the prevention of allergiclike reactions to iodinated and gadolinium-based contrast material in patients at highest risk of an allergiclike reaction. However, it has only a weak mitigating effect on allergiclike reactions, probably does not affect the severity of subsequent reactions, and does not prevent all reactions. Breakthrough reactions occur, are usually the same severity as the index reaction, and can occasionally be life threatening. Premedication of inpatients is likely associated with substantial cost and harm because of hospital length-of-stay prolongation; these indirect effects may exceed the benefits of premedication in this population.

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Index

Publication date: March 2017
Source:Radiologic Clinics of North America, Volume 55, Issue 2

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Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.

Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.

Ann Emerg Med. 2017 Jan 19;:

Authors: Driver BE, McGill JW

Abstract
STUDY OBJECTIVE: Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution.
METHODS: We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort.
RESULTS: We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated.
CONCLUSION: In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.

PMID: 28110989 [PubMed - as supplied by publisher]

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Ultrasonographic assessment of tonsillar volume in children

Adenotonsillar hypertrophy in children is the most common anatomical abnormality associated with obstructive sleep apnoea. Perioperative complications associated with adenotonsillectomy are more common in children with severe obstructive sleep apnoea. An objective preoperative method to determine the size of tonsils is missing. This study assessed the validity of ultrasound as a tool for measuring tonsillar size in children.

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Editorial: Towards Improving the Science of Hormones and Cancer

http://ift.tt/2jOWkAL

Broad spectrum antibiotic enrofloxacin modulates contact sensitivity through gut microbiota in a murine model

Removal of phenanthrene in contaminated soil by combination of alfalfa, white-rot fungus, and earthworms

Abstract

The aim of this study was to investigate the removal of phenanthrene by combination of alfalfa, white-rot fungus, and earthworms in soil. A 60-day experiment was conducted. Inoculation with earthworms and/or white-rot fungus increased alfalfa biomass and phenanthrene accumulation in alfalfa. However, inoculations of alfalfa and white-rot fungus can significantly decrease the accumulation of phenanthrene in earthworms. The removal rates for phenanthrene in soil were 33, 48, 66, 74, 85, and 93% under treatments control, only earthworms, only alfalfa, earthworms + alfalfa, alfalfa + white-rot fungus, and alfalfa + earthworms + white-rot fungus, respectively. The present study demonstrated that the combination of alfalfa, earthworms, and white-rot fungus is an effective way to remove phenanthrene in the soil. The removal is mainly via stimulating both microbial development and soil enzyme activity.

http://ift.tt/2jWxNfd

Evaluating phytoextraction efficiency of two high-biomass crops after soil amendment and inoculation with rhizobacterial strains

Abstract

We evaluated the effect of compost amendment and/or bacterial inoculants on the growth and metal accumulation of Salix caprea (clone BOKU 01 AT-004) and Nicotiana tabacum (in vitro-bred clone NBCu10-8). Soil was collected from an abandoned Pb/Zn mine and rhizobacterial inoculants were previously isolated from plants growing at the same site. Plants were grown in untreated or compost-amended (5% w/w) soil and were inoculated with five rhizobacterial strains. Non-inoculated plants were also established as a control. Compost addition increased the shoot DW yield of N. tabacum but not S. caprea, while it decreased soil metal availability and lowered shoot Cd/Zn concentrations in tobacco plants. Compost amendment enhanced the shoot Cd/Zn removal due to the growth promotion of N. tabacum or to the increase in metal concentration in S. caprea leaves. Bacterial inoculants increased photosynthetic efficiency (particularly in N. tabacum) and sometimes modified soil metal availability, but this did not lead to a significant increase in Cd/Zn removal. Compost amendment was more effective in improving the Cd and Zn phytoextraction efficiency than bioaugmentation.

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Dental health status in crack/cocaine-addicted men: a cross-sectional study

Abstract

The aim of this study was to evaluate the association between crack/cocaine addiction and dental health in men. Forty crack/cocaine-addicted patients and 120 nonaddicted patients (≥18 years) underwent full-mouth dental examinations. Decayed, missing, and filled teeth (DMFT) were identified using the criteria recommended by the World Health Organization. Crack/cocaine addiction was determined, based on the medical records and interviews of each patient. All drug-addicted patients used both crack and cocaine. The chi-square test and logistic regression analysis were used to assess the association between DMFT and crack/cocaine addiction (p ≤ 0.05). Decayed teeth showed a positive association with crack/cocaine addiction (odds ratio (OR) = 3.65; 95% confidence interval (CI), 1.68–7.92; p = 0.001), whereas filled and missing teeth showed a negative association (filled teeth: OR = 0.37; 95% CI, 0.18–0.76; p = 0.008; missing teeth: OR = 0.33; 95% CI, 0.13–0.81; p = 0.02). The DMFT was only associated with age (OR = 2.12; 95% CI, 1.11–4.08, p = 0.023). In the present population, crack/cocaine addiction was associated with a greater decayed teeth index and a lower filled and missing teeth index. Programs aimed to encourage self-esteem and encourage individuals to seek dental care are required for this population. Further studies using a larger sample size and studies with women are required to confirm the results.

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A Rare Case of Locally Advanced Recurrent Neuroendocrine Tumour of Neck Salvaged by a Radical Surgical Approach

Abstract

Neuroendocrine tumours of head and neck are rare neoplasms and even more rare are those of cutaneous adenoid cystic carcinoma with neuroendocrine differentiation. Virtually every known variant of neoplasia with neuroendocrine differentiation can arise in complex structures of head and neck (Mills in Endocr Pathol 7(4):329–343. doi:10.1007/BF02739841) [1]. Such tumours are usually non functional, locally aggressive and may spread to lymph nodes or lungs. They are diagnosed by histopathology, immunohistochemistry and radionuclide imaging. When these tumours involve the carotid artery, they pose challenges in the surgical management.

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Pleomorphic Adenoma (Mixed Tumor) of Dorsum of Nose: A Rare Tumor at a Rare Site

http://ift.tt/2jncClL

Evolving healthcare delivery paradigms and the optimization of 'value' in anesthesiology.

Purpose of review: Healthcare worldwide is evolving to yield enhanced care provided at a lowered cost. Patient-centric paradigms that hasten surgical recovery and strengthen collaboration amongst medical professionals are gaining impetus. This review will discuss the changing healthcare landscape and outline its implications on anesthesiology practice. Recent findings: Anesthesiologists must be nimble and versatile as they adapt to healthcare redesign. An increased responsibility for patient outcomes should be embraced by extending the breadth and depth of clinical practice throughout the surgical care continuum. The perioperative surgical home and enhanced recovery after surgery provide paradigms to further integrate expanding clinical opportunities and improved patient outcomes. Investment is needed in perioperative medical education and research efforts to best position anesthesiologists for success both now and in the future. Summary: Exemplifying opportunities to demonstrate value-added care, the scope of anesthesiology education and clinical practice should diversify to further integrate perioperative care of surgical patients. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Quality organization and risk in anaesthesia: the French perspective.

Purpose of review: Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization. Recent findings: Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands. Summary: The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Assessment of competence: developing trends and ethical considerations.

Purpose of review: This review explores new concepts in competency assessment in anesthesiology, the associated ethical challenges, and directions for new research. Recent findings: Many new tools for the assessment of competence are currently in development to address changes in medical education curricula. The assessment of competence currently focuses on technical skills, nontechnical skills, and the interaction of both through the use of simulation, with increasing emphasis on validity and reliability testing. Summary: The search for objective measures of competence is well underway. Current methods require substantial investment of resources, and further research into more efficient and financially feasible tools of assessment is needed. As these assessments become more common in use, the ethical challenges raised by defining competency in high-stakes clinical practice situations will need to be addressed. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2k0Bq44

Update on low-dose corticosteroids.

Purpose of review: Low-dose hydrocortisone is recommended in patients with septic shock unresponsive to fluid and vasopressor therapy. Recent research added new data for patients with septic shock and other target groups such as patients with severe sepsis, acute respiratory distress syndrome (ARDS), community-acquired pneumonia, and burns. The objective of this review is to summarize and comment recent findings on low-dose corticosteroids (LDC) in critically ill patients. Recent findings: In the last 2 years, a series of clinical trials and retrospective analyses investigated LDC therapy in critically ill patients with severe systemic inflammation of various origins. Improvement in morbidity has been demonstrated in ARDS and community-acquired pneumonia. Retrospective propensity-score analyses also suggest that LDC administered in severe septic shock or in septic shock due to community-acquired pneumonia or intestinal perforation may improve survival. Summary: Low-dose hydrocortisone or a corresponding low-dose corticosteroid therapy may improve morbidity in specific target groups of critically ill patients. Beneficial effects on mortality remain to be demonstrated in large-scale randomized controlled trials. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Pleomorphic Adenoma (Mixed Tumor) of Dorsum of Nose: A Rare Tumor at a Rare Site

http://ift.tt/2jncClL

A Rare Case of Locally Advanced Recurrent Neuroendocrine Tumour of Neck Salvaged by a Radical Surgical Approach

Abstract

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Concurrent panniculectomy in the obese ventral hernia patient: assessment of short-term complications, hernia recurrence, and healthcare utilization

Panniculectomy (PAN) is often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice have not been fully established in part due to paucity of comparative effectiveness studies. Presented herein is a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients.

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Might Trauma Be a Triggering Factor for Craniofacial Fibrous Dysplasia?.

Fibrous dysplasia (FD) is a rare, benign disease of unclear etiology where normal bone is replaced with abnormal fibrous and weak osseous tissue. Any bone of the skeleton might be involved but skull is one of the most commonly affected sites. Fibrous dysplasia is known to be caused by a genetic mutation leading to inappropriate proliferation and differentiation of osteoblastic cells. However; it is not known whether any triggering factor exists which might contribute to this genetic mutation. The authors postulated that trauma might be a triggering factor for this disease. Trauma, as a triggering factor, has not been reported to be clearly linked to FD in the literature so far. Through this perspective; the authors report a patient of fronto-orbital fibrous dysplasia developing 6 years after a fronto-orbital skull fracture, at the same localization of the fracture line. (C) 2017 by Mutaz B. Habal, MD.

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Endoscopic-Assisted Removal of a Rare Mucocele Complicating From Alloplastic Medial Orbital Fracture Reconstruction.

Orbital wall fracture reconstruction is usually recommended to prevent subsequent functional and esthetic complications. Mucocele development following such injuries or its management is recognized but rare sequelae. When they occur, they represent a diagnostic and management dilemma. The authors described a patient with orbital and ethmoidal mucocele. A 62-year-old female patient presented with progressive left exophthalmos 1 year following titanium mesh reconstruction of a medial orbital wall fracture. Computed tomography and magnetic resonance imaging demonstrated an encysted lesion encasing the mesh plate in the left orbit and extending into the ethmoidal sinus. The patient is treated surgically through endoscopic-assisted approach with complete removal of the lesion and lacrimal duct stenting. The patient improved immediately after surgery. (C) 2017 by Mutaz B. Habal, MD.

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A Rare Complication of Infraorbital Nerve Hyperesthesia in Surgically Repaired Orbital Fracture Patients.

Injury to the peripheral sensory branches of the trigeminal nerve can follow a wide variety of craniofacial injuries. Many patients with facial fractures complain about the symptom of numbness to the distribution of injured nerve, which is indicative of hypoesthesia. Hyperesthesia involving the infraorbital nerve is rare in comparison to hypoesthesia secondary to facial trauma. The authors report on 2 patients with infraorbital nerve hyperesthesia in surgically repaired orbital fracture patients. Surgical decompression of the infraorbital nerve led to rapid resolution of hyperesthesia. To the best of our knowledge, these were rare cases of patients who presented with persistent hyperesthesia. Clinician should perform early surgical decompression of the infraorbital nerve in patient with persistent hyperesthesia of the infraorbital nerve. (C) 2017 by Mutaz B. Habal, MD.

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Giant Orf on the Nose.

Orf is a zoonotic infectious disease caused by parapoxvirus. Orf lesions are typically seen on the hand, but they have rarely been reported on the nose. Herein, the authors report a rare patient of an orf lesion on the nose of a 52-year-old man after the Muslim celebration of the feast of the sacrifice. The lesion spontaneously recovered 8 weeks after the initial appearance and showed no evidence of recurrence after 1 year of follow-up. Orf virus infections may occur more often after the celebration of the feast of the sacrifice in Muslim countries. (C) 2017 by Mutaz B. Habal, MD.

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A Rare Concha Variation: Coronal Cleft.

Nasal turbinates are embryologically derived from a series of outgrowths from the foetal lateral nasal wall. These outgrowths form a series of ridges, referred to as "ethmoturbinals" and have several vital functions. Several different turbinate variations have been reported so far. The authors presented 3 patients of coronal clefted concha who were diagnosed with magnetic resonance imaging. Computed tomography scans and nasal endoscopic examinations are also performed subsequently. These patients are the first coronal clefted concha cases in the literature and also the first radiological study defining concha cleft. This shows paucity of data documenting variations in the lateral nasal wall. Understanding the anatomy and the anatomic variations of the nasal cavity and nasal turbinates is critical to guide the procedure due to its close proximity to vital structures such as orbita and skull base, especially for functional endoscopic sinus surgery that is a widely used technique nowadays. (C) 2017 by Mutaz B. Habal, MD.

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Cephalometric Analysis of Modifications of the Mandible Due to Reduction Mandibuloplasty in Patients With Prominent Mandibular Angle.

Cephalometry has been used to measure hard and soft facial tissues as well as to conduct the ostectomy to determine the characteristics of the prominent mandibular angles (PMA). The changes produced on the mandibles by reduction mandibuloplasty are not known. The objective of the present study was to identify by cephalometric analysis the anatomical changes of the mandibles that occur in patients with PMA after reduction mandibuloplasty. Forty-two patients with PMA were submitted to cephalometric analysis before, 1 week and 6 months after surgery to evaluate the changes of the mandibles produced by reduction mandibuloplasty. Cephalometry was standardized to obtain descriptive measurements of the dimensions of the mandibles. The modifications of the mandibles due to reduction mandibuloplasty showed a significant change obtained by cephalometry. At 1 week after surgery, the average distance between the gonions decreased 17.70 +/- 8.46 mm, the average length of the mandibular ramus reduced 5.84 +/- 3.26 mm, the average mandibular body length increased 4.61 +/- 2.74 mm, the average gonial angle increased 14.78 +/- 6.65[degrees], the average mandibular plane angle increased 10.29 +/- 3.82[degrees]. At 6 months postoperatively, the first 3 linear measurements increased 3.68 +/- 2.91, 1.66 +/- 2.51, and 2.10 +/- 2.37 mm respectively; however, the last 2 angular measurements reduced 2.86 +/- 3.02[degrees] and 1.77 +/- 2.62[degrees] respectively. The results demonstrated that reduction mandibuloplasty can modificate mandibular contouring three-dimensionally. The data of 6 months postoperatively compare to those of the beauty people reported in the literature, there were statistically differences between the linear measurements, but no statistically differences between the angular measurements. Despite bone regeneration result in linear or angular measurements change, postoperative angular shape was predominantly maintained, and the preoperative angular prominence did not recur. (C) 2017 by Mutaz B. Habal, MD.

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Ameloblastoma in a Patient With Williams Syndrome and Use of Fibular Flap.

No abstract available

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Novel Treatment Planning of Hemimandibular Hyperplasia by the Use of Three-Dimensional Computer-Aided-Design and Computer-Aided-Manufacturing Technologies.

Rationale and Aim: Hemimandibular hyperplasia is characterized by an obvious overgrowth in the size of the mandible on one side, which can extend up to the midline causing facial asymmetry. Surgical resection of the overgrowth depends heavily on the skill and experience of the surgeon. This report describes a novel methodology of applying three-dimensional computer-aided-design and computer-aided-manufacturing principles in improving the outcome of surgery in 2 mandibular hyperplasia patients. Methodology: Both patients had their cone beam computer tomography (CBCT) scan performed. CMF Pro Plan software (v. 2.1) was used to process the scan data into virtual 3-dimensional models of the maxilla and mandible. Head tilt was adjusted manually by following horizontal reference. Facial asymmetry secondary to mandibular hypertrophy was obvious on frontal and lateral views. Simulation functions were followed including mirror imaging of the unaffected mandibular side into the hyperplastic side and position was optimized by translation and orientation functions. Reconstruction of virtual symmetry was assessed and checked by running 3-dimensional measurements. Then, subtraction functions were used to create a 3-dimensional template defining the outline of the lower mandibular osteotomy needed. Precision of mandibular teeth was enhanced by amalgamating the CBCT scan with e-cast scan of the patient lower teeth. 3-Matic software (v. 10.0) was used in designing cutting guide(s) that define the amount of overgrowth to be resected. The top section of the guide was resting on the teeth hence ensuring stability and accuracy while positioning it. The guide design was exported as an .stl file and printed using in-house 3-dimensional printer in biocompatible resin. Conclusion: Three-dimensional technologies of both softwares (CMF Pro Plan and 3-Matic) are accurate and reliable methods in the diagnosis, treatment planning, and designing of cutting guides that optimize surgical correction of hemimandibular hyperplasia at timely and cost-effect manner. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2jnEOF4

Postoperative Three-Dimensional Evaluation of Mandibular Contouring Surgery Using Computer-Assisted Simulation Planning and a Three-Dimensional-Printed Surgical Guide.

Mandibular contouring surgery was performed using computer-assisted simulation planning (CASP) and 3-dimensional printed surgical guide. The outcome of the surgery was evaluated by overlapping preoperative image. The patient underwent mandibular contouring surgery according to CASP for his residual facial asymmetry of the mandibular angle and mental area. The overall facial aesthetic of the patient was improved. In the overlapping image, the left mandibular border area was slightly overcorrected. However, the other portion was operated as planned. The overcorrection was due to the improper adaptation of the surgical guide adjacent to the mental foramen. In conclusion, usage of CASP and a surgical guide could reduce operation time and increase the accuracy of the operation. However, the design of the stent should be improved around the mental foramen to avoid nerve damage and improper adaptation. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2juDXAa

The Study of Calcium, Phosphonium, Magnesium, and Ferrum Concentration in Serum of Patients With Primary Trigeminal Neuralgia.

Objective: To measure the concentration of 4 essential elements (Ca, P, Mg, Fe) in serum of patients with primary trigeminal neuralgia. And evaluate the role of the 4 elements in serum on the pathogenesis of trigeminal neuralgia (TN), and the relevance of etiology. Methods: From June 2013 to June 2014, a number of 80 patients with primary trigeminal neuralgia were collected. We present a retrospective review of the concentration of 4 essential elements with those of control group of 80 patients without TN. The concentrations of 4 elements were measured with Olympus AU 400 automatic biochemistry analyzer. Results: In primary TN patients, the concentration of Ca, P, Mg in serum is lower than the control group obviously (P

http://ift.tt/2jnCHkM

Microtia and Social Media: Patient Versus Physician Perspective of Quality of Information.

Introduction: Previous research demonstrates that patients seek high-quality information on the World Wide Web, especially in rare conditions such as microtia. Social media has overtaken other sources of patient information but quality remains untested. This study quantifies the quality of information for patients with Microtia on social media compared with nonsocial media websites and compares physician and patient scoring on quality using the DISCERN tool. Methods: In phase 1, quality of the top 100 websites featuring information "Microtia" was ranked according to quality score and position on Google showing the position of social media websites among other nonsocial media websites. Phase 2 involved independent scoring of websites on microtia compared with a patient group with microtia to test whether physicians score differently to patients with t test comparison. Results: Social media websites account for 2% of the scored websites with health providers linking to social media. Social media websites were among the highest ranked on Google. No correlation was found between the quality of information and Google rank. Social media scored higher than nonsocial media websites regarding quality of information on microtia. No significant difference existed between physician and patient quality of information scores on social media and nonsocial media websites (p 1.033). Conclusion: Physicians and patients objectively score microtia websites alike. Social media websites have higher use despite being few in number compared with nonsocial media websites. Physicians providing links to social media on information websites on rare conditions such as microtia are engaging in current information-seeking trends. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2juF5E1

Comparison of Two Screw-Retained Free Gingival Grafting Techniques.

Free gingival graft is a predictable technique for increasing the amount of attached gingiva and root coverage; however, its use is limited for cosmetic reasons. To overcome this issue, this study sought to compare 2 free gingival graft techniques that use oral screws to attach grafts. Free gingival graft was performed on teeth 44 to 46 using the traditional technique, while on the opposite side, on teeth 34 to 36, partly epithelialized free gingival grafts were performed. The partly epithelialized free gingival grafts were found to provide better cosmetic results relative to the completely epithelialized free gingival graft, and the use of stabilizing screws was found to be simple and effective. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2jnFZ7p

Antronasal Polyp Extending to Orbital Fossa.

Sinonasal infections and nasal polyps can be taken as 2 components of a disease. Polyps due to chronic inflammations of nasal cavity and sinuses are not rare. They may present with various clinical signs and symptoms, while the secondary complications may cause serious problems. They are most commonly treated medically, although surgery is the therapy of choice in some conditions. The complications can be listed as mucocele formation, orbital inflammation, intracranial extension by erosion of the boney structures. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2juAUIi

Microvascular Tissue Transfers for Midfacial and Anterior Cranial Base Reconstruction.

Reconstruction of a midfacial defect can represent a difficult challenge for the plastic surgeon. Although many midfacial deformities have traumatic or congenital origins, the vast majority of head and neck defects occur after resection of malignant head and neck neoplasms. Autogenous reconstruction is now routinely performed for larger, complex defects resulting from surgical resection or trauma. In this study, the authors present 27 patients with midfacial defects reconstructed with free flaps. Twenty-two of the defects were created by surgical ablation of cancer (maxillectomy) and the others were traumatic. The maxillectomy defects were classified into 4 according to the classification proposed by Cordeiro. Eighteen of the patients were male and 9 were female. Twenty-nine free flaps were performed. Six different types of flaps including radial forearm flap, vertical rectus abdominis (VRAM) flap, anterolateral thigh (ALT) flap, tensor fasciae latae (TFL) flap, fibula osteocutaneous flap, and iliac osteocutaneous flap were accomplished. Types I and II defects were reconstructed with radial forearm flap. Type III defects were reconstructed with VRAM and ALT. Type IV defects were reconstructed with VRAM and TFL. Two patients underwent a second flap reconstruction due to recurrent disease (9.1%). Average patient age was 53.1 years. Free-flap survival was 100%. Free tissue transfer is the method of choice in midfacial reconstruction. Following a reconstructive algorithm is useful in the decision-making process for patient evaluation and treatment. Every reconstructive microsurgeon might have different experiences with different flaps. Therefore, the algorithm for flap choices is not universal among surgeons. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2jnIBlX

Clinical Observation of Treatment of Chronic Subdural Hematoma With Novel Double Needle Minimally Invasive Aspiration Technology.

Objective: The aim of the present study was to explore the clinical effects, including the prevention of complications, of the treatment of chronic subdural hematoma with double needle aspiration. Methods: The clinical data of 31 patients with chronic subdural hematoma treated by double YL-1 needle double skull drilling and 31 controls treated by traditional drilling and drainage were analyzed retrospectively. Results: In the YL-1 needle group, only 1 patient was with hematoma recurrence, 1 patient was with intracranial pneumocephalus, and the remaining patients who were followed up for 3 months achieved a clinical cure. In the traditional drilling and drainage group, 13 patients were with hematoma recurrence within 3 months after the operation and 7 patients were with postoperative intracranial pneumocephalus. Conclusions: The method of double YL-1 needle is better than the traditional drilling and drainage method for the treatment of chronic subdural hematoma because it reduces the postoperative recurrence rate and complications. (C) 2017 by Mutaz B. Habal, MD.

http://ift.tt/2juDU7s

A Review of "Role of Surgeons in the Changing Sociocultural, Political, and Environmental Climate" by Frilling A in Ann Surg 264: 691-695, 2016.

No abstract available

http://ift.tt/2jnENku

Xanthomatous Hypophysitis Is Associated with Ruptured Rathke’s Cleft Cyst

Abstract

Xanthomatous hypophysitis is a rare inflammatory disease of the pituitary gland that can mimic a neoplastic lesion clinically and radiologically. Its pathogenesis remains largely unknown, although recent evidence suggests that pituitary inflammation may occur as a secondary reaction to mucous content released from a ruptured cyst. In a series of 1221 pituitary specimens, we identified seven cases of xanthomatous hypophysitis. Six patients had complete radiological and biochemical workup preoperatively: a cystic-appearing pituitary mass was identified in all six patients (100%) with a mean size of 2.0 cm (range 1.4–2.5 cm) on imaging, and pituitary endocrine dysfunction was noted in five patients (83.3%). In all cases, the pituitary mass was resected through an endoscopic transsphenoidal approach. Pathological examination revealed the presence of foamy macrophages admixed with variable amounts of giant cells and chronic inflammatory cells, confirming the diagnosis of xanthomatous hypophysitis. Additionally, all cases presented with concurrent findings of ruptured Rathke's cleft cyst, with the exception of one patient who had previous surgery for a Rathke's cleft cyst, followed by recurrence and diagnosis of xanthomatous hypophysitis. While accurate distinction of hypophysitis from a pituitary neoplasm can be problematic in the preoperative setting, the identification of a cystic lesion in the sella turcica should raise the possibility of such an entity in the clinical and radiological differential diagnosis. The current series provides further evidence that xanthomatous hypophysitis predominantly occurs as a secondary reaction to a ruptured Rathke's cleft cyst; thus, it is best classified as a secondary (reactive) hypophysitis.

http://ift.tt/2juM0Nf

Thiazolidine reacts with thioreactive biomolecules

Publication date: Available online 24 January 2017
Source:Free Radical Biology and Medicine
Author(s): Deyuan Su, Yin Nian, Fenglei Zhang, Jinsheng Hu, Jianmin Cui, Ming Zhou, Jian Yang, Shu Wang
The thiazolidine ring is a biologically active chemical structure and is associated with many pharmacological activities. However, the biological molecules that can interact with the thiazolidine ring are not known. We show that thiazolidine causes sustained activation of the TRPA1 channel and chemically reacts with glutathione, and the chemical reactivity of thiazolidine ring is required for TRPA1 activation. Reducing agents reverse thiazolidine-induced TRPA1 activation, and mutagenesis studies show that nucleophilic cysteine residues in TRPA1 are critical, suggesting an activation mechanism involving thioreactive chemical reactions. In vivo studies show that thiazolidine induces acute pain and inflammation in mouse and these responses are specifically dependent on TRPA1. These results indicate that thiazolidine compounds can chemically react with biological molecules containing nucleophilic cysteines, thereby exerting biological activities.

http://ift.tt/2jnCRIA

Two- and Three-Dimensional Transesophageal Echocardiography for Two Separate Primary Cardiac Lymphomas in the Right Heart.

No abstract available

http://ift.tt/2kg4Jgf

The Potential for Advanced Neuro MRI Techniques in Pediatric Stroke Research

Publication date: Available online 24 January 2017
Source:Pediatric Neurology
Author(s): Trish Domi, Arastoo Vossough, Nicholas V. Stence, Ryan J. Felling, Jackie Leung, Pradeep Krishnan, Christopher J. Watson, P. Ellen Grant, Andrea Kassner
PurposeThis paper was written to provide clinicians and researchers with an overview of a number of advanced neuroimaging in an effort to promote increased utility, and the design of future studies using advanced neuroimaging techniques in childhood stroke.BackgroundThe current capabilities of advanced magnetic resonance imaging (MRI) techniques provide the opportunity to build on our knowledge of the consequences of stroke on the developing brain. These capabilities include providing information about the physiology, metabolism, structure, and function of the brain that are not routinely evaluated in the clinical setting.MethodsDuring the Proceedings of the Stroke Imaging Laboratory for Children (SILC) Workshop in Toronto in June 2015, a subgroup of clinicians and imaging researchers discussed how the application of advanced neuroimaging techniques could further our understanding of the mechanisms of stroke injury and repair in the pediatric population. This subgroup was established based on their interest and commitment to design collaborative, advanced neuroimaging studies in the pediatric stroke population. In working towards this goal, we first sought to describe here the MRI techniques that are currently available for use, and how they have been applied in other stroke populations (for example, adult and perinatal stroke).ConclusionsWith the continued improvement of advanced neuroimaging techniques, including shorter acquisition times, there is an opportunity to apply these techniques to their full potential in the research setting, and learn more about the effects of stroke in the developing brain.

http://ift.tt/2jbZTyR

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Τρίτη 24 Ιανουαρίου 2017

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