Head and Neck Diseases by Alexandros G.Sfakianakis: 06/22/16

Τετάρτη 22 Ιουνίου 2016

Hearing thresholds, tinnitus, and headphone listening habits in nine-year-old children

10.1080/14992027.2016.1190871<br/>Sara Båsjö

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Sudden sensorineural hearing loss with positional vertigo: Initial findings of positional nystagmus and hearing outcomes

10.1080/14992027.2016.1194532<br/>Chang-Hee Kim

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Results using the OPAL strategy in Mandarin speaking cochlear implant recipients

10.1080/14992027.2016.1190872<br/>Andrew E. Vandali

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Results using the OPAL strategy in Mandarin speaking cochlear implant recipients

TACTIC: a multicentre, open-label, single-arm phase II trial of panitumumab, cisplatin, and gemcitabine in biliary tract cancer

TACTIC: a multicentre, open-label, single-arm phase II trial of panitumumab, cisplatin, and gemcitabine in biliary tract cancer:

Abstract

Purpose

The phase II TACTIC trial prospectively selected patients with KRAS wild-type advanced biliary tract cancer for first-line treatment with panitumumab and combination chemotherapy.

Methods

Of 78 patients screened, 85 % had KRAS wild-type tumours and 48 were enrolled. Participants received cisplatin 25 mg/m2 and gemcitabine 1000 mg/m2 on day 1 and day 8 of each 21-day cycle and panitumumab 9 mg/kg on day 1 of each cycle. Treatment was continued until disease progression, unacceptable toxicity, or request to discontinue. The primary endpoint was the clinical benefit rate (CBR) at 12 weeks (complete response, partial response, or stable disease). CBR of 70 % was considered to be of clinical interest. Secondary outcomes were progression-free survival, time to treatment failure, overall survival, CA19.9 response and safety.

Results

Thirty-four patients had a clinical benefit at 12 weeks, an actuarial rate of 80 % (95 % CI 65–89 %). 46 % had a complete or partial response. Median progression-free survival was 8.0 months (95 % CI 5.1–9.9) and median overall survival 11.9 months (95 % CI 7.4–15.8). Infection accounted for 27 % of the grade 3 or 4 toxicity, with rash (13 %), fatigue (13 %), and hypomagnesemia (10 %) among the more common grade 3 or 4 non-haematological toxicities.

Conclusion

A marker-driven approach to patient selection was feasible in advanced biliary tract cancer in an Australian population. The combination of panitumumab, gemcitabine, and cisplatin in KRAS wild-type cancers was generally well tolerated and showed promising clinical efficacy. Further exploration of anti-EGFR therapy in a more selected population is warranted.

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Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials

Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials:

Abstract

Purpose

To report the final analysis of survival outcomes for children with newly diagnosed high-grade glioma (HGG) treated on the "Head Start" (HS) II and III protocols with chemotherapy and intent to avoid irradiation in children

Patients and Methods

Between 1997 and 2009, 32 eligible children were enrolled in HS II and III with anaplastic astrocytoma (AA, n = 19), glioblastoma multiforme (GBM, n = 11), or other HGG (n = 2). Central pathology review was completed on 78% of patients. Patients with predominantly brainstem tumors were excluded. Patients were to be treated with single induction chemotherapy regimen C, comprising four cycles of vincristine, carboplatin, and temozolomide. Following induction, patients underwent marrow-ablative chemotherapy and autologous hematopoietic cell rescue. Irradiation was used for patients with residual tumor after consolidation or >6 years old or at the time of tumor progression.

Results

Conclusions

Irradiation-avoiding treatment strategies should be evaluated further in young children with HGG given similar survival rates to older children receiving standard irradiation-containing therapies.

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Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials

Abstract

Purpose

Patients and Methods

Results

The 5-year event-free survival (EFS) and overall survival (OS) for all HGG patients were 25 ± 8% and 36 ± 9%, respectively. The EFS at 5 years for patients with AA and GBM were 24 ± 11% and 30 ± 16%, respectively (P = 0.65). The OS at 5 years for patients with AA and GBM was 34 ± 12% and 35 ± 16%, respectively (P = 0.83). Children <36 months old experienced improved 5-year EFS and OS of 44 ± 17% and 63 ± 17%, compared with children 36–71 months old (31 ± 13% and 38 ± 14%) and children >72 months old (0% and 13 ± 12%).

Conclusions

Irradiation-avoiding treatment strategies should be evaluated further in young children with HGG given similar survival rates to older children receiving standard irradiation-containing therapies.

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http://ift.tt/28NrzWU Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174

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Sarcoma-like tumor originating from oligodendroglioma

Sarcoma-like tumor originating from oligodendroglioma:

Abstract

We present a case of sarcoma occurring at a site of resected oligodendroglioma without preceding radiotherapy or chemotherapy. Oligosarcoma occurring at sites of resected oligodendroglioma or anaplastic oligodendroglioma with sarcomatous components are rare. Although meningioma or sarcoma-like lesions are sometimes reported after glioma-targeted radiotherapy, those without preceding radiotherapy are quite rare. Moreover, cases of sarcoma without oligodendroglial components occurring at a site of resected oligodendroglioma have never been reported. In this case, fluorescent in situ hybridization analysis revealed 1p/19q co-deletion in both the first tumor and second tumors. Additionally, immunohistochemistry revealed mutated isocitrate dehydrogenase 1 in both tumors. Taken together, these findings suggest a monoclonal tumor origin. Consequently, this case may indicate a new mechanism of development of sarcomatous lesions occurring at the site of a resected glioma.

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Sober legal advice for LAFD's new EMS program

The LAFD SOBER unit for Skid Row's frequent users is a good idea, but potential dangers to paramedics cannot be ignored

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75 paramedic students complete all-day field ops training

400 instructors, volunteers and patient actors, along with 26 ambulances and two helicopters, helped paramedic students complete 70 different scenarios

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Aphanin, a triterpenoid from Amoora rohituka inhibits K-Ras mutant activity and STAT3 in pancreatic carcinoma cells

Aphanin, a triterpenoid from Amoora rohituka inhibits K-Ras mutant activity and STAT3 in pancreatic carcinoma cells:

Abstract

Mutations of the K-Ras gene occur in over 90 % of pancreatic carcinomas, and to date, no targeted therapies exist for this genetically defined subset of cancers. STAT3 plays a critical role in KRAS-driven pancreatic tumorigenesis, suggesting its potential as a therapeutic target in this cancer. Therefore, finding novel and potential drugs to inhibit oncogenic K-Ras is a major challenge in cancer therapy. In an attempt to develop novel anti-KRAS mutant chemotherapeutics, we isolated three novel triterpenoids from Amoora rohituka stem and their chemical structures were characterized by extensive 1H-NMR, 13C-NMR, Mass, IR spectroscopic studies and chemical transformations. Aphanin (3 alpha-angeloyloxyolean-12-en-28-oic acid) is one of the isolated novel triterpenoid compounds. We found aphanin exhibited antiproliferative effects, caused G0-G1 cell cycle arrest, inhibits K-Ras G12D mutant activity by decreased STAT3, p-STAT3, Akt, p-Akt, cyclin D1 and c-Myc expressions, and induced apoptosis in pancreatic cancer HPAF-II (ΔKRAS G12D ) cells. The apoptosis proceeded through depletion of GSH with a concomitant increase in the reactive oxygen species production. The results of our study have important implications for the development of aphanin as potential novel agent for the treatment of K-Ras mutant pancreatic cancer, and STAT3-cMyc-cyclinD1 axis may serve as an important predictive biomarker for the therapeutic efficacy.

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Expression of mitochondrial genes MT-ND1, MT-ND6, MT-CYB, MT-COI, MT-ATP6, and 12S/MT-RNR1 in colorectal adenopolyps

Expression of mitochondrial genes MT-ND1, MT-ND6, MT-CYB, MT-COI, MT-ATP6, and 12S/MT-RNR1 in colorectal adenopolyps:

Abstract

Despite improvements in treatment strategies, colorectal cancer (CRC) still has high mortality rates. Most CRCs develop from adenopolyps via the adenoma-carcinoma sequence. A mechanism for inhibition of this sequence in individuals with a high risk of developing CRC is urgently needed. Differential studies of mitochondrial (mt) gene expressions in the progressive stages of CRC with villous architecture are warranted to reveal early risk assessments and new targets for chemoprevention of the disease. In the present study, reverse transcription-quantitative PCR (RT-qPCR) was used to determine the relative amount of the transcripts of six mt genes [MT-RNR1, MT-ND1, MT-COI, MT-ATP6, MT-ND6, and MT-CYB (region 648–15887)] which are involved in the normal metabolism of mitochondria. A total of 42 pairs of tissue samples obtained from colorectal adenopolyps, adenocarcinomas, and their corresponding adjacent normal tissues were examined. Additionally, electron transport chain (ETC), complexes I (NADH: ubiquinone oxidoreductase) and III (CoQH2-cytochrome C reductase), and carbonyl protein group contents were analyzed. Results indicate that there were differential expressions of the six mt genes and elevated carbonyl protein contents among the colorectal adenopolyps compared to their paired adjacent normal tissues (p

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Secretome of tumor-associated leukocytes augment epithelial-mesenchymal transition in positive lymph node breast cancer patients via activation of EGFR/Tyr845 and NF-κB/p65 signaling pathway

Secretome of tumor-associated leukocytes augment epithelial-mesenchymal transition in positive lymph node breast cancer patients via activation of EGFR/Tyr845 and NF-κB/p65 signaling pathway:

Abstract

Epithelial-mesenchymal transition (EMT) is an essential process in breast cancer metastasis. The aim of the present study was to determine the role of secretions of tumor-associated leukocytes (TALs) isolated from negative and positive lymph nodes (nLNs and pLNs, respectively) breast cancer patients in regulating EMT mechanism and the associated signaling pathways. We found an increased infiltration of TALs, which was associated with downregulation of E-cadherin and over-expression of vimentin in the breast carcinoma tissues of pLNs as compared to nLNs patients and normal breast tissues obtained from healthy volunteers during mammoplasty. Furthermore, TALs isolated from pLNs breast cancer patients secreted an elevated panel of cytokines by up to 2–5-fold when compared with those isolated from nLNs patients. Secretome of TALs of pLNs possessed higher TARC, IGF-1, IL-3, TNF-β, IL-5, G-CSF, IL-4, and IL-1α with more than a fivefold compared to those of nLNs. Using the human breast cancer cell lines MCF-7 and MDA-MB-231, we found that cytokines secreted by TALs isolated from nLNs and pLNs breast cancer patients promoted EMT via upregulation of TGF-β and vimentin and downregulation of E-cadherin at messenger RNA (mRNA) levels in both cell lines and at protein level in MCF-7. While TGF-β is over-expressed by MDA-MB-231 seeded in media conditioned by secretome of TALs isolated from nLNs and pLNs breast cancer patients. The downstream TGF-β signaling transcription factors, Snail, Slug, and Twist, known to be associated with EMT mechanism were over-expressed by MCF-7 and MDA-MB-231 seeded in media conditioned by secretome of TALs isolated from nLNs and pLNs breast cancer patients. Acquisition of EMT in MCF-7 cells is mechanistically attributed to the activation of EGFR(Tyr845) and NF-κB/p65(Ser276) signaling which are significantly highly expressed by MCF-7 cells seeded in media conditioned by secretome of TALs isolated from pLNs compared to nLNs patients. Overall, this study provides implications of secretome of TALs and activated EGFR(Tyr845) and NF-κB/p65(Ser276) in EMT process that may be considered a therapeutic strategy to inhibit lymph node metastasis in breast cancer patients.

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Predictors of health-related quality of life over time among pediatric hematopoietic stem cell transplant recipients

Predictors of health-related quality of life over time among pediatric hematopoietic stem cell transplant recipients:

Abstract

Background

Advances in hematopoietic stem cell transplantation (HSCT) have contributed to increased survival for pediatric patients. However, there are inconsistent findings regarding the impact of HSCT on health-related quality of life (HRQOL) outcomes for children. This study aimed to establish trajectories of HRQOL following HSCT and identify predictors of the HRQOL course.

Procedure

Ninety caregivers of a child who received HSCT (mean age = 6.42 years) for various oncologic, immunologic, and metabolic conditions completed questionnaires regarding family psychosocial functioning and child HRQOL at the time of discharge from HSCT and follow-up HRQOL at four additional time points.

Results

There was a significant change in overall HRQOL in 3 months postdischarge, with the greatest improvement in physical functioning. Caregiver stress and social support, and child psychosocial problems predicted changes in HRQOL over time.

Conclusions

These results point to potentially modifiable factors that are related to the course of HRQOL following HSCT, and interventions aimed at these factors should be implemented.

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Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials

Outcome of young children with high-grade glioma treated with irradiation-avoiding intensive chemotherapy regimens: Final report of the Head Start II and III trials:

Abstract

Purpose

Patients and Methods

Results

Conclusions

Irradiation-avoiding treatment strategies should be evaluated further in young children with HGG given similar survival rates to older children receiving standard irradiation-containing therapies.

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Expression of mitochondrial genes MT-ND1, MT-ND6, MT-CYB, MT-COI, MT-ATP6, and 12S/MT-RNR1 in colorectal adenopolyps

Abstract

Despite improvements in treatment strategies, colorectal cancer (CRC) still has high mortality rates. Most CRCs develop from adenopolyps via the adenoma-carcinoma sequence. A mechanism for inhibition of this sequence in individuals with a high risk of developing CRC is urgently needed. Differential studies of mitochondrial (mt) gene expressions in the progressive stages of CRC with villous architecture are warranted to reveal early risk assessments and new targets for chemoprevention of the disease. In the present study, reverse transcription-quantitative PCR (RT-qPCR) was used to determine the relative amount of the transcripts of six mt genes [MT-RNR1, MT-ND1, MT-COI, MT-ATP6, MT-ND6, and MT-CYB (region 648–15887)] which are involved in the normal metabolism of mitochondria. A total of 42 pairs of tissue samples obtained from colorectal adenopolyps, adenocarcinomas, and their corresponding adjacent normal tissues were examined. Additionally, electron transport chain (ETC), complexes I (NADH: ubiquinone oxidoreductase) and III (CoQH2-cytochrome C reductase), and carbonyl protein group contents were analyzed. Results indicate that there were differential expressions of the six mt genes and elevated carbonyl protein contents among the colorectal adenopolyps compared to their paired adjacent normal tissues (p < 0.05). The levels of complexes I and III were higher in tumor tissues relative to adjacent normal tissues. Noticeably, the expression of MT-COI was overexpressed in late colorectal carcinomas among all studied transcripts. Our data suggest that increased expressions in certain mt genes and elevated levels of ROS may potentially play a critical role in the colorectal tumors evolving from adenopolyps to malignant lesions.

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Aphanin, a triterpenoid from Amoora rohituka inhibits K-Ras mutant activity and STAT3 in pancreatic carcinoma cells

Abstract

Mutations of the K-Ras gene occur in over 90 % of pancreatic carcinomas, and to date, no targeted therapies exist for this genetically defined subset of cancers. STAT3 plays a critical role in KRAS-driven pancreatic tumorigenesis, suggesting its potential as a therapeutic target in this cancer. Therefore, finding novel and potential drugs to inhibit oncogenic K-Ras is a major challenge in cancer therapy. In an attempt to develop novel anti-KRAS mutant chemotherapeutics, we isolated three novel triterpenoids from Amoora rohituka stem and their chemical structures were characterized by extensive ¹H-NMR, ¹³C-NMR, Mass, IR spectroscopic studies and chemical transformations. Aphanin (3 alpha-angeloyloxyolean-12-en-28-oic acid) is one of the isolated novel triterpenoid compounds. We found aphanin exhibited antiproliferative effects, caused G₀-G₁ cell cycle arrest, inhibits K-Ras G12D mutant activity by decreased STAT3, p-STAT3, Akt, p-Akt, cyclin D1 and c-Myc expressions, and induced apoptosis in pancreatic cancer HPAF-II (ΔKRAS ^G12D ) cells. The apoptosis proceeded through depletion of GSH with a concomitant increase in the reactive oxygen species production. The results of our study have important implications for the development of aphanin as potential novel agent for the treatment of K-Ras mutant pancreatic cancer, and STAT3-cMyc-cyclinD1 axis may serve as an important predictive biomarker for the therapeutic efficacy.

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Secretome of tumor-associated leukocytes augment epithelial-mesenchymal transition in positive lymph node breast cancer patients via activation of EGFR/Tyr845 and NF-κB/p65 signaling pathway

Abstract

Epithelial-mesenchymal transition (EMT) is an essential process in breast cancer metastasis. The aim of the present study was to determine the role of secretions of tumor-associated leukocytes (TALs) isolated from negative and positive lymph nodes (nLNs and pLNs, respectively) breast cancer patients in regulating EMT mechanism and the associated signaling pathways. We found an increased infiltration of TALs, which was associated with downregulation of E-cadherin and over-expression of vimentin in the breast carcinoma tissues of pLNs as compared to nLNs patients and normal breast tissues obtained from healthy volunteers during mammoplasty. Furthermore, TALs isolated from pLNs breast cancer patients secreted an elevated panel of cytokines by up to 2–5-fold when compared with those isolated from nLNs patients. Secretome of TALs of pLNs possessed higher TARC, IGF-1, IL-3, TNF-β, IL-5, G-CSF, IL-4, and IL-1α with more than a fivefold compared to those of nLNs. Using the human breast cancer cell lines MCF-7 and MDA-MB-231, we found that cytokines secreted by TALs isolated from nLNs and pLNs breast cancer patients promoted EMT via upregulation of TGF-β and vimentin and downregulation of E-cadherin at messenger RNA (mRNA) levels in both cell lines and at protein level in MCF-7. While TGF-β is over-expressed by MDA-MB-231 seeded in media conditioned by secretome of TALs isolated from nLNs and pLNs breast cancer patients. The downstream TGF-β signaling transcription factors, Snail, Slug, and Twist, known to be associated with EMT mechanism were over-expressed by MCF-7 and MDA-MB-231 seeded in media conditioned by secretome of TALs isolated from nLNs and pLNs breast cancer patients. Acquisition of EMT in MCF-7 cells is mechanistically attributed to the activation of EGFR^(Tyr845) and NF-κB/p65^(Ser276) signaling which are significantly highly expressed by MCF-7 cells seeded in media conditioned by secretome of TALs isolated from pLNs compared to nLNs patients. Overall, this study provides implications of secretome of TALs and activated EGFR^(Tyr845) and NF-κB/p65^(Ser276) in EMT process that may be considered a therapeutic strategy to inhibit lymph node metastasis in breast cancer patients.

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Optimal contrast enhancement liquid for dynamic MRI of swallowing.

Optimal contrast enhancement liquid for dynamic MRI of swallowing.

J Oral Rehabil. 2016 Jun 21;

Authors: Ohkubo M, Higaki T, Nishikawa K, Otonari-Yamamoto M, Sugiyama T, Ishida R, Wakoh M

Abstract
Several dynamic magnetic resonance imaging (MRI) techniques to observe swallowing and their parameters have been reported. Although these studies used several contrast enhancement liquids, no studies were conducted to investigate the most suitable liquids. The purpose of this study was to identify the optimal contrast enhancement liquid for dynamic MRI of swallowing. MRI was performed using a new sequence consisting of true fast imaging with steady-state precession, generalised auto-calibrating partially parallel acquisition and a keyhole imaging technique. Seven liquids were studied, including pure distilled water, distilled water with thickener at 10, 20 and 30 mg mL(-1) concentrations and oral MRI contrast medium at 1, 2 or 3 mg mL(-1) . Distilled water showed the highest signal intensity. There were statistically significant differences among the following contrast media: distilled water with thickener at 20 mg mL(-1) and the oral MRI contrast medium at 2 mg mL(-1) and 1 mg mL(-1) . It can be concluded that the optimal liquid for dynamic MRI of swallowing is a water-based substance that allows variations in viscosity.

PMID: 27328011 [PubMed - as supplied by publisher]

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Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015).

Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015).

J Vet Intern Med. 2016 Jun 21;

Authors: Johnstone LK, Engiles JB, Aceto H, Buechner-Maxwell V, Divers T, Gardner R, Levine R, Scherrer N, Tewari D, Tomlinson J, Johnson AL

Abstract
BACKGROUND: Equine neuroborreliosis (NB), Lyme disease, is difficult to diagnose and has limited description in the literature.
OBJECTIVE: Provide a detailed description of clinical signs, diagnostic, and pathologic findings of horses with NB.
ANIMALS: Sixteen horses with histologically confirmed NB.
METHODS: Retrospective review of medical records at the University of Pennsylvania and via an ACVIM listserv query with inclusion criteria requiring possible exposure to Borrelia burgdorferi and histologic findings consistent with previous reports of NB without evidence of other disease.
RESULTS: Sixteen horses were identified, 12 of which had additional evidence of NB. Clinical signs were variable including muscle atrophy or weight loss (12), cranial nerve deficits (11), ataxia (10), changes in behavior (9), dysphagia (7), fasciculations (6), neck stiffness (6), episodic respiratory distress (5), uveitis (5), fever (2), joint effusion (2), and cardiac arrhythmias (1). Serologic analysis was positive for B. burgdorferi infection in 6/13 cases tested. CSF abnormalities were present in 8/13 cases tested, including xanthochromia (4/13), increased total protein (5/13; median: 91 mg/dL, range: 25-219 mg/dL), and a neutrophilic (6/13) or lymphocytic (2/13) pleocytosis (median: 25 nucleated cells/μL, range: 0-922 nucleated cells/μL). PCR on CSF for B. burgdorferi was negative in the 7 cases that were tested.
CONCLUSION AND CLINICAL IMPORTANCE: Diagnosis of equine NB is challenging due to variable clinical presentation and lack of sensitive and specific diagnostic tests. Negative serology and normal CSF analysis do not exclude the diagnosis of NB.

PMID: 27327172 [PubMed - as supplied by publisher]

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[Aberrant parapharyngeal internal carotid artery: a case series].

[Aberrant parapharyngeal internal carotid artery: a case series].

Kulak Burun Bogaz Ihtis Derg. 2015;25(6):361-6

Authors: Jafarov S, İnan S, Aydın E

Abstract
In this article, we report eight elderly cases who were diagnosed with aberrant internal carotid artery at the Department of Otorhinolaryngology and Head and Neck Surgery of Başkent University Ankara Hospital. Three cases had dysphagia, two cases had foreign body sensation in the throat, one case had increased tinnitus, and one case had complaints of aspiration which was not previously reported in the literature and chocking sensation. One patient was asymptomatic. Five cases had kink form of aberrant parapharyngeal internal carotid artery, one case had tortuosity and one case had both tortuosity and kink form. In one case, internal carotid artery was in form of 90 degrees angle in the right side and S-shaped in the left side, which was not described in the classification.

PMID: 26572182 [PubMed - indexed for MEDLINE]

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Non-asthmatic Eosinophilic Bronchitis and Idiopathic Eosinophilic Esophagitis.

Non-asthmatic Eosinophilic Bronchitis and Idiopathic Eosinophilic Esophagitis.

J Investig Allergol Clin Immunol. 2016 Jun;26(3):190-191

Authors: Gómez Torrijos E, Mur Gimeno P, Martín Iglesias A, García Rodriguez R, Galindo Bonilla P, El Kaddioui S, Mendez Díaz YC, Quirce Gancedo S

PMID: 27326988 [PubMed - as supplied by publisher]

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Aberrant right subclavian artery in fetuses with Down syndrome: a systematic review and meta-analysis.

http:--media.wiley.com-assets-7315-18-Wi

http:--media.wiley.com-assets-7315-19-Wi

Aberrant right subclavian artery in fetuses with Down syndrome: a systematic review and meta-analysis.

Ultrasound Obstet Gynecol. 2015 Sep;46(3):266-76

Authors: Scala C, Leone Roberti Maggiore U, Candiani M, Venturini PL, Ferrero S, Greco T, Cavoretto P

Abstract
OBJECTIVES: The primary objective was to estimate the prevalence of aberrant right subclavian artery (ARSA) in fetuses with Down syndrome. Secondary objectives were to assess the prevalence of ARSA in euploid fetuses, the feasibility of ultrasound evaluation of the right subclavian artery (RSA) in the first and second trimesters of pregnancy, the performance of ARSA in screening for trisomy 21 and its association with other abnormalities.
METHODS: Web-based databases (PubMed, EMBASE and MEDLINE) were searched up to July 2014. The STROBE, PRISMA and QUIPS instruments were used to assess all included studies and for reporting of methodology, results and conclusions. Original studies that reported prenatal ultrasound evaluation of ARSA, assessment of its prevalence in Down-syndrome and euploid fetuses, feasibility of ultrasound evaluation of the RSA in the first and second trimesters of pregnancy and correlation of ARSA with other abnormalities were included, excluding duplications and case reports. Collected data were summarized to estimate prevalence and feasibility. A meta-analysis was performed pooling the study-specific positive and negative likelihood ratios (LR+ and LR-), detection rates and false-positive rates for trisomy 21.
RESULTS: Prevalence of ARSA in Down-syndrome fetuses was 23.6% (95% CI, 19.4-27.9%), whereas in euploid fetuses it was 1.02% (95% CI, 0.86-1.10%). Ultrasound evaluation of the RSA course and origin in the first and second trimesters of pregnancy was feasible in 85% and 98% of cases (first and second trimester, respectively) and it was directly related to sonographic experience and fetal crown-rump length and inversely related to maternal body mass index. In more than 20% of fetuses with ARSA there was an association with other abnormalities but ARSA seemed to be an independent marker of trisomy 21. The meta-analysis showed that ARSA is a significant risk factor for Down syndrome (pooled LR+ = 26.93, 95% CI, 19.36-37.47, P for effect < 0.001, P for Q = 0.3, I(2) = 17.3%), whereas normal RSA is a significant protective marker (pooled LR- = 0.71, 95% CI, 0.51-0.99, P for effect = 0.043, P for Q = 0.9, I(2) = 0%).
CONCLUSIONS: ARSA appears to be a clinically useful prenatal ultrasound marker of Down syndrome. Additional testing when ARSA is diagnosed should involve evaluation of all risk factors by applying a mathematical model. There is insufficient evidence to recommend fetal karyotyping in cases with isolated ARSA. If the background risk is higher or additional markers are present, full fetal karyotyping is advisable, including analysis for 22q11 microdeletion.

PMID: 25586729 [PubMed - indexed for MEDLINE]

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Reasons of Dysphagia After Operation of Anterior Cervical Decompression and Fusion.

Reasons of Dysphagia After Operation of Anterior Cervical Decompression and Fusion.

Clin Spine Surg. 2016 Jun 20;

Authors: Wu B, Song F, Zhu S

Abstract
STUDY DESIGN: Retrospective study.
OBJECTIVE: To analyze the reasons, clinical manifestation, risk factors, prevention and treatment of dysphagia after operation of anterior cervical decompression and fusion.
SUMMARYOF BACKGROUND DATA: Dysphagia is one of severe complications after anterior cervical decompression and fusion. There were a few studies about reasons and prevention of dysphagia.
METHODS: We retrospectively reviewed medical charts of patients underwent anterior cervical decompression and fusion in our hospital from January 2012 to December 2012. Clinical symptom of dysphagia was recorded at the perioperative period, third and sixth month of the follow-up after surgery and assign according to the Bazaz dysphagia score. We analyzed the reasons and risk factors leading to dysphagia and tried to find effective programs of prevention and treatment.
RESULTS: There were 358 patients underwent anterior cervical decompression and fusion. Of 358 patients, 39 patients including 14 males and 25 females complained dysphagia. The mean aged was 46.8 years with the age from 38 to 67 years old. Clinical manifestation of dysphagia included difficulty to swallow, swallowing pain, sticky throat feeling and choking. All the patients were followed up over six months. The incidences of dysphagia were 10.9%, 6.4%, 2.7% respectively at 1-5 days, three months and six months after surgery. There was no severe dysphagia at three months after surgery. Mild or moderate dysphagia slightly affected the quality of life. Logistic regression showed multilevel cervical spine and high-level cervical spine surgeries are high risk factors for postoperative dysphagia.
CONCLUSIONS: Dysphagia is common complication of anterior cervical decompression and fusion. Causes of leading to dysphagia are multilevel cervical spine and upper cervical spine surgeries. Using methylprednisolone and careful operating can reduce the incidence and receive a good prognosis.

PMID: 27326961 [PubMed - as supplied by publisher]

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Aberrant right subclavian artery in fetuses with Down syndrome: a systematic review and meta-analysis.

Aberrant right subclavian artery in fetuses with Down syndrome: a systematic review and meta-analysis.

Ultrasound Obstet Gynecol. 2015 Sep;46(3):266-76

Authors: Scala C, Leone Roberti Maggiore U, Candiani M, Venturini PL, Ferrero S, Greco T, Cavoretto P

PMID: 25586729 [PubMed - indexed for MEDLINE]

Could acupuncture be an adequate alternative to dexamethasone in pediatric tonsillectomy?

Summary

Background

Usage of nonpharmacological treatment contributes to an overall patient well-being, assisting in physical and emotional healing. Acupuncture has been reported to be useful in reducing early postoperative vomiting and attenuating postoperative pain.

Aim

The aim of this study was to compare the effect of dexamethasone vs acupuncture at P6 bilaterally and CV13 on the incidence and severity of POV in children undergoing tonsillectomy with or without adenoidectomy.

Method

One hundred and twenty children, ASA I–III aged 2–8 years undergoing elective tonsillectomy were included in this prospective randomized double-blind study. Children were randomly divided into two equal groups (60 each). At induction of anesthesia, the dexamethasone group received 0.15 mg·kg⁻¹ dexamethasone IV plus sham acupuncture, and the acupuncture group received acupuncture at P6 bilaterally and CV13 plus 2 ml of normal saline IV. Vomiting was recorded at 0–6, 6–24, and 0–24 h postoperatively.

Results

There was no difference in the incidence of vomiting between the acupuncture and dexamethasone groups. The mean difference in time to first oral intake (95% CI) was 4.3 (0.5–8.6) min between dexamethasone group and acupuncture group; P = 0.426. The mean difference in time until first vomit (95% CI) was 12 (9.5–13.8) min between both groups. No significant differences between Kaplan–Meier curves for time until first vomit (log-rank test) were obtained (P < 0.697).

Conclusion

Acupuncture at P6 bilaterally and CV13 provided similar antiemetic effect to dexamethasone in children undergoing tonsillectomy.

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Could acupuncture be an adequate alternative to dexamethasone in pediatric tonsillectomy?

Summary

Background

Aim

Method

Results

Conclusion

Acupuncture at P6 bilaterally and CV13 provided similar antiemetic effect to dexamethasone in children undergoing tonsillectomy.

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Ablation of ventricular arrhythmia originating at the papillary muscle using an automatic pacemapping module.

Ablation of ventricular arrhythmia originating at the papillary muscle using an automatic pacemapping module.

Heart Rhythm. 2016 Jul;13(7):1431-40

Authors: Chang YT, Lin YJ, Chung FP, Lo LW, Hu YF, Chang SL, Chao TF, Liao JN, Tuan TC, Lin CY, Wang HY, Jhuo SJ, Lin CH, Suresh A, Walia R, Te AL, Yamada S, Chen SA

Abstract
BACKGROUND: Ventricular arrhythmia originating from the papillary muscle (VA-PM) is characterized by multiple exits and morphologic alternations. The conventional ablation strategy relies on activation mapping, but the results might be suboptimal.
OBJECTIVE: The purpose of this study was to propose a novel pacemapping strategy aimed at multiple exits using high-output software as a complementary approach to the conventional strategy.
METHODS: A consecutive 13 patients with VA-PM were enrolled in this study. Novel pacemapping based on an automatic matching algorithm and integrated electroanatomic mapping was used to quantify the morphology variation in these patients and to identify the potential exits of VA-PM. Complementary ablation targeting at the best matching site of each morphology was performed.
RESULTS: Twelve of 13 patients (92%) experienced morphologic alternation, and a total of 34 morphologies were detected (2.6 ± 1.0 per patient). A total of 23 (68%) morphologies were detected as spontaneous pleomorphic ventricular premature complexes (VPCs) before procedure, and 4 morphologies (12%) were induced under isoproterenol infusion. Another 7 of 34 morphologies (21%) could be found only after radiofrequency ablation attempts. Exits with a high pacemapping correlation index for corresponding morphology would be mapped, so preferential exits could be identified. Mean interexit distance was 15.1 ± 5.9 mm. Acute success rate was 100%. During mean follow-up of 12.2 ± 6.9 months, only 1 case recurred with ventricular tachycardia. Although 3 cases recurred with different VPC morphologies, the VPC burden decreased from 16.3% ± 8.8% to 2.6% ± 1.7%.
CONCLUSION: This novel pacemapping strategy could effectively eliminate multiple exits as a complementary approach to the conventional strategy.

PMID: 27324561 [PubMed - in process]

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Contrast enhanced ultrasonography used for post-treatment responses evaluation of radiofrequency ablations for hepatocellular carcinoma: a meta-analysis.

Contrast enhanced ultrasonography used for post-treatment responses evaluation of radiofrequency ablations for hepatocellular carcinoma: a meta-analysis.

Br J Radiol. 2016 Jun 21;:20150973

Authors: Shi W, He Y, Ding W, Gong S, Wang Y, Xiao J, He B

Abstract
OBJECTIVES: This meta-analysis aims to analyze the usefulness of contrast enhanced ultrasonography (CEUS) for post-treatment responses evaluation of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) management.
METHODS: Literature retrieval in three databases PubMed, Embase and Cochrane Library, was conducted up to September 2015, with predefined criteria. The technical success rate, local tumor recurrence, local tumor progression were the measurement indexes. Cochran's Q test and I(2) were used for heterogeneity detection. Subgroup analyses were performed for complete ablation rate stratified by study designs, contrast agents and postoperative testing time points. Statistical analyses were conducted using Stata 12.0 software.
RESULTS: Twelve studies consisting of 772 patients were enrolled in this study. The CEUS evaluated success rate of RFA for HCCs was 91%. The proportion of ablative margin < 5 mm was 53%. The local tumor recurrence rate and local tumor progression rate were 4% and 8%, respectively. Subgroup analysis indicated that the CEUS assessed technical success rate with Sonazoid as contrast agent was higher (95%) than those with other agents (SH U 508A 86%; SonoVue 87%). The success rate assessed within 24 h (94%) after treatment was higher than longer time (1-3 days 86%; 1 month 91%).
CONCLUSION: The meta-analysis showed that the CEUS evaluated success rate of RFA for HCCs was 91%. The local tumor recurrence rate and local tumor progression rate were 4% and 8%, respectively.
ADVANCES IN KNOWLEDGE: Using meta-analysis, the study provided more reliable assessment of usefulness of CEUS, which could provide guidelines for HCC treatment.

PMID: 27327401 [PubMed - as supplied by publisher]

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Osteoid osteoma mimicking monoarticular juvenile idiopathic arthritis in a girl.

Osteoid osteoma mimicking monoarticular juvenile idiopathic arthritis in a girl.

Pediatr Int. 2016 Jun 21;

Authors: Massei F, Laccetta G, Barrani M, Fabbri L, Zampa V, Paolicchi A, Cioni R, Ciancia EM, Scaglione M, Consolini R

Abstract
Osteoid osteoma (OO) is a benign osteogenic neoplasm, usually affecting children and young adults, that is typically characterized by nocturnal pain and response to non-steroidal anti-inflammatory drugs. OO is frequently misdiagnosed because it mimics juvenile idiopathic arthritis (JIA), bone infection or malignancy. Herein we report the case of a girl who presented with chronic monoarthritis of the knee mimicking JIA. After 1 year, OO of the femoral distal metaphysis was diagnosed. OO was treated with computed tomography-guided radiofrequency ablation with disappearance of the symptoms and resolution of the neoplasm. No recurrences have been observed 3 years after the treatment. This case highlights that intra-articular or juxta-articular OO should be suspected in the case of misleading symptoms and signs, such as swelling, lack of typical pain and synovial thickening on ultrasound; needle biopsy of the lesion is necessary in the case of confusing imaging.

PMID: 27325304 [PubMed - as supplied by publisher]

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Malignant biliary obstruction: From palliation to treatment.

Malignant biliary obstruction: From palliation to treatment.

World J Gastrointest Oncol. 2016 Jun 15;8(6):498-508

Authors: Boulay BR, Birg A

Abstract
Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

PMID: 27326319 [PubMed]

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Contemporary Issues Surrounding Small Renal Masses: Evaluation, Diagnostic Biopsy, Nephron Sparing, and Novel Treatment Modalities.

Contemporary Issues Surrounding Small Renal Masses: Evaluation, Diagnostic Biopsy, Nephron Sparing, and Novel Treatment Modalities.

Oncology (Williston Park). 2016 Jun;30(6)

Authors: Leone AR, Diorio GJ, Spiess PE, Gilbert SM

Abstract
Incidental identification of small renal masses (SRMs) has become increasingly common with widespread adoption of cross-sectional imaging. To date, early detection of SRMs has not translated to a substantial improvement in cancer-specific survival. Guidelines on the management of SRMs are evolving to reflect recent developments in treatment. The major approaches to managing SRMs include active surveillance, partial/radical nephrectomy, and ablative therapies, such as radiofrequency ablation with cryoablation. The goal of treatment is to optimize oncologic and renal function outcomes while avoiding overtreatment and associated morbidity. In this review, we summarize the diagnosis of SRMs, the role of renal mass biopsy, different treatment strategies, and future directions, including emerging molecular biomarkers.

PMID: 27323710 [PubMed - in process]

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Is Stereotactic Body Radiotherapy Better Than Radiofrequency Ablation for the Treatment of Hepatocellular Carcinoma?

Is Stereotactic Body Radiotherapy Better Than Radiofrequency Ablation for the Treatment of Hepatocellular Carcinoma?

J Clin Oncol. 2016 Jun 20;

Authors: Yang JF, Lo CH, Huang WY

PMID: 27325860 [PubMed - as supplied by publisher]

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Influence of Clinical Parameters and Anticoagulation on Intraprocedural Cerebral Microembolic Signals during Pulmonary Vein Isolation.

Influence of Clinical Parameters and Anticoagulation on Intraprocedural Cerebral Microembolic Signals during Pulmonary Vein Isolation.

PLoS One. 2016;11(6):e0157886

Authors: Larbig R, Dittrich R, Kochhaeuser S, Leitz P, Guener F, Korsukewitz C, Dechering D, Pott C, Wasmer K, Schmitges J, Kerckhoff M, Eckardt L, Moennig G

Abstract
OBJECTIVE: We had the objective to determine the impact of clinical parameters and anticoagulation status on cerebral microembolic signals (MES) during pulmonary vein isolation (PVI) for atrial fibrillation (AF).
BACKGROUND: Thromboembolism and stroke are the most feared complications of PVI. MES can help to evaluate embolic burden. It is unknown whether clinical parameters have an impact on embolic risk during PVI.
METHODS: In this retrospective analysis we investigated the impact of clinical parameters, including the CHADS2- and CHA2DS2-VASc-score, pulmonary vein variants and echocardiographic parameters on MES rates in patients that underwent PVI using three different ablation approaches (radiofrequency ablation (iRF), pulmonary vein ablation catheter (PVAC) with deactivated electrode pair 1 or 5 (PVAC-red) or PVAC without deactivation (PVAC-all).
RESULTS: 118 AF patients (61±12 years) were included between 2011 and 2013 (Median: 489 MES during PVI). Patients were more likely to have more MES (within 4th quartile) with the PVAC-all approach (60.7% vs. 25.0% (iRF) vs. 14.3% (PVAC-red) respectively (p<0.001). Patients with oral anticoagulation (OAC) pre-ablation were more likely to have lower MES-counts (1st-3rd quartile); (65.6% vs. 35.7%; p = 0.005). Additionally, patients with lower MES counts (1st-3rd quartile) had significantly higher INR values than those in the 4th quartile (1.78 vs. 1.09; p = 0.029). 2 patients developed a potentially thromboembolic event during the procedure.
CONCLUSION: Clinical predictors of cerebral emboli and stroke do not correlate with cerebral embolic burden during PVI. Pre-ablation OAC and increased INR values correlate with decreased MES-rates. Therefore, it might be beneficial to perform PVI with pre-ablation anticoagulation even in low risk patients.

PMID: 27327662 [PubMed - as supplied by publisher]

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Characterization, Mapping and Ablation of Complex Atrial Tachycardia: Initial Experience with a Novel Method of Ultra High-Density 3D Mapping.

Characterization, Mapping and Ablation of Complex Atrial Tachycardia: Initial Experience with a Novel Method of Ultra High-Density 3D Mapping.

J Cardiovasc Electrophysiol. 2016 Jun 21;

Authors: Schaeffer B, Hoffmann BA, Meyer C, Akbulak RÖ, Moser J, Jularic M, Eickholt C, Nührich JM, Kuklik P, Willems S

Abstract
INTRODUCTION: Conventional mapping of complex atrial tachycardias (AT) can be challenging. Thus, we evaluated feasibility and utility of a novel, ultra high-density 3D mapping approach to characterize and map AT in these cases.
METHODS AND RESULTS: Overall, 21 patients (67.4±7.6 years; male: 52.4%, 1.9±1.4 previous ablation procedures) with documented AT referred to our center underwent catheter ablation including ultra high-density mapping using a novel 64-electrode mini-basket catheter and an adjunctive 3D mapping system. A total of 24 AT (20 left atrial, 4 right atrial AT) were analyzed in 19 cases. In 2 patients map acquisition failed due to scarce local electrograms and unstable AT cycle length, respectively. Underlying mechanisms were focal (n = 3), as well as local (n = 8) and macro (n = 13) reentry tachycardias with a mean cycle length of 311.8±67.7 ms. The analysis of propagation waves, activation and voltage revealed complex activation patterns and allowed for the identification of critical sites of AT initiation or maintenance without the need for further mapping techniques. In all cases critical sites could be verified by successful consecutive ablation. Mean mapping time was 19.4±7.6 min., mean number of mapping points was 19,217±10,270. Radiofrequency application until first effect was 165.1±374.2 sec.; total procedure time was 157.6±51.4 min., fluoroscopy time 21.7±13.8 min. and total radiofrequency duration 1016±951.9 sec, respectively. No severe complications occurred.
CONCLUSION: Ultra high-density mapping of complex AT is safe and feasible. Further, it enables detailed insight into AT mechanisms. Critical AT sites can be identified precisely in order to guide successful catheter ablation. This article is protected by copyright. All rights reserved.

PMID: 27325527 [PubMed - as supplied by publisher]

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Successful re-ablation of a permanent junctional reciprocating tachycardia with cryoenergy : Case report of a 19-year-old patient.

Successful re-ablation of a permanent junctional reciprocating tachycardia with cryoenergy : Case report of a 19-year-old patient.

Wien Med Wochenschr. 2016 Jun 20;

Authors: Bellmann B, Roser M, Muntean BG

Abstract
We report the case of a 19-year-old male patient who presented with a permanent junctional reciprocating tachycardia (PJRT). After a primarily successful radiofrequency ablation of a para-Hisian, midseptal, accessory pathway, recurrence of tachycardia was documented. Thereafter, successful ablation using cryoenergy was performed. Since this second ablation the patient has been free of tachycardia. Our case study shows that the treatment of PJRT in young adults using cryoenergy can be successfully and safely conducted, especially after tachycardia recurrence following an initial radiofrequency ablation.

PMID: 27324511 [PubMed - as supplied by publisher]

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Overview and History of Trigeminal Neuralgia.

Overview and History of Trigeminal Neuralgia.

Neurosurg Clin N Am. 2016 Jul;27(3):265-76

Authors: Patel SK, Liu JK

Abstract
Although the symptoms associated with trigeminal neuralgia have been well documented, the root cause of this disease initially eluded most surgeons. Although early remedies were haphazard because of a lack of understanding about the condition, near the 20th century both medical and procedural therapies were established for the treatment of trigeminal neuralgia. These treatments include a variety of medications, chemoneurolysis, radiofrequency lesioning, percutaneous ablative procedures, stereotactic radiosurgery, and open rhizotomy and microvascular decompression. This report recounts the history of trigeminal neuralgia, from its earliest descriptions to the historical evolution of nonsurgical and surgical therapies.

PMID: 27324994 [PubMed - in process]

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The discovery of vemurafenib for the treatment of BRAF-mutated metastatic melanoma.

The discovery of vemurafenib for the treatment of BRAF-mutated metastatic melanoma.:

The discovery of vemurafenib for the treatment of BRAF-mutated metastatic melanoma.

Expert Opin Drug Discov. 2016 Jun 21;

Authors: Kim A, Cohen MS

Abstract
INTRODUCTION: In the era of precision medicine and sophisticated modern genetics, the discovery of the BRAF(V600) inhibitor, vemurafenib, quickly became the model for targeted therapy in melanomas. As early as 2002, the majority of metastatic melanomas were described to harbor the BRAF(V600) mutation, setting the stage for an explosion of interest for targeting this protein as a novel therapeutic strategy. The highly selective BRAF(V600) inhibitor, vemurafenib, was identified initially through a large-scale drug screen.
AREAS COVERED: Here we examine vemurafenib's journey from discovery to clinical use in metastatic melanoma. Topics covered include preclinical data, single agent Phase 1,2 and 3 clinical trials, resistance issues and mechanisms, adverse effects including the development of squamous cell cancers, and combination trials.
EXPERT OPINION: Due to its tolerance, low toxicity profile, rapid tumor response, and improved outcomes in melanoma patients with BRAF(V600) mutations, vemurafenib was advanced rapidly through clinical trials to receive FDA approval in 2011. While its efficacy is well documented, durability has become an issue for most patients who experience therapeutic resistance in approximately 6-8 months. In addition, a concerning toxicity observed in patients taking the drug include development of localized cutaneous squamous cell carcinomas (SCCs). It is hypothesized that drug resistance and SCC development result from a similar paradoxical activation of protein signaling pathways, specifically MAPK. Identification of these mechanisms has led to additional treatment strategies involving new combination therapies.

PMID: 27327499 [PubMed - as supplied by publisher]

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Clinical Management of Severe Cutaneous Myiasis in a Brangus-Cross Calf

2016-06-22T04-40-34Z
Source: International Journal of Livestock Research
Faez Firdaus Abdullah Jesse, Muhammad Abubakar Sadiq, Yusuf Abba, Konto Mohammed, Azrol Harith, Eric Lim Teik Chung, Asinamai Athliamai Bitrus, Mohd Azmi Mohd Lila, Abd Wahid Haron, Abdul Aziz Saharee.
Ten days old, female Brangus-cross calf weighing 40 kg was presented in the Large Animal Unit of the Veterinary Hospital, Universiti Putra Malaysia with an extensive maggot wound measuring 20cm x 10 cm in diameter and 6cm in depth at the perineum. Physically, the calf was bright and alert, all vital parameters were within the normal range. Wound examination revealed a necrotic tissue full of maggots around the vulva and anus. The calf was managed extensively with commercially formulated feed. Diagnosis revealed a clinical case of severe cutaneous myiasis and inflammation. The wound was managed as open wound and secondary intention wound healing process was adopted. Daily wound cleaning with 0.05% chlorhexidine diacetate, followed by hydrogen peroxide and povidone iodine was applied on the wound. Dermapred® was applied topically and woundsarex spray® was used as spray at the periphery of the wound as fly repellent. Systemic intramuscular injection of 0.9mL of Flunixin meglumine 1.1mg/kg was administered for 3 days to the calf for pain management. An intramuscular injection of Penicillin and streptomycin 8mg/kg was given as systemic broad spectrum antibiotic daily for 3 days. Multivitamin 10mg/ml (vitavet) was given once as an adjunct treatment. Prognosis of the calf was well as the wound healed timely and the calf was released back into the paddock 37 days post treatment. Administering the right treatment at the right time is always associated with a good prognostic outcome. Daily follow-up and care is really significant in enhancing the healing process.

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Analytical data in support of the liver and peripheral blood concentration (L/P) ratio as a marker of postmortem redistribution

2016-06-22T04-06-49Z
Source: European Journal of Forensic Sciences
Iain M McIntyre.
Postmortem redistribution (PMR) refers to the changes that can occur in drug concentrations after death. Consequently, postmortem blood concentrations may not always reflect the antemortem drug levels. A recent literature review has postulated a model describing drugs with a liver (L) to peripheral blood (P) concentration ratio less than 5 L/kg as being prone to little or no PMR, while drugs with an L/P ratio greater than 20-30 L/kg exhibit propensity for substantial PMR. Antidepressants including tricyclic antidepressants and some selective serotonin re-uptake inhibitors, for example, were obviously distinguished from drugs confirmed to be free from, or demonstrate little PMR. This current paper presents analytical L/P data from 867 postmortem cases yielding a ranking of 44 different drugs propensity for (and degree of) PMR.

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Belatacept Conversion in an HIV Positive Kidney Transplant Recipient with Prolonged Delayed Graft Function

Abstract

We report an HIV renal transplant recipient with delayed graft function who was converted from tacrolimus to belatacept, in an attempt to improve renal function. The patient had kidney biopsies at four and eight weeks post-transplant that revealed acute tubular necrosis and mild fibrosis. After 14 weeks of delayed function belatacept was initiated and tacrolimus was weaned off. Shortly after discontinuing tacrolimus renal function began to improve. The patient was able to discontinue dialysis 21 weeks post- transplant. HIV viral load was undetectable at last follow up. To our knowledge this is the first report of belatacept use in an HIV patient.

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OtoRhinoLaryngology & Medicine,New Articles,June 22nd,2016,afternoon

High-Sensitive C-Reactive Protein Predicts Recurrent Stroke and Poor Functional Outcome: Subanalysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events Trial [Original Contribution]2016-06-22 15:49:01 PM

High-Sensitive C-Reactive Protein Predicts Recurrent Stroke and Poor Functional Outcome: Subanalysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events Trial [Original Contribution]: Background and Purpose—

Minor stroke and transient ischemic attack are common disorders with high rate of subsequent disabling stroke. We aim to investigate the role of high-sensitive C-reactive protein (hsCRP) in predicting recurrent stroke and poor functional outcome.

Methods—

In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, 3044 (59%) consecutive patients from 73 (64%) prespecified centers had hsCRP levels measured. The primary outcome was any stroke within 90 days. The secondary outcome included combined vascular events and dependence or death defined as modified Rankin Scale score of 2 to 6 at 90 days and a new vascular event during 1-year follow-up. The associations of hsCRP with recurrent stroke and functional outcome were analyzed by using Cox proportional hazards and logistic regression models.

Results—

Elevated hsCRP (>3.0 mg/L) was observed in 32% of the study population. Patients with hsCRP >3 mg/L had an increased risk of recurrent stroke (adjusted hazard ratio, 1.46; 95% confidence interval, 1.08–1.98; P=0.039), ischemic stroke and combined vascular events, and poor functional outcome (adjusted odds ratio, 1.68; 95% confidence interval, 1.22–2.32; P=0.002) compared with those with hsCRP <1 mg/L within 90-day follow-up period. High hsCRP levels also independently predicted recurrent stroke during 1-year follow-up. There was no interaction of hsCRP levels with randomized antiplatelet therapy.

Conclusions—

High hsCRP levels predict recurrent stroke and poor functional outcome in acute patients with minor stroke or transient ischemic attack.

Clinical Trial Registration—

URL: http://ift.tt/PmpYKN. Unique identifier: NCT00979589.

http://ift.tt/28NlcE4

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ACR Appropriateness Criteria® Locoregional therapy for resectable oropharyngeal squamous cell carcinomas2016-06-22 15:48:52 PM

ACR Appropriateness Criteria® Locoregional therapy for resectable oropharyngeal squamous cell carcinomas:

Abstract

Background

There are no level I studies to guide treatment for resectable oropharyngeal squamous cell carcinoma (SCC). Treatment toxicities influence management recommendations. Ongoing investigations are examining deintensified treatments for human papillomavirus (HPV)-associated oropharyngeal SCC.

Methods

The Appropriateness Criteria panel, using modified Delphi methodology, produced a literature summary, an assessment of treatment recommendations, and cases to illustrate their use.

Results

A multidisciplinary team produces optimum results. Based on HPV status, smoking history, and staging, patients are divided into groups at low, intermediate, and high-risk of death. In the future, treatment recommendations may be influenced by HPV status, which has changed the epidemiology of oropharyngeal SCC.

Conclusion

T1 to T2N0M0 resectable oropharyngeal SCC can be treated with surgery or radiation without chemotherapy. Patients with T1-2N1-2aM0 disease can receive radiation, chemoradiation, or transoral surgery with neck dissection and appropriate adjuvant therapy. Patients with T1-2N2b-3M0 disease should receive chemoradiation or transoral surgery with neck dissection and appropriate adjuvant therapy. Concurrent chemoradiation is preferred for T3 to T4 disease. © 2016 American College of Radiology. Head Neck, 2016

http://ift.tt/28OkOsN

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The efficacy of submucosal corticosteroid injection and dilatation in subglottic stenosis of different aetiology2016-06-22 15:48:44 PM

Main Articles

The efficacy of submucosal corticosteroid injection and dilatation in subglottic stenosis of different aetiology

M Wierzbicka^a1 ^c1, M Tokarski^a1, M Puszczewicz^a2 and W Szyfter^a1

^a1Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, Poland

^a2Department of Rheumatology and Internal Medicine, Poznan University of Medical Sciences, Poland

Abstract

Objective: To determine the long-term efficacy of submucosal corticosteroid injection plus dilatation for subglottic stenosis as a single modality treatment in granulomatosis with polyangiitis and relapsing polychondritis, as compared with idiopathic subglottic stenosis and traumatic subglottic stenosis.

Method: Patients who underwent dilatation for autoimmune causes were identified. Corticosteroid injection into the submucosa of a stenotic segment was followed by serial dilatation. Definitive improvement was defined as good airway patency for more than 24 months with no further procedures needed. Clinical, demographic and procedural data were recorded.

Results: Patients (n = 45) were divided into three subglottic stenosis groups: traumatic (n = 24), idiopathic (n = 9) and autoimmune (n = 12). Patients were treated with dilatations, with a median follow-up time of 76 months. Six patients were tracheostomy-dependent. There were no statistical differences in the number of final improvements between autoimmune, idiopathic and traumatic groups, with values of 75, 56 and 71 per cent, respectively. There was no statistical difference between granulomatosis with polyangiitis plus relapsing polychondritis and idiopathic subglottic stenosis in terms of decannulation rates.

Conclusion: Granulomatosis with polyangiitis and relapsing polychondritis patients have better improvement rates than patients with other subglottic stenosis types.

http://ift.tt/28NkVRD

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Cell origin in the macula flava of the human newborn vocal fold2016-06-22 15:48:39 PM

Main Articles

Cell origin in the macula flava of the human newborn vocal fold

K Sato^a1 ^c1, S Chitose^a1, T Kurita^a1 and H Umeno^a1

^a1Department of Otolaryngology – Head and Neck Surgery, Kurume University School of Medicine, Japan

Abstract

Background: There is growing evidence to suggest that cells in the maculae flavae are tissue stem cells of the human vocal fold and maculae flavae are a stem cell niche.

Methods: Three newborn vocal folds were investigated. Immunoreactivity to antibodies directed to cytokeratin, desmin, glial fibrillary acidic protein, vimentin, cluster of differentiation 34, cluster of differentiation 45, collagen type I, telomerase reverse transcriptase, SOX17 and stage-specific embryonic antigen 3 was investigated.

Results: The cells in the newborn maculae flavae expressed haematopoietic markers (cluster of differentiation 34, cluster of differentiation 45) and collagen type I, which are the major makers of bone marrow derived circulating fibrocytes. The cells expressed epithelium, muscle, neural and mesenchymal cell associated proteins, and endodermal marker, indicating that they are undifferentiated and express proteins of all three germ layers. The cells also expressed stage-specific embryonic antigen 3 and telomerase reverse transcriptase.

Conclusion: The cells in the newborn maculae flavae are undifferentiated cells arising from the differentiation of bone marrow cells. The results of this study are consistent with the hypothesis that the cells in maculae flavae are tissue stem cells.

http://ift.tt/28NkZRk

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Economic impact of recurrent respiratory papillomas in a UK adult population2016-06-22 15:48:27 PM

Main Articles

Economic impact of recurrent respiratory papillomas in a UK adult population

A Harrison^a1 ^c1, J Montgomery^a2 and F B Macgregor^a3

^a1Department of Otolaryngology, North Manchester General Hospital, Pennine Acute Trust, UK

^a2Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK

^a3Department of Otolaryngology, Gartnavel General Hospital, Glasgow, Scotland, UK

Abstract

Objective: To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients.

Background: Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease.

Methods: Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division.

Results: Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478.

Conclusion: Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.

http://ift.tt/28PzSns

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Management of isolated cricopharyngeal dysfunction: systematic review2016-06-22 15:48:18 PM

Review Articles

Management of isolated cricopharyngeal dysfunction: systematic review

A Ashman^a1 ^c1, O T Dale^a2 and D L Baldwin^a1

^a1ENT Department, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, UK

^a2ENT Department, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, UK

Abstract

Objective: A systematic review was performed to evaluate the safety and efficacy of different therapeutic interventions available for the management of isolated cricopharyngeal dysfunction.

Methods: Studies were identified using the following databases: Ovid (Medline, Embase), the Cochrane Library, PubMed and Google Scholar. An initial search identified 339 articles. All titles and abstracts were reviewed. Fifty-six relevant articles were inspected in more detail; of these, 47 were included in the qualitative analysis.

Results: No relevant randomised trials were found. A range of case series were used to perform a qualitative analysis. Botulinum toxin A injection and cricopharyngeal dilatation were associated with a higher risk of recurrence, but appear to be more suitable in elderly and co-morbid patients. In those patients requiring formal myotomy, endoscopic approaches appear to be as effective but less morbid when compared with classical open surgery.

Conclusion: There is good evidence for the safety and efficacy of the different therapeutic options for isolated cricopharyngeal dysfunction. However, further studies are required to compare the efficacy of the various treatment modalities.

http://ift.tt/28W2dHZ

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Optimal outcomes for hearing preservation in the management of small vestibular schwannomas2016-06-22 15:48:09 PM

Review Articles

Optimal outcomes for hearing preservation in the management of small vestibular schwannomas

K A Peng^a1 and E P Wilkinson^a1 ^c1

^a1House Clinic, Los Angeles, California, USA

Abstract

Objective: To undertake a systematic review of the role of microsurgery, in relation to observation and stereotactic radiation, in the management of small vestibular schwannomas with serviceable hearing.

Methods: The Medline database was searched for publications that included the terms 'vestibular schwannoma' and/or 'acoustic neuroma', occurring in conjunction with 'hearing'. Articles were manually screened to identify those concerning vestibular schwannomas under 1.5 cm in greatest dimension. Thereafter, only publications discussing both pre-operative and post-operative hearing were considered.

Results: Twenty-six papers were identified. Observation is an acceptable strategy for small tumours with slow growth where hearing preservation is not a consideration. In contrast, microsurgery, including the middle fossa approach, may provide excellent hearing outcomes, particularly when a small tumour has begun to cause hearing loss. Immediate post-operative hearing usually predicts long-term hearing. Recent data on stereotactic radiation suggest long-term deterioration of hearing following definitive therapy.

Conclusion: In patients under the age of 65 years with small vestibular schwannomas, microsurgery via the middle fossa approach offers durable preservation of hearing.

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Reversible hearing loss following cryptococcal meningitis: case study2016-06-22 15:47:59 PM

Clinical Record

Reversible hearing loss following cryptococcal meningitis: case study

W L Neo^a1 ^c1, N Durisala^a2 and E C Ho^a1

^a1Department of Otolaryngology, Tan Tock Seng Hospital, Singapore

^a2Department of Audiology, Tan Tock Seng Hospital, Singapore

Abstract

Background: Sensorineural hearing loss is a recognised complication of cryptococcal meningitis. The mechanism of hearing loss in patients with cryptococcal meningitis is different from that in bacterial meningitis.

Case report: An immune-competent man with cryptococcal meningitis presented with sudden onset, bilateral, severe to profound sensorineural hearing loss and vestibular dysfunction. He was initially evaluated for cochlear implantation. However, he had a significant recovery; he no longer required surgery and was able to cope without a hearing aid.

Conclusion: Typically, cochlear implantation is performed with some urgency in patients with hearing loss post-bacterial meningitis, because of the risk of labyrinthitis ossificans. However, this process has not been described in patients with cryptococcal meningitis. Furthermore, patients with hearing loss associated with cryptococcal meningitis have shown varying degrees of reversibility. In this case report, hearing loss from cryptococcal meningitis is compared with that from bacterial meningitis, and the need for cochlear implantation in patients with cryptococcal meningitis is discussed.

http://ift.tt/28W287o

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Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study2016-06-22 15:47:55 PM

Main Articles

Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study

M Kara^a1 ^c1, H Erdoğan^a1, H B Altinişik^a2, H Aylanç^a3, O Güçlü^a1 and F S Dereköy^a1

^a1Department of Otorhinolaryngology, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey

^a2Department of Anesthesiology and Reanimation, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey

^a3Department of Pediatry, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey

Abstract

Background: To evaluate the effects of autologous serum usage on throat pain, haemorrhage and tonsillar fossa epithelisation in patients after tonsillectomy.

Methods: Thirty-two patients (aged 4–15 years) were included in the study. Tonsillectomy was performed and autologous serum was administered topically to the right tonsillar fossa during the operation, and at 8 and 24 hours post-operatively. The left side served as the control. A visual analogue scale was used to record the patient's pain every day. Each patient's oropharynx was observed on the 5th and 10th post-operative days to examine bleeding and epithelisation.

Results: The pain scores for the side administered autologous serum were significantly lower than those for the control side, on the night following the operation and on the 1st, 2nd, 5th and 6th post-operative days. Tonsillar fossa epithelisation was significantly accelerated on the study side compared with the control side on the 5th and 10th post-operative days.

Conclusion: In tonsillectomy patients, topically administered autologous serum contributed to throat pain relief and tonsillar fossa epithelisation during the post-operative period.

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Age of onset of Ménière's disease in the Netherlands: data from a specialised dizziness clinic2016-06-22 15:47:43 PM

Main Articles

Age of onset of Ménière's disease in the Netherlands: data from a specialised dizziness clinic

B F Van Esch^a1 ^c1, P P G Van Benthem^a1, H J Van Der Zaag-Loonen^a1 and TJ D Bruintjes^a1

^a1Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, The Netherlands

Abstract

Objectives: To determine the age of onset of Ménière's disease in patients who visited a specialised dizziness clinic, and to verify whether the trend of a delayed onset age of Ménière's disease as reported for the Japanese population also occurs in the Netherlands.

Method: A retrospective data analysis was performed of patients diagnosed with 'definite' Ménière's disease who visited our clinic between January 2000 and December 2013.

Results: Mean onset age of Ménière's disease among the 296 patients was 53.0 ± 14.1 years; 209 patients (71 per cent) were diagnosed between the fifth and seventh decades of life. No trend towards a later onset of Ménière's disease was found (regression beta co-efficient for year of presentation was 0.03; 95 per cent confidence interval = −0.34–0.61; p = 0.58).

Conclusion: Ménière's disease has a peak incidence between 40 and 69 years of age. No shift towards a later onset age of Ménière's disease was found.

http://ift.tt/28W2gDH

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The Pharmacokinetics of Atomized Lidocaine Administered via the Trachea2016-06-22 15:53:48 PM
A Randomized Trial: BACKGROUND: Under emergent conditions, endotracheal drug administration may be an effective method of delivering emergency drugs. A common technique is to administer these drugs using a nonatomized spray. Atomized drug delivery may be an attractive alternative to nonatomized delivery because atomized particles are small, cover a large surface area, and may better adhere to endotracheal membrane resulting in more effective drug absorption. In this study, we compared the pharmacokinetic profile of lidocaine administered into the trachea using an atomized or a nonatomized technique.

METHODS: Twenty patients were anesthetized using propofol and remifentanil. Ten minutes after rocuronium was administered, patients received 4% lidocaine (2 mg/kg) intratracheally over 2 seconds before tracheal intubation. Ten patients received atomized lidocaine using a mucosal atomization device, and the other 10 patients received nonatomized lidocaine using a traditional spray tube. Arterial lidocaine plasma concentrations were measured before; at 1, 3, 5, 7, 10, 15, 20, 30, 45, and 60 minutes; and then every 60 minutes after the administration of lidocaine until the end of the operation. We developed a pharmacokinetic model to examine whether bioavailability or absorption rate was different between atomized versus nonatomized lidocaine administration. The total body clearance was fixed at a published value to determine the bioavailability.

RESULTS: Peak plasma concentrations were larger using the mucosal atomization device (median [range]: 1.9 [1.4−3.2] μg/mL) than the spray tube (1.1 [0.6−2.0] μg/mL; P = 0.0021). Our pharmacokinetic model estimated a difference of bioavailability between the atomized and the nonatomized lidocaine (0.801 and 0.559 respectively, P = 0.0005), whereas our model estimated no difference in the absorption rate constant (0.00688/min).

CONCLUSIONS: Our results suggest that when using atomized delivery of lidocaine, less drug is required to achieve a near equivalent plasma lidocaine concentration. Atomized drug administration may be a more efficient method for endotracheal drug administration.

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A Primer on Population Health Management and Its Perioperative Application2016-06-22 15:53:15 PM
A Primer on Population Health Management and Its Perioperative Application: The movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues. The Triple Aim of Healthcare includes (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care. The Perioperative Surgical Home essentially seeks to transform perioperative care by achieving the Triple Aim, including improving the health of the surgical population. Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.

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Hemostatic Therapy Using Tranexamic Acid and Coagulation Factor Concentrates2016-06-22 15:52:55 PM
in a Model of Traumatic Liver Injury: BACKGROUND: The potential clinical benefits of targeted therapy with coagulation factor concentrates (e.g., fibrinogen) and antifibrinolytic agents (e.g., tranexamic acid [TXA]) for the treatment of trauma-induced coagulopathy are increasingly recognized. We hypothesized that human fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC), administered as combined therapy with TXA, would provide additive effects for reducing blood loss in an animal trauma model.

METHODS: Thirty-six pigs were subjected to 2 consecutive blunt liver injuries, resulting in severe hemorrhagic shock and coagulopathy. Intervention comprised saline (control group); TXA (15 mg kg−1, TXA group); TXA and FC (90 mg kg−1, TXA–FC); or TXA, FC, and PCC (20 U kg−1, TXA–FC–PCC). Blood loss, thromboelastometry (ROTEM), measures of thrombin generation, platelet activation, and global coagulation variables were monitored for 4 hours. Tissue sections were examined to determine the occurrence of thromboembolic events.

RESULTS: Total blood loss was similar in the TXA–FC and TXA–FC–PCC groups (mean ± SD: 1012 ± 86 mL and 1037 ± 118 mL, respectively; P = 1.000). These values were both lower (P

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The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs2016-06-22 15:52:24 PM
The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs: BACKGROUND: Even as the use of peripheral nerve blockade in the perioperative setting is increasing, neural injury secondary to accidental intraneural injection remains a significant patient safety concern. Current modalities, including electrical stimulation and ultrasound imaging, still lack consistency and absolute reliability in both the detection and prevention of this complication. The measurement of electrical impedance (EI) could be an easy and valuable additional tool to detect intraneural needle placement. Our objectives in this study were to measure the change in EI with intraneural needle advancement in recently amputated human limbs.

METHODS: The study was conducted within 45 minutes of amputation. The nerves that were studied were the sciatic nerve in the popliteal fossa in above-knee amputations or the tibial nerve below the calf in below-knee amputations. The amputated limb was placed on a tray and under ultrasound imaging guidance, an insulated peripheral block needle connected to a nerve stimulator was placed extraneurally and subsequently advanced intraneurally. The experiment was repeated on the same nerve after exposure by surgical dissection. The differences in impedance measurements between intraneural and extraneural needle placement were compared.

RESULTS: In the below-knee amputated extremity (tibial nerve, n = 6) specimens based on the ultrasound methods, mean ± SD for ultrasound-guided intraneural impedance was 10 ± 2 kΩ compared with an extraneural impedance of 6 ± 1.6 kΩ (P = 0.005). The difference between intraneural and extraneural impedance after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.005). Similarly, in the above-the-knee amputated extremity (sciatic nerve, n = 5) specimens, mean intraneural impedance was 35.2 ± 7.9 kΩ compared with an extraneural impedance of 25.2 ± 5.3 kΩ (P = 0.037). The difference between intraneural and extraneural impedance obtained after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.0002). The impedance values were consistent and similar to those obtained after open dissection.

CONCLUSIONS: There is no reliable "gold standard" to predict or prevent intraneural needle placement during peripheral nerve blockade. This small sample-sized study demonstrated that there is a change in EI with intraneural needle advancement. In clinical practice, measurement of the EI in conjunction with nerve stimulation may serve as another tool to use for identifying intraneural needle placement during peripheral nerve blockade.

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Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study2016-06-22 15:52:00 PM
Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study: BACKGROUND: Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients.

METHODS: We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5.

RESULTS: The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ2 analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72–0.93] for Mini-Cog and 11 for CIB).

CONCLUSIONS: Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.

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The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor2016-06-22 15:51:35 PM
The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor: BACKGROUND: Sleep disruption in critically ill adults can result in acute decrements in cognitive function, including delirium, but it is underdiagnosed in the setting of the intensive care unit (ICU). Although sleep stages can be assessed by polysomnography (PSG), acquisition and interpretation of PSG is costly, is labor intensive, is difficult to do over an extended period of time with critically ill patients (multiple days of continuous recording), and may interfere with patient care. In this pilot study, we investigated the feasibility and utility of monitoring sleep in the ICU setting using a portable electroencephalography (EEG) monitor, the SedLine® brain monitor.

METHODS: We first performed a baseline comparison study of the SedLine brain monitor by comparing its recordings to PSG recorded in a sleep laboratory (n = 3). In a separate patient cohort, we enrolled patients in the ICU who were monitored continuously with the SedLine monitor for sleep disruption (n = 23). In all enrolled patients, we continuously monitored their EEG. The raw EEG was retrieved and sleep stages and arousals were analyzed by a board-certified technologist. Delirium was measured by a trained research nurse using the Confusion Assessment Method developed for the ICU.

RESULTS: For all enrolled patients, we continuously monitored their EEGs and were able to retrieve the raw EEGs for analysis of sleep stages. Overall, the SedLine brain monitor was able to differentiate sleep stages, as well as capture arousals and transitions between sleep stages compared with the PSG performed in the sleep laboratory. The percentage agreement was 67% for the wake stage, 77% for the non-rapid eye movement (REM) stage (N1 = 29%, N2 = 88%, and N3 = 6%), and 89% for the REM stage. The overall agreement was measured with the use of weighted kappa, which was 0.61, 95% confidence interval, 0.58 to 0.64. In the ICU study, the mean recording time for the 23 enrolled patients was 19.10 hours. There were several signs indicative of poor-quality sleep, where sleep was distributed throughout the day, with reduced time spent in REM (1.38% ± 2.74% of total sleep time), and stage N3 (2.17% ± 5.53% of total sleep time) coupled with a high arousal index (34.63 ± 19.04 arousals per hour). The occurrence of ICU delirium was not significantly different between patients with and without sleep disruption.

CONCLUSIONS: Our results suggest the utility of a portable EEG monitor to measure different sleep stages, transitions, and arousals; however, the accuracy in measuring different sleep stages by the SedLine monitor varies compared with PSG. Our results also support previous findings that sleep is fragmented in critically ill patients. Further research is necessary to develop portable EEG monitors that have higher agreement with PSG.

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Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine2016-06-22 15:51:12 PM
Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine: BACKGROUND: Histamine receptors are known to participate in spinal cord nociceptive transmission, and previous studies have suggested that histaminergic receptors are involved in the analgesic effects of morphine. Herein, we investigated the effect of intrathecal injection of histaminergic agonists and antagonists in a model of acute articular inflammation and their interaction with morphine.

METHODS: After carrageenan injection in the right knee joint, articular incapacitation was measured hourly, for up to 6 hours, by the paw elevation time during 1-minute periods of stimulated walking. Inflammatory edema was also assessed hourly by determining an increase in articular diameter. Spinal treatments were administered 20 minutes before knee-joint carrageenan injection and were compared with the saline-treated control group.

RESULTS: Intrathecally injected histamine increased incapacitation and articular edema, whereas the H1R antagonist, cetirizine, decreased both parameters. The H3R agonist, immepip, decreased both incapacitation and edema, but the H3R antagonist, thioperamide, increased both incapacitation and edema. Morphine inhibited both incapacitation and edema. Furthermore, combining a subeffective dose of morphine with cetirizine or immepip potentiated the analgesic and antiedematogenic effect.

CONCLUSIONS: Histamine seems to act at the spinal level via H1 and H3 receptors to modulate acute arthritis in rats. An H1R antagonist and H3R agonist were found to potentiate the analgesic and antiedematogenic effects of morphine, suggesting that histaminergic and opioid spinal systems may be explored for means of improving analgesia, as well as peripheral anti-inflammatory effects.

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Vermilion Reconstruction with Genital Mucosa2016-06-22 15:50:50 PM
Vermilion Reconstruction with Genital Mucosa:

Summary: Functional and aesthetical reconstruction, especially of the upper lip after ablative tumor surgery, can be very challenging. The skin of the lip might be sufficiently reconstructed by transpositional flaps from the nasolabial or facial area. Large defects of the lip mucosa, including the vestibule, are even more challenging due to the fact that flaps from the inner lining of the oral cavity often lead to functional impairments. We present a case of multiple vermilion and skin resections of the upper lip. At the last step, we had to resect even the whole vermilion mucosa, including parts of the oral mucosa of the vestibule, leaving a bare orbicularis oris muscle. To reconstruct the mucosal layer, we used a mucosal graft from the labia minora and placed it on the compromised lip and the former transpositional flaps for the reconstructed skin of the upper lip with very good functional and aesthetic results.

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Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction2016-06-22 15:50:06 PM
Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction: During microtia reconstruction, the intra-operative design of the cartilage framework is important for the appearance and symmetry of the bilateral auricles. Templates (traditionally, the x-ray film template) are usually utilized to complete the task, which can provide cues regarding size, cranioauricular angle and positioning to the surgeons. With a combination of three-dimensional (3D) scanning and additive manufacturing (AM) techniques, we utilized two different ear-shaped templates (sheet moulding and three-dimensional templates) during the fabrication of 3D customized autologous cartilage frameworks for auricle reconstruction.

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A method to switch from oral dopamine agonists to rotigotine in patients with restless legs syndrome and mild augmentation2016-06-22 15:49:45 PM
Article in Press

John W Winkelman, MD, PhD
,
Susan E Mackie
,
Leslie A Mei
,
Samuel Platt
,
Laura Schoerning

DOI: http://ift.tt/28P7sem
Highlights

• Augmentation of RLS symptoms with oral dopamine agonists is common.

• Optimal management of augmentation in such cases is controversial.

• Cross-titration to rotigotine was successful in 70% of patients with mild augmentation at 5 weeks.

• However, at 1 year, 50% had discontinued rotigotine due to lack of continued efficacy or side effects.

Abstract

Background

We examined the short- and long-term efficacy and tolerability of a cross-titration algorithm from oral dopamine agonists to the rotigotine transdermal patch in patients dissatisfied with their RLS treatment, predominantly with mild augmentation.

Methods

Patients with RLS (n=20) were recruited at a single site. The cross-titration consisted of decreasing oral dopaminergic agents (ropinirole by 1 mg or pramipexole by 0.25 mg) and increasing rotigotine by 1 mg every two days. Efficacy and AEs were assessed at 1, 3, 6 and 12 months after the switch.

Results

Patients had moderate-severe RLS symptoms at baseline (mean IRLS score 19.4 ± 5.5); 85% had augmentation and 45% reported afternoon RLS symptoms. Baseline mean pramipexole equivalent dose was 0.6 ± 0.3 mg. At Week 5, 85% (17/20) had successfully switched from their oral dopamine agonist to rotigotine (mean dose 2.5 ± 0.6 mg; change in IRLS score: -6.7 ± 8.4, p=0.002); 14 patients were CGI-I responders (much or very much improved). Three patients withdrew due to lack of efficacy. Twelve months after cross-titration, 10 patients continued on rotigotine, of whom 4 required either higher doses of rotigotine or supplemental RLS medication compared to their optimal Week 5 dose; five patients withdrew due to AEs and 2 due to lack of efficacy.

Conclusion

A cross-titration to rotigotine was efficacious after 5 weeks in 70% of patients dissatisfied with RLS treatment, most of whom had mild augmentation. At 1 year following the medication switch 50% had discontinued rotigotine due to lack of continued efficacy or side effects.

Key words:
restless legs syndrome, rotigotine, augmentation, pramipexole, ropinirole
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Sleep disordered breathing and nocturnal hypoxemia in young adults with sickle cell disease2016-06-22 15:49:00 PM
P.L. Whitesell
,
O. Owoyemi
,
P. Oneal
,
M. Nouraie
,
E.S. Klings
,
A. Rock
,
T.A. Mellman
,
T. Berihun
,
J. Lavella
,
R.E. Taylor
,
S.P. Perrine

DOI: http://ift.tt/28P7ovc
Highlights

• An AHI > 5 was seen in 10 of 20 subjects attending a sickle cell disease clinic.

• Elevated AHI correlated with systolic BP, mitral valve E/A ratio, and QoL scores.

• Hypoxemia occurred in some subjects independently from sleep apnea events.

• Results suggest further study with larger subject numbers is warranted.

Abstract

Sleep disordered breathing (SDB) is reported in up to 69% of adolescents and children with sickle cell disease (SCD) [1], but data regarding the prevalence of SDB in adults with SCD are limited. To obtain a preliminary assessment of the frequency and degree of sleep-related hypoxemia and potential associations with cardiovascular function in adults with SCD, we performed overnight sleep studies, 6-minute walk tests, echocardiograms, hematologic and chemistry panels, and administered the Pittsburgh Sleep Quality Index (PSQI), fatigue and health related quality of life measurement in 20 young adults with SCD attending a sickle cell clinic for routine care. Sleep apnea, defined as an apnea-hypopnea index (AHI) >5 events/hour, was found in 50% of subjects. Traditional clinical indicators such as obesity, the presence of snoring, and reported sleep complaints did not reliably differentiate these subjects. Subjects with an AHI>5 had higher mean systolic blood pressure (p =.03), evidence of impaired left ventricular diastolic function (i.e. increased mitral valve E/A ratio, p =.05), a trend toward greater reduction in 6 minute walk distances (p =.06), and lower Health-related Quality of Life scores (p <=.01). Three of nine subjects with more severe anemia (total Hb < 9.0) demonstrated nocturnal hypoxemia in the absence of sleep apnea. As prolonged and frequent hypoxemic episodes likely increase risks for vaso-occlusive, cardiovascular, and neurologic complications of SCD, these results suggest that the prevalence and severity of SDB should be investigated further in studies of larger patient populations. If confirmed, these findings could identify opportunities to prevent or reduce nocturnal hypoxia and improve outcomes.

Keywords:
sickle cell disease, sleep apnea, hypoxia, hypertension
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Free Tissue Transfer to Head and Neck2016-06-22 15:47:51 PM

Mayo Clinic Experience with Unfavorable Results After

via Plastic Surgery

Publication date: Available online 22 June 2016
Source:Clinics in Plastic Surgery
Author(s): Thomas H. Nagel, Richard E. Hayden

Teaser
Free tissue transfer to the head and neck in the modern era has a high success rate. To maximize success with reconstructive surgery in the head and neck region, it helps to understand those factors that present unique challenges. These factors include contamination by the upper aerodigestive tract, tissue mobility, and a high percentage of patients receiving radiotherapy for oncologic treatment. This article reviews the authors' experience in the head and neck, specifically how addressing these factors can best lead to successful functional and aesthetic outcomes. The authors share surgical techniques and lessons learned from their successes and failures.

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Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology2016-06-22 15:42:15 PM
Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology: Objective

Nonthyroid metastases to the thyroid gland can cause morbidity, including dysphagia, dysphonia, and airway compromise. Because metastatic malignancies portend a poor prognosis, obtaining equipoise between treatment morbidity and local disease progression is paramount. We reviewed cases of nonthyroid metastases to determine treatment and prognostic recommendations.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Subjects and Methods

We searched PubMed for reported cases between 1994 and September 2013 using search terms as follows: any combination of primary tumor locations and thyroid, as well as the terms thyroid and metastasis. Only unique cases of nonthyroid metastases were included. Combined with 17 additional tumors at our own institution, we found 818 unique nonthyroid metastases, of which 384 had management and survival data available.

Results

Renal cell carcinoma was most common, presenting in 293 (35.8%) patients, followed by lung and gastrointestinal malignancies. Patients were treated with total thyroidectomy (34.0%), subtotal thyroidectomy including lobectomy (32.6%), and no surgery (33.5%). Surgical management was associated with improved survival duration (P < .01). Locoregional recurrence was less likely in patients treated with total versus partial thyroidectomy (4.8% vs 13%). Extent of surgical management did not have a significant effect on patient survival. Delayed presentation was associated with improved survival duration (P = .01).

Conclusions

Nonthyroid metastases to the thyroid gland are unusual tumors. Surgical intervention is associated with improved survival, but expected morbidity of untreated tumors is difficult to assess. Site of origin, time to diagnosis, and surgical approach are related to survival and recurrence rates.

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ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?2016-06-22 15:42:00 PM
ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?:

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator is meant to provide an estimation of perioperative risk. Our goal was to determine the clinical applicability of the calculator in major head and neck surgery. A retrospective chart review was completed for major head and neck operations performed at 1 institution from 2013 to 2014. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. Overall, the ACS NSQIP calculator had little predictive value for pneumonia, surgical site infection, 30-day return to operating room, or length of stay within this cohort (P > .05). The calculator appears to have some value predicting total numbers of complications but has poor performance predicting an individual's risk of suffering a perioperative complication. In conclusion, in our small cohort of patients, the ACS NSQIP calculator was a poor predictor of perioperative complications following major head and neck operations.

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Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care2016-06-22 15:41:51 PM
Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care: Objectives

(1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care.

Study Design

A prospective quality improvement study.

Setting

Hospital-based otolaryngology clinic.

Subjects and Methods

The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test.

Results

Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively.

Conclusion

Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

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Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy2016-06-22 15:41:41 PM
Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy: Objective

To determine if decisional regret (DR) in parents following tonsillectomy/adenotonsillectomy (TA) in their children is related to preoperative decisional conflict, perceived outcome of surgery, complications of surgery, or other factors.

Study Design

Observational analytic cohort study.

Setting

Tertiary care children's hospital.

Subjects and Methods

Preoperative decisional conflict (DC) and SURE tests were administered to a parent of a child scheduled for TA between July 2014 and July 2015. The DR tests were given 1 to 3 months postoperatively. Data were collected on patient age, sex, perceived outcome of surgery, complications (including bleeding), emergency room visits, and clinic phone calls.

Results

A total of 102 families were studied, including 48 female and 54 male patients with an average age of 6.29 years. Parental respondents included 83 mothers, 14 fathers, and 5 grandmothers. Overall, DC and DR were both low in this group, with a median of 0 for each (means: 7.74 for DC and 8.78 for DR). DC was higher in parents who canceled surgery or failed to keep follow-up appointments (27.19) versus parents who brought their children for surgery (6.78; P < .05). DR was significantly higher in parents with DC (20.00 vs 7.59; P < .05). It was not related to age of the patient, sex, parental perception of resolution of preoperative complaints, complications (including bleeding or dehydration), emergency department visits, or parental phone calls to the otolaryngology clinic. SURE tests indicated that every parent was confident of his or her decision on the day of surgery.

Conclusion

Preoperative DC is likely the most important factor in determining parental DR after the child undergoes TA.

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Clinical Practice Guidelines: Whose Practice Are We Guiding?2016-06-22 15:41:27 PM
Clinical Practice Guidelines: Whose Practice Are We Guiding?:

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has just released an update to the clinical practice guideline (CPG) on otitis media with effusion. This common condition is frequently managed by primary care providers; however, their awareness and utilization of the AAO-HNSF CPGs are unknown. We performed a cross-sectional survey to assess familiarity with otologic diagnoses, evaluation skills, and guidelines. Only 38.5% of respondents use pneumatic otoscopy, and roughly 50% utilize a CPG for management of otitis media or for referral for tympanostomy tube insertion. Providers predominantly use the acute otitis media guideline from the American Academy of Pediatrics. In this single-institution study, providers are largely unaware of the AAO-HNSF CPGs and could benefit from additional training, including workshops taught by otolaryngologists within individual health care systems or development of a national otolaryngology medical student curriculum. A more immediate option includes referencing our CPGs on specialty societies' websites or newsletters.

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Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends2016-06-22 15:41:15 PM
Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends:

Four-dimensional computed tomography (4D-CT) is a new modality for preoperative localization of parathyroid adenomas. We performed a survey study to describe the role and trends in the utilization of 4D-CT. Of 361 radiologists, 200 (55%) reported that 4D-CT was used in their practices. Nineteen (10%) used 4D-CT as the first-line imaging study; 155 (76%) reported that 4D-CT played a secondary role; and 26 (13%) reported that it is performed routinely in combination with ultrasound and scintigraphy. Early adopters of 4D-CT (use for >3 years) were 3 times more likely to use 4D-CT in a first-line role (18%) when compared with radiologists who used 4D-CT for ≤3 years (6%; P < .05). In conclusion, more than half of radiologists perform 4D-CT, and a majority reported that 4D-CT plays a secondary role. However, this role may change, as utilization is increasing and radiologists may follow early adopters, who are more likely to use it as a first-line study.

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Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes2016-06-22 15:41:06 PM
Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes: Objectives

to determine national benchmarks for established quality indicators in head and neck cancer (HNCA) surgery, focusing on differences between academic and nonacademic institutions.

Study Design

Cross-sectional analysis of national database.

Subjects and Methods

HNCA surgery admissions from the 2009-2011 Nationwide Inpatient Sample were analyzed for preoperative characteristics and postoperative outcomes. Multivariate analyses were used to identify factors influencing quality indicators after HNCA surgery. Quality metrics—including length of stay (LOS), inpatient death, return to the operating room (OR), wound infection, and transfusion—were compared for academic versus nonacademic institutions.

Results

A total of 38,379 HNCA surgery inpatient admissions (mean age, 56.5 years; 52.4% male) were analyzed (28,288 teaching vs 10,091 nonteaching). Nationally representative quality metrics for HNCA surgery were as follows: mean LOS, 4.26 ± 0.12 days; return to OR, 3.3% ± 0.2%; inpatient mortality, 0.7% ± 0.1%; wound infection rate, 0.9% ± 0.1%; wound complication rate, 4.3% ± 0.2%; and transfusion rate, 4.3% ± 0.3%. HNCA surgery patients at teaching hospitals had a greater proportion of males, radiation history, and high-acuity procedures and greater comorbidity scores (all P < .001). Multivariate analyses adjusting for age, sex, income, payer, prior radiation, comorbidity scores, and procedural acuity demonstrated that teaching hospitals had a slightly increased LOS (+0.30 days; P = .009) and odds ratio for wound infection (1.54; 95% CI: 1.22-1.94) versus nonteaching hospitals. There were no significant differences in return to OR (P = .271), inpatient mortality (P = .686), or transfusion rate (P = .960).

Conclusion

Despite caring for substantially more complex HNCA surgery patients with greater comorbidities, teaching hospitals demonstrate only a marginally increased LOS and wound complication rate versus nonteaching hospitals, while other established quality metrics are similar.

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Are Online Zenkers Diverticulum Materials Readable and Understandable?2016-06-22 15:40:55 PM
Are Online Zenkers Diverticulum Materials Readable and Understandable?: Objective

Patients use a multitude of resources to learn about Zenker's diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability.

Methods

The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability.

Results

The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability (r = –0.62, P < .05). Fleiss' interrater reliability for the raters demonstrated substantial agreement between the 4 raters ( = 0.64).

Conclusion

Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels.

Implications for Practice

Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.

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The Pharmacokinetics of Atomized Lidocaine Administered via the Trachea2016-06-22 16:00:46 PM

A Randomized Trial: BACKGROUND: Under emergent conditions, endotracheal drug administration may be an effective method of delivering emergency drugs. A common technique is to administer these drugs using a nonatomized spray. Atomized drug delivery may be an attractive alternative to nonatomized delivery because atomized particles are small, cover a large surface area, and may better adhere to endotracheal membrane resulting in more effective drug absorption. In this study, we compared the pharmacokinetic profile of lidocaine administered into the trachea using an atomized or a nonatomized technique.

METHODS: Twenty patients were anesthetized using propofol and remifentanil. Ten minutes after rocuronium was administered, patients received 4% lidocaine (2 mg/kg) intratracheally over 2 seconds before tracheal intubation. Ten patients received atomized lidocaine using a mucosal atomization device, and the other 10 patients received nonatomized lidocaine using a traditional spray tube. Arterial lidocaine plasma concentrations were measured before; at 1, 3, 5, 7, 10, 15, 20, 30, 45, and 60 minutes; and then every 60 minutes after the administration of lidocaine until the end of the operation. We developed a pharmacokinetic model to examine whether bioavailability or absorption rate was different between atomized versus nonatomized lidocaine administration. The total body clearance was fixed at a published value to determine the bioavailability.

RESULTS: Peak plasma concentrations were larger using the mucosal atomization device (median [range]: 1.9 [1.4−3.2] μg/mL) than the spray tube (1.1 [0.6−2.0] μg/mL; P = 0.0021). Our pharmacokinetic model estimated a difference of bioavailability between the atomized and the nonatomized lidocaine (0.801 and 0.559 respectively, P = 0.0005), whereas our model estimated no difference in the absorption rate constant (0.00688/min).

CONCLUSIONS: Our results suggest that when using atomized delivery of lidocaine, less drug is required to achieve a near equivalent plasma lidocaine concentration. Atomized drug administration may be a more efficient method for endotracheal drug administration.

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A Primer on Population Health Management and Its Perioperative Application2016-06-22 16:00:36 PM

A Primer on Population Health Management and Its Perioperative Application: The movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues. The Triple Aim of Healthcare includes (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care. The Perioperative Surgical Home essentially seeks to transform perioperative care by achieving the Triple Aim, including improving the health of the surgical population. Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.

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Hemostatic Therapy Using Tranexamic Acid and Coagulation Factor Concentrates2016-06-22 16:00:22 PM

in a Model of Traumatic Liver Injury: BACKGROUND: The potential clinical benefits of targeted therapy with coagulation factor concentrates (e.g., fibrinogen) and antifibrinolytic agents (e.g., tranexamic acid [TXA]) for the treatment of trauma-induced coagulopathy are increasingly recognized. We hypothesized that human fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC), administered as combined therapy with TXA, would provide additive effects for reducing blood loss in an animal trauma model.

METHODS: Thirty-six pigs were subjected to 2 consecutive blunt liver injuries, resulting in severe hemorrhagic shock and coagulopathy. Intervention comprised saline (control group); TXA (15 mg kg−1, TXA group); TXA and FC (90 mg kg−1, TXA–FC); or TXA, FC, and PCC (20 U kg−1, TXA–FC–PCC). Blood loss, thromboelastometry (ROTEM), measures of thrombin generation, platelet activation, and global coagulation variables were monitored for 4 hours. Tissue sections were examined to determine the occurrence of thromboembolic events.

RESULTS: Total blood loss was similar in the TXA–FC and TXA–FC–PCC groups (mean ± SD: 1012 ± 86 mL and 1037 ± 118 mL, respectively; P = 1.000). These values were both lower (P

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The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs2016-06-22 16:00:09 PM

The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves: A Study on Amputated Human Limbs: BACKGROUND: Even as the use of peripheral nerve blockade in the perioperative setting is increasing, neural injury secondary to accidental intraneural injection remains a significant patient safety concern. Current modalities, including electrical stimulation and ultrasound imaging, still lack consistency and absolute reliability in both the detection and prevention of this complication. The measurement of electrical impedance (EI) could be an easy and valuable additional tool to detect intraneural needle placement. Our objectives in this study were to measure the change in EI with intraneural needle advancement in recently amputated human limbs.

METHODS: The study was conducted within 45 minutes of amputation. The nerves that were studied were the sciatic nerve in the popliteal fossa in above-knee amputations or the tibial nerve below the calf in below-knee amputations. The amputated limb was placed on a tray and under ultrasound imaging guidance, an insulated peripheral block needle connected to a nerve stimulator was placed extraneurally and subsequently advanced intraneurally. The experiment was repeated on the same nerve after exposure by surgical dissection. The differences in impedance measurements between intraneural and extraneural needle placement were compared.

RESULTS: In the below-knee amputated extremity (tibial nerve, n = 6) specimens based on the ultrasound methods, mean ± SD for ultrasound-guided intraneural impedance was 10 ± 2 kΩ compared with an extraneural impedance of 6 ± 1.6 kΩ (P = 0.005). The difference between intraneural and extraneural impedance after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.005). Similarly, in the above-the-knee amputated extremity (sciatic nerve, n = 5) specimens, mean intraneural impedance was 35.2 ± 7.9 kΩ compared with an extraneural impedance of 25.2 ± 5.3 kΩ (P = 0.037). The difference between intraneural and extraneural impedance obtained after open dissection was also significant when we repeated the analysis based on the same specimens (P = 0.0002). The impedance values were consistent and similar to those obtained after open dissection.

CONCLUSIONS: There is no reliable "gold standard" to predict or prevent intraneural needle placement during peripheral nerve blockade. This small sample-sized study demonstrated that there is a change in EI with intraneural needle advancement. In clinical practice, measurement of the EI in conjunction with nerve stimulation may serve as another tool to use for identifying intraneural needle placement during peripheral nerve blockade.

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Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study2016-06-22 16:00:00 PM

Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study: BACKGROUND: Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients.

METHODS: We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5.

RESULTS: The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ2 analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72–0.93] for Mini-Cog and 11 for CIB).

CONCLUSIONS: Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.

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The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor2016-06-22 15:59:52 PM

The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor: BACKGROUND: Sleep disruption in critically ill adults can result in acute decrements in cognitive function, including delirium, but it is underdiagnosed in the setting of the intensive care unit (ICU). Although sleep stages can be assessed by polysomnography (PSG), acquisition and interpretation of PSG is costly, is labor intensive, is difficult to do over an extended period of time with critically ill patients (multiple days of continuous recording), and may interfere with patient care. In this pilot study, we investigated the feasibility and utility of monitoring sleep in the ICU setting using a portable electroencephalography (EEG) monitor, the SedLine® brain monitor.

METHODS: We first performed a baseline comparison study of the SedLine brain monitor by comparing its recordings to PSG recorded in a sleep laboratory (n = 3). In a separate patient cohort, we enrolled patients in the ICU who were monitored continuously with the SedLine monitor for sleep disruption (n = 23). In all enrolled patients, we continuously monitored their EEG. The raw EEG was retrieved and sleep stages and arousals were analyzed by a board-certified technologist. Delirium was measured by a trained research nurse using the Confusion Assessment Method developed for the ICU.

RESULTS: For all enrolled patients, we continuously monitored their EEGs and were able to retrieve the raw EEGs for analysis of sleep stages. Overall, the SedLine brain monitor was able to differentiate sleep stages, as well as capture arousals and transitions between sleep stages compared with the PSG performed in the sleep laboratory. The percentage agreement was 67% for the wake stage, 77% for the non-rapid eye movement (REM) stage (N1 = 29%, N2 = 88%, and N3 = 6%), and 89% for the REM stage. The overall agreement was measured with the use of weighted kappa, which was 0.61, 95% confidence interval, 0.58 to 0.64. In the ICU study, the mean recording time for the 23 enrolled patients was 19.10 hours. There were several signs indicative of poor-quality sleep, where sleep was distributed throughout the day, with reduced time spent in REM (1.38% ± 2.74% of total sleep time), and stage N3 (2.17% ± 5.53% of total sleep time) coupled with a high arousal index (34.63 ± 19.04 arousals per hour). The occurrence of ICU delirium was not significantly different between patients with and without sleep disruption.

CONCLUSIONS: Our results suggest the utility of a portable EEG monitor to measure different sleep stages, transitions, and arousals; however, the accuracy in measuring different sleep stages by the SedLine monitor varies compared with PSG. Our results also support previous findings that sleep is fragmented in critically ill patients. Further research is necessary to develop portable EEG monitors that have higher agreement with PSG.

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Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine2016-06-22 15:59:43 PM

Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine: BACKGROUND: Histamine receptors are known to participate in spinal cord nociceptive transmission, and previous studies have suggested that histaminergic receptors are involved in the analgesic effects of morphine. Herein, we investigated the effect of intrathecal injection of histaminergic agonists and antagonists in a model of acute articular inflammation and their interaction with morphine.

METHODS: After carrageenan injection in the right knee joint, articular incapacitation was measured hourly, for up to 6 hours, by the paw elevation time during 1-minute periods of stimulated walking. Inflammatory edema was also assessed hourly by determining an increase in articular diameter. Spinal treatments were administered 20 minutes before knee-joint carrageenan injection and were compared with the saline-treated control group.

RESULTS: Intrathecally injected histamine increased incapacitation and articular edema, whereas the H1R antagonist, cetirizine, decreased both parameters. The H3R agonist, immepip, decreased both incapacitation and edema, but the H3R antagonist, thioperamide, increased both incapacitation and edema. Morphine inhibited both incapacitation and edema. Furthermore, combining a subeffective dose of morphine with cetirizine or immepip potentiated the analgesic and antiedematogenic effect.

CONCLUSIONS: Histamine seems to act at the spinal level via H1 and H3 receptors to modulate acute arthritis in rats. An H1R antagonist and H3R agonist were found to potentiate the analgesic and antiedematogenic effects of morphine, suggesting that histaminergic and opioid spinal systems may be explored for means of improving analgesia, as well as peripheral anti-inflammatory effects.

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Vermilion Reconstruction with Genital Mucosa2016-06-22 15:59:35 PM

Vermilion Reconstruction with Genital Mucosa:

Summary: Functional and aesthetical reconstruction, especially of the upper lip after ablative tumor surgery, can be very challenging. The skin of the lip might be sufficiently reconstructed by transpositional flaps from the nasolabial or facial area. Large defects of the lip mucosa, including the vestibule, are even more challenging due to the fact that flaps from the inner lining of the oral cavity often lead to functional impairments. We present a case of multiple vermilion and skin resections of the upper lip. At the last step, we had to resect even the whole vermilion mucosa, including parts of the oral mucosa of the vestibule, leaving a bare orbicularis oris muscle. To reconstruct the mucosal layer, we used a mucosal graft from the labia minora and placed it on the compromised lip and the former transpositional flaps for the reconstructed skin of the upper lip with very good functional and aesthetic results.

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Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction2016-06-22 15:59:27 PM

Three-dimensional autologous cartilage framework fabrication assisted by new additive manufactured ear-shaped templates for microtia reconstruction: During microtia reconstruction, the intra-operative design of the cartilage framework is important for the appearance and symmetry of the bilateral auricles. Templates (traditionally, the x-ray film template) are usually utilized to complete the task, which can provide cues regarding size, cranioauricular angle and positioning to the surgeons. With a combination of three-dimensional (3D) scanning and additive manufacturing (AM) techniques, we utilized two different ear-shaped templates (sheet moulding and three-dimensional templates) during the fabrication of 3D customized autologous cartilage frameworks for auricle reconstruction.

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A method to switch from oral dopamine agonists to rotigotine in patients with restless legs syndrome and mild augmentation2016-06-22 15:59:21 PM
Article in Press

John W Winkelman, MD, PhD

,

Susan E Mackie

,

Leslie A Mei

,

Samuel Platt

,

Laura Schoerning

DOI: http://ift.tt/28P7sem
Highlights

• Augmentation of RLS symptoms with oral dopamine agonists is common.

• Optimal management of augmentation in such cases is controversial.

• Cross-titration to rotigotine was successful in 70% of patients with mild augmentation at 5 weeks.

• However, at 1 year, 50% had discontinued rotigotine due to lack of continued efficacy or side effects.

Abstract

Background

We examined the short- and long-term efficacy and tolerability of a cross-titration algorithm from oral dopamine agonists to the rotigotine transdermal patch in patients dissatisfied with their RLS treatment, predominantly with mild augmentation.

Methods

Patients with RLS (n=20) were recruited at a single site. The cross-titration consisted of decreasing oral dopaminergic agents (ropinirole by 1 mg or pramipexole by 0.25 mg) and increasing rotigotine by 1 mg every two days. Efficacy and AEs were assessed at 1, 3, 6 and 12 months after the switch.

Results

Patients had moderate-severe RLS symptoms at baseline (mean IRLS score 19.4 ± 5.5); 85% had augmentation and 45% reported afternoon RLS symptoms. Baseline mean pramipexole equivalent dose was 0.6 ± 0.3 mg. At Week 5, 85% (17/20) had successfully switched from their oral dopamine agonist to rotigotine (mean dose 2.5 ± 0.6 mg; change in IRLS score: -6.7 ± 8.4, p=0.002); 14 patients were CGI-I responders (much or very much improved). Three patients withdrew due to lack of efficacy. Twelve months after cross-titration, 10 patients continued on rotigotine, of whom 4 required either higher doses of rotigotine or supplemental RLS medication compared to their optimal Week 5 dose; five patients withdrew due to AEs and 2 due to lack of efficacy.

Conclusion

A cross-titration to rotigotine was efficacious after 5 weeks in 70% of patients dissatisfied with RLS treatment, most of whom had mild augmentation. At 1 year following the medication switch 50% had discontinued rotigotine due to lack of continued efficacy or side effects.

Key words:

restless legs syndrome, rotigotine, augmentation, pramipexole, ropinirole
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Sleep disordered breathing and nocturnal hypoxemia in young adults with sickle cell disease2016-06-22 15:59:13 PM
P.L. Whitesell

,

O. Owoyemi

,

P. Oneal

,

M. Nouraie

,

E.S. Klings

,

A. Rock

,

T.A. Mellman

,

T. Berihun

,

J. Lavella

,

R.E. Taylor

,

S.P. Perrine

DOI: http://ift.tt/28P7ovc
Highlights

• An AHI > 5 was seen in 10 of 20 subjects attending a sickle cell disease clinic.

• Elevated AHI correlated with systolic BP, mitral valve E/A ratio, and QoL scores.

• Hypoxemia occurred in some subjects independently from sleep apnea events.

• Results suggest further study with larger subject numbers is warranted.

Abstract

Sleep disordered breathing (SDB) is reported in up to 69% of adolescents and children with sickle cell disease (SCD) [1], but data regarding the prevalence of SDB in adults with SCD are limited. To obtain a preliminary assessment of the frequency and degree of sleep-related hypoxemia and potential associations with cardiovascular function in adults with SCD, we performed overnight sleep studies, 6-minute walk tests, echocardiograms, hematologic and chemistry panels, and administered the Pittsburgh Sleep Quality Index (PSQI), fatigue and health related quality of life measurement in 20 young adults with SCD attending a sickle cell clinic for routine care. Sleep apnea, defined as an apnea-hypopnea index (AHI) >5 events/hour, was found in 50% of subjects. Traditional clinical indicators such as obesity, the presence of snoring, and reported sleep complaints did not reliably differentiate these subjects. Subjects with an AHI>5 had higher mean systolic blood pressure (p =.03), evidence of impaired left ventricular diastolic function (i.e. increased mitral valve E/A ratio, p =.05), a trend toward greater reduction in 6 minute walk distances (p =.06), and lower Health-related Quality of Life scores (p <=.01). Three of nine subjects with more severe anemia (total Hb < 9.0) demonstrated nocturnal hypoxemia in the absence of sleep apnea. As prolonged and frequent hypoxemic episodes likely increase risks for vaso-occlusive, cardiovascular, and neurologic complications of SCD, these results suggest that the prevalence and severity of SDB should be investigated further in studies of larger patient populations. If confirmed, these findings could identify opportunities to prevent or reduce nocturnal hypoxia and improve outcomes.

Keywords:

sickle cell disease, sleep apnea, hypoxia, hypertension
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Free Tissue Transfer to Head and Neck2016-06-22 15:59:10 PM

Mayo Clinic Experience with Unfavorable Results After

via Plastic Surgery

Publication date: Available online 22 June 2016
Source:Clinics in Plastic Surgery
Author(s): Thomas H. Nagel, Richard E. Hayden
Teaser

Free tissue transfer to the head and neck in the modern era has a high success rate. To maximize success with reconstructive surgery in the head and neck region, it helps to understand those factors that present unique challenges. These factors include contamination by the upper aerodigestive tract, tissue mobility, and a high percentage of patients receiving radiotherapy for oncologic treatment. This article reviews the authors' experience in the head and neck, specifically how addressing these factors can best lead to successful functional and aesthetic outcomes. The authors share surgical techniques and lessons learned from their successes and failures.

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Intergenotype recombinant analysis of full-length hepatitis B virus genomes from 516 Chinese patients with different illness categories2016-06-22 15:57:28 PM
Intergenotype recombinant analysis of full-length hepatitis B virus genomes from 516 Chinese patients with different illness categories:
Abstract

This study aimed to reveal characteristics and clinical relevance of HBV intergenotypic recombinants. Serum samples of 516 patients from Northern China were collected, including 131 with acute hepatitis B (AHB), 239 with chronic hepatitis B (CHB) and 146 with acute-on-chronic liver failure (ACLF). Full-length HBV genomes were sequenced and HBV genotypes were analyzed. Genotype C, B, D, and intergenotypic recombinants were detected in 71.12% (367/516), 19.96% (103/516), 0.78% (4/516), and 8.14% (42/516) of the patients. The latter comprised 21 with AHB, ten with CHB and eleven with ACLF; and the occupations of intergenotypic recombinants in AHB, CHB, and ACLF groups were 16.03%, 4.18%, and 7.53% (P

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The evaluation of local oxidative/nitrosative stress in patients with pityriasis versicolor: a preliminary study2016-06-22 15:57:28 PM
The evaluation of local oxidative/nitrosative stress in patients with pityriasis versicolor: a preliminary study:
Summary

Yeast of Malassezia, members of the microbiologic flora of the skin, cause pityriasis versicolor and have also been implicated in the pathogenesis of other superficial dermatoses. The mechanisms by which the yeast cause these dermatoses, however, are not yet clear, and there have been no studies on the interaction between fungi and keratinocytes, especially the effects of fungi on the production of reactive oxygen/nitrogen species by human keratinocytes. This is the first study we aimed to evaluate the role of oxidative/nitrosative stress in affected skin areas in patients with pityriasis versicolor. Sixty pityriasis versicolor patients and 60 healthy subjects as control group were enrolled. Scraping samples were obtained from the lesional skin areas in patients and from the normal skin areas in controls. The distribution of lesions of pityriasis versicolor was mild in all patients. We have isolated two Malassezia species: M. furfur being isolated in 75% of patients, followed by M. globosa (25%). The levels of oxidative/nitrosative stress biomarkers were significantly higher in patients than the controls (P

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Disorders of the biceps and triceps tendons at the elbow2016-06-22 15:57:28 PM
Disorders of the biceps and triceps tendons at the elbow:
Orthopaedics and Trauma
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Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?2016-06-22 15:57:28 PM
Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?:
Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?

Emerging Microbes & Infections 5, e58 (June 2016). doi:10.1038/emi.2016.57

Authors: Marycelin Baba, Daniel K Masiga, Rosemary Sang & Jandouwe Villinger

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The emergence and outbreak of multidrug-resistant typhoid fever in China2016-06-22 15:57:28 PM
The emergence and outbreak of multidrug-resistant typhoid fever in China:
The emergence and outbreak of multidrug-resistant typhoid fever in China

Emerging Microbes & Infections 5, e62 (June 2016). doi:10.1038/emi.2016.62

Authors: Meiying Yan, Xinlan Li, Qiaohong Liao, Fang Li, Jing Zhang & Biao Kan

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Study design and results of a population-based study on perceived stress following Hurricane Sandy2016-06-22 15:57:28 PM
Study design and results of a population-based study on perceived stress following Hurricane Sandy:
Disaster Medicine and Public Health Preparedness
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An outbreak of cutaneous anthrax in Yunnan, China2016-06-22 15:57:28 PM
An outbreak of cutaneous anthrax in Yunnan, China:
An outbreak of cutaneous anthrax in Yunnan, China

Emerging Microbes & Infections 5, e64 (June 2016). doi:10.1038/emi.2016.65

Authors: Ying Huang, Yingrong Du, Yaling Wang, Ning Wang, Jinsong Bai, Haiyun Chen, Hua He, Jun Xu, Yan Wu, Yun Luo, Xiaolong Li & Guodong Liang

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Clinical analysis of preoperative risk factors for the incidence of deep venous thromboembolism in patients undergoing posterior lumbar interbody fusion2016-06-22 15:57:28 PM
Clinical analysis of preoperative risk factors for the incidence of deep venous thromboembolism in patients undergoing posterior lumbar interbody fusion:
Journal of Orthopaedic Surgery and Research
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Intergenotype recombinant analysis of full-length hepatitis B virus genomes from 516 Chinese patients with different illness categories2016-06-22 15:57:28 PM
Intergenotype recombinant analysis of full-length hepatitis B virus genomes from 516 Chinese patients with different illness categories:
Abstract

This study aimed to reveal characteristics and clinical relevance of HBV intergenotypic recombinants. Serum samples of 516 patients from Northern China were collected, including 131 with acute hepatitis B (AHB), 239 with chronic hepatitis B (CHB) and 146 with acute-on-chronic liver failure (ACLF). Full-length HBV genomes were sequenced and HBV genotypes were analyzed. Genotype C, B, D, and intergenotypic recombinants were detected in 71.12% (367/516), 19.96% (103/516), 0.78% (4/516), and 8.14% (42/516) of the patients. The latter comprised 21 with AHB, ten with CHB and eleven with ACLF; and the occupations of intergenotypic recombinants in AHB, CHB, and ACLF groups were 16.03%, 4.18%, and 7.53% (P

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The evaluation of local oxidative/nitrosative stress in patients with pityriasis versicolor: a preliminary study2016-06-22 15:57:28 PM
The evaluation of local oxidative/nitrosative stress in patients with pityriasis versicolor: a preliminary study:
Summary

Yeast of Malassezia, members of the microbiologic flora of the skin, cause pityriasis versicolor and have also been implicated in the pathogenesis of other superficial dermatoses. The mechanisms by which the yeast cause these dermatoses, however, are not yet clear, and there have been no studies on the interaction between fungi and keratinocytes, especially the effects of fungi on the production of reactive oxygen/nitrogen species by human keratinocytes. This is the first study we aimed to evaluate the role of oxidative/nitrosative stress in affected skin areas in patients with pityriasis versicolor. Sixty pityriasis versicolor patients and 60 healthy subjects as control group were enrolled. Scraping samples were obtained from the lesional skin areas in patients and from the normal skin areas in controls. The distribution of lesions of pityriasis versicolor was mild in all patients. We have isolated two Malassezia species: M. furfur being isolated in 75% of patients, followed by M. globosa (25%). The levels of oxidative/nitrosative stress biomarkers were significantly higher in patients than the controls (P

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Disorders of the biceps and triceps tendons at the elbow2016-06-22 15:57:28 PM
Disorders of the biceps and triceps tendons at the elbow:
Orthopaedics and Trauma
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Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?2016-06-22 15:57:28 PM
Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?:
Has Rift Valley fever virus evolved with increasing severity in human populations in East Africa?

Emerging Microbes & Infections 5, e58 (June 2016). doi:10.1038/emi.2016.57

Authors: Marycelin Baba, Daniel K Masiga, Rosemary Sang & Jandouwe Villinger

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The emergence and outbreak of multidrug-resistant typhoid fever in China2016-06-22 15:57:28 PM
The emergence and outbreak of multidrug-resistant typhoid fever in China:
The emergence and outbreak of multidrug-resistant typhoid fever in China

Emerging Microbes & Infections 5, e62 (June 2016). doi:10.1038/emi.2016.62

Authors: Meiying Yan, Xinlan Li, Qiaohong Liao, Fang Li, Jing Zhang & Biao Kan

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Study design and results of a population-based study on perceived stress following Hurricane Sandy2016-06-22 15:57:28 PM
Study design and results of a population-based study on perceived stress following Hurricane Sandy:
Disaster Medicine and Public Health Preparedness
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An outbreak of cutaneous anthrax in Yunnan, China2016-06-22 15:57:28 PM
An outbreak of cutaneous anthrax in Yunnan, China:
An outbreak of cutaneous anthrax in Yunnan, China

Emerging Microbes & Infections 5, e64 (June 2016). doi:10.1038/emi.2016.65

Authors: Ying Huang, Yingrong Du, Yaling Wang, Ning Wang, Jinsong Bai, Haiyun Chen, Hua He, Jun Xu, Yan Wu, Yun Luo, Xiaolong Li & Guodong Liang

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Clinical analysis of preoperative risk factors for the incidence of deep venous thromboembolism in patients undergoing posterior lumbar interbody fusion2016-06-22 15:57:28 PM
Clinical analysis of preoperative risk factors for the incidence of deep venous thromboembolism in patients undergoing posterior lumbar interbody fusion:
Journal of Orthopaedic Surgery and Research
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An immunogen containing four tandem 10E8 epitope repeats with exposed key residues induces antibodies that neutralize HIV-1 and activates an ADCC reporter gene2016-06-22 15:57:28 PM
An immunogen containing four tandem 10E8 epitope repeats with exposed key residues induces antibodies that neutralize HIV-1 and activates an ADCC reporter gene:
An immunogen containing four tandem 10E8 epitope repeats with exposed key residues induces antibodies that neutralize HIV-1 and activates an ADCC reporter gene

Emerging Microbes & Infections 5, e65 (June 2016). doi:10.1038/emi.2016.86

Authors: Zhiwu Sun, Yun Zhu, Qian Wang, Ling Ye, Yanyan Dai, Shan Su, Fei Yu, Tianlei Ying, Chinglai Yang, Shibo Jiang & Lu Lu

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World's first vaccine developed against toxic shock syndrome2016-06-22 15:57:28 PM
World's first vaccine developed against toxic shock syndrome:
Medical University of Vienna
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Therapeutic observation of needle embedding for constipation after thoracolumbar vertebral fracture2016-06-22 15:57:28 PM
Therapeutic observation of needle embedding for constipation after thoracolumbar vertebral fracture:
Journal of Acupuncture and Tuina Science
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Invisible wounds: Obstetric violence in the United States2016-06-22 15:57:28 PM
Invisible wounds: Obstetric violence in the United States:
Reproductive Health Matters
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Sex hormones protect against amyloid-beta induced oxidative stress in the choroid plexus cell line Z3102016-06-22 15:57:28 PM
Sex hormones protect against amyloid-beta induced oxidative stress in the choroid plexus cell line Z310:
Abstract

The choroid plexus (CP) epithelium is a unique structure in the brain that forms the interface between the peripheral blood on the basal side and the cerebrospinal fluid (CSF) on the apical side. It is a relevant source of many polypeptides secreted to the CSF with neuroprotective functions and participates in the elimination and detoxification of brain metabolites, such as β-amyloid (Aβ) removal from the CSF through transporter-mediated influx. The CP is also a target tissue for sex hormones (SHs) which have recognized neuroprotective effects against a variety of insults, including Aβ toxicity and oxidative stress in the central nervous system. This study aimed at understanding how SHs modulate Aβ-induced oxidative stress in a CP cell line (Z310 cell line) by analysing the effects of Aβ1-42 on oxidative stress, mitochondrial function and apoptosis, and assessing how 17β-estradiol (E2) and 5α-dihydrotestosterone (DHT) modulated these effects and the cellular uptake of Aβ1-42 by CP cells. Our findings show that E2 and DHT treatment reduce Aβ1-42-induced oxidative stress and the internalization of Aβ1-42 by CP epithelial cells, highlighting the importance of considering the SHs background and therefore sex-related differences in the Aβ metabolism and clearance by CP cells.

This article is protected by copyright. All rights reserved.

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Routine radiographs at time of pin removal after closed reduction and percutaneous pinning for type 2 supracondylar humerus fractures do not change management: A retrospective cohort study2016-06-22 15:57:28 PM
Routine radiographs at time of pin removal after closed reduction and percutaneous pinning for type 2 supracondylar humerus fractures do not change management: A retrospective cohort study:
Journal of Children's Orthopaedics
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Effect of Hurricane Sandy on Long Island Emergency Departments Visits2016-06-22 15:57:28 PM
Effect of Hurricane Sandy on Long Island Emergency Departments Visits:
Disaster Medicine and Public Health Preparedness
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Continuous infusion versus intermittent flushing: Maintaining peripheral intravenous access in newborn infants2016-06-22 15:57:28 PM
Continuous infusion versus intermittent flushing: Maintaining peripheral intravenous access in newborn infants:
Journal of Perinatology
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Working mechanisms of a behavioural intervention promoting physical activity in persons with subacute spinal cord injury2016-06-22 15:57:28 PM
Working mechanisms of a behavioural intervention promoting physical activity in persons with subacute spinal cord injury:
Journal of Rehabilitation Medicine
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Diagnostic accuracy of flexion-extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography2016-06-22 15:57:28 PM
Diagnostic accuracy of flexion-extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography:
Emergency Medicine Australasia
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Nonossifying fibromas of the distal tibia: Possible etiologic relationship to the interosseous membrane2016-06-22 15:57:28 PM
Nonossifying fibromas of the distal tibia: Possible etiologic relationship to the interosseous membrane:
Journal of Children's Orthopaedics
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Prehospital Indicators for Disaster Preparedness and Response: New York City Emergency Medical Services in Hurricane Sandy2016-06-22 15:57:28 PM
Prehospital Indicators for Disaster Preparedness and Response: New York City Emergency Medical Services in Hurricane Sandy:
Disaster Medicine and Public Health Preparedness
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Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology2016-06-22 15:50:28 PM

Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology: Objective

Nonthyroid metastases to the thyroid gland can cause morbidity, including dysphagia, dysphonia, and airway compromise. Because metastatic malignancies portend a poor prognosis, obtaining equipoise between treatment morbidity and local disease progression is paramount. We reviewed cases of nonthyroid metastases to determine treatment and prognostic recommendations.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Subjects and Methods

We searched PubMed for reported cases between 1994 and September 2013 using search terms as follows: any combination of primary tumor locations and thyroid, as well as the terms thyroid and metastasis. Only unique cases of nonthyroid metastases were included. Combined with 17 additional tumors at our own institution, we found 818 unique nonthyroid metastases, of which 384 had management and survival data available.

Results

Renal cell carcinoma was most common, presenting in 293 (35.8%) patients, followed by lung and gastrointestinal malignancies. Patients were treated with total thyroidectomy (34.0%), subtotal thyroidectomy including lobectomy (32.6%), and no surgery (33.5%). Surgical management was associated with improved survival duration (P < .01). Locoregional recurrence was less likely in patients treated with total versus partial thyroidectomy (4.8% vs 13%). Extent of surgical management did not have a significant effect on patient survival. Delayed presentation was associated with improved survival duration (P = .01).

Conclusions

Nonthyroid metastases to the thyroid gland are unusual tumors. Surgical intervention is associated with improved survival, but expected morbidity of untreated tumors is difficult to assess. Site of origin, time to diagnosis, and surgical approach are related to survival and recurrence rates.

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ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?2016-06-22 15:50:16 PM

ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?:

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator is meant to provide an estimation of perioperative risk. Our goal was to determine the clinical applicability of the calculator in major head and neck surgery. A retrospective chart review was completed for major head and neck operations performed at 1 institution from 2013 to 2014. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. Overall, the ACS NSQIP calculator had little predictive value for pneumonia, surgical site infection, 30-day return to operating room, or length of stay within this cohort (P > .05). The calculator appears to have some value predicting total numbers of complications but has poor performance predicting an individual's risk of suffering a perioperative complication. In conclusion, in our small cohort of patients, the ACS NSQIP calculator was a poor predictor of perioperative complications following major head and neck operations.

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Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care2016-06-22 15:50:08 PM

Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care: Objectives

(1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care.

Study Design

A prospective quality improvement study.

Setting

Hospital-based otolaryngology clinic.

Subjects and Methods

The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test.

Results

Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively.

Conclusion

Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

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Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy2016-06-22 15:50:02 PM

Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy: Objective

To determine if decisional regret (DR) in parents following tonsillectomy/adenotonsillectomy (TA) in their children is related to preoperative decisional conflict, perceived outcome of surgery, complications of surgery, or other factors.

Study Design

Observational analytic cohort study.

Setting

Tertiary care children's hospital.

Subjects and Methods

Preoperative decisional conflict (DC) and SURE tests were administered to a parent of a child scheduled for TA between July 2014 and July 2015. The DR tests were given 1 to 3 months postoperatively. Data were collected on patient age, sex, perceived outcome of surgery, complications (including bleeding), emergency room visits, and clinic phone calls.

Results

A total of 102 families were studied, including 48 female and 54 male patients with an average age of 6.29 years. Parental respondents included 83 mothers, 14 fathers, and 5 grandmothers. Overall, DC and DR were both low in this group, with a median of 0 for each (means: 7.74 for DC and 8.78 for DR). DC was higher in parents who canceled surgery or failed to keep follow-up appointments (27.19) versus parents who brought their children for surgery (6.78; P < .05). DR was significantly higher in parents with DC (20.00 vs 7.59; P < .05). It was not related to age of the patient, sex, parental perception of resolution of preoperative complaints, complications (including bleeding or dehydration), emergency department visits, or parental phone calls to the otolaryngology clinic. SURE tests indicated that every parent was confident of his or her decision on the day of surgery.

Conclusion

Preoperative DC is likely the most important factor in determining parental DR after the child undergoes TA.

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Clinical Practice Guidelines: Whose Practice Are We Guiding?2016-06-22 15:49:51 PM

Clinical Practice Guidelines: Whose Practice Are We Guiding?:

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has just released an update to the clinical practice guideline (CPG) on otitis media with effusion. This common condition is frequently managed by primary care providers; however, their awareness and utilization of the AAO-HNSF CPGs are unknown. We performed a cross-sectional survey to assess familiarity with otologic diagnoses, evaluation skills, and guidelines. Only 38.5% of respondents use pneumatic otoscopy, and roughly 50% utilize a CPG for management of otitis media or for referral for tympanostomy tube insertion. Providers predominantly use the acute otitis media guideline from the American Academy of Pediatrics. In this single-institution study, providers are largely unaware of the AAO-HNSF CPGs and could benefit from additional training, including workshops taught by otolaryngologists within individual health care systems or development of a national otolaryngology medical student curriculum. A more immediate option includes referencing our CPGs on specialty societies' websites or newsletters.

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Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends2016-06-22 15:49:43 PM

Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends:

Four-dimensional computed tomography (4D-CT) is a new modality for preoperative localization of parathyroid adenomas. We performed a survey study to describe the role and trends in the utilization of 4D-CT. Of 361 radiologists, 200 (55%) reported that 4D-CT was used in their practices. Nineteen (10%) used 4D-CT as the first-line imaging study; 155 (76%) reported that 4D-CT played a secondary role; and 26 (13%) reported that it is performed routinely in combination with ultrasound and scintigraphy. Early adopters of 4D-CT (use for >3 years) were 3 times more likely to use 4D-CT in a first-line role (18%) when compared with radiologists who used 4D-CT for ≤3 years (6%; P < .05). In conclusion, more than half of radiologists perform 4D-CT, and a majority reported that 4D-CT plays a secondary role. However, this role may change, as utilization is increasing and radiologists may follow early adopters, who are more likely to use it as a first-line study.

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Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes2016-06-22 15:49:38 PM

Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes: Objectives

to determine national benchmarks for established quality indicators in head and neck cancer (HNCA) surgery, focusing on differences between academic and nonacademic institutions.

Study Design

Cross-sectional analysis of national database.

Subjects and Methods

HNCA surgery admissions from the 2009-2011 Nationwide Inpatient Sample were analyzed for preoperative characteristics and postoperative outcomes. Multivariate analyses were used to identify factors influencing quality indicators after HNCA surgery. Quality metrics—including length of stay (LOS), inpatient death, return to the operating room (OR), wound infection, and transfusion—were compared for academic versus nonacademic institutions.

Results

A total of 38,379 HNCA surgery inpatient admissions (mean age, 56.5 years; 52.4% male) were analyzed (28,288 teaching vs 10,091 nonteaching). Nationally representative quality metrics for HNCA surgery were as follows: mean LOS, 4.26 ± 0.12 days; return to OR, 3.3% ± 0.2%; inpatient mortality, 0.7% ± 0.1%; wound infection rate, 0.9% ± 0.1%; wound complication rate, 4.3% ± 0.2%; and transfusion rate, 4.3% ± 0.3%. HNCA surgery patients at teaching hospitals had a greater proportion of males, radiation history, and high-acuity procedures and greater comorbidity scores (all P < .001). Multivariate analyses adjusting for age, sex, income, payer, prior radiation, comorbidity scores, and procedural acuity demonstrated that teaching hospitals had a slightly increased LOS (+0.30 days; P = .009) and odds ratio for wound infection (1.54; 95% CI: 1.22-1.94) versus nonteaching hospitals. There were no significant differences in return to OR (P = .271), inpatient mortality (P = .686), or transfusion rate (P = .960).

Conclusion

Despite caring for substantially more complex HNCA surgery patients with greater comorbidities, teaching hospitals demonstrate only a marginally increased LOS and wound complication rate versus nonteaching hospitals, while other established quality metrics are similar.

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Are Online Zenkers Diverticulum Materials Readable and Understandable?2016-06-22 15:49:27 PM

Are Online Zenkers Diverticulum Materials Readable and Understandable?: Objective

Patients use a multitude of resources to learn about Zenker's diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability.

Methods

The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability.

Results

The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability (r = –0.62, P < .05). Fleiss' interrater reliability for the raters demonstrated substantial agreement between the 4 raters ( = 0.64).

Conclusion

Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels.

Implications for Practice

Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.

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Near-Infrared Optical Imaging for Diagnosis of Maxillary Sinusitis2016-06-22 15:49:18 PM

Near-Infrared Optical Imaging for Diagnosis of Maxillary Sinusitis:

Computed tomography (CT) is the current gold standard imaging for chronic rhinosinusitis (CRS) but is limited by cost, risk of radiation, and difficulty of being performed in the typical outpatient primary care setting. We describe the novel use of a low-cost, handheld technology to deliver an intraoral near-infrared (NIR) wavelength light to optically image the maxillary sinuses. Digital images were collected for subjects presenting with sinus disease using an intraoral NIR light source for transillumination of the maxillary sinuses, captured by a modified digital single-lens reflex camera. Light intensity contrasts were enhanced using computer analysis and subsequently compared to CT findings. NIR illumination produced unique patterns reflecting different disease states: normal sinus anatomy, mild sinus disease and/or mucosal thickening, and complete opacification of the sinus. Current results suggest that NIR imaging may facilitate the diagnosis of sinusitis in the outpatient setting with minimal cost and no radiation exposure.

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Stapedotomy vs Cochlear Implantation for Advanced Otosclerosis: Systematic Review and Meta-analysis2016-06-22 15:49:10 PM

Stapedotomy vs Cochlear Implantation for Advanced Otosclerosis: Systematic Review and Meta-analysis: Objectives

To compare the hearing outcomes of stapedotomy vs cochlear implantation in patients with advanced otosclerosis.

Data Sources

PubMed, EMBASE, and The Cochrane Library were searched for the terms otosclerosis, stapedotomy, and cochlear implantation and their synonyms with no language restrictions up to March 10, 2015.

Methods

Studies comparing the hearing outcomes of stapedotomy with cochlear implantation and studies comparing the hearing outcomes of primary cochlear implantation with salvage cochlear implantation after an unsuccessful stapedotomy in patients with advanced otosclerosis were included. Postoperative speech recognition scores were compared using the weighted mean difference and a 95% confidence interval.

Results

Only 4 studies met our inclusion criteria. Cochlear implantation leads to significantly better speech recognition scores than stapedotomy (P < .0001). However, this appears to be due to the variability in outcomes after stapedotomy. Cochlear implantation does not lead to superior speech recognition scores compared with the subgroup of successful cases of stapedotomy plus hearing aid (P = .47). There is also no significant difference with respect to speech recognition between primary cochlear implantation and those secondary to a failed stapedotomy (P = .22).

Conclusions

Cochlear implantation leads to a statistically greater and consistent improvement in speech recognition scores. Stapedotomy is not universally effective; however, it yields good results comparable to cochlear implantations in at least half of patients. For cases of unsuccessful stapedotomy, the option of cochlear implantation is still open, and the results obtained through salvage cochlear implantation are as good as those of primary cochlear implantation.

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from #Med Blogs by Alexandros G.Sfakianakis via Alexandros G.Sfakianakis on Inoreader http://ift.tt/28NdGvD
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Αρχειοθήκη ιστολογίου

! # Ola via Alexandros G.Sfakianakis on Inoreader

Η λίστα ιστολογίων μου

Τετάρτη 22 Ιουνίου 2016

Abstract

Abstract

Abstract

Summary

Background

Aim

Method

Results

Conclusion

Summary

Background

Aim

Method

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Abstract

Abstract

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Results

Conclusion

Main Articles

M Wierzbickaa1 c1, M Tokarskia1, M Puszczewicza2 and W Szyftera1

Main Articles

K Satoa1 c1, S Chitosea1, T Kuritaa1 and H Umenoa1

Main Articles

A Harrisona1 c1, J Montgomerya2 and F B Macgregora3

Review Articles

A Ashmana1 c1, O T Dalea2 and D L Baldwina1

Review Articles

K A Penga1 and E P Wilkinsona1 c1

Clinical Record

W L Neoa1 c1, N Durisalaa2 and E C Hoa1

Main Articles

M Karaa1 c1, H Erdoğana1, H B Altinişika2, H Aylança3, O Güçlüa1 and F S Dereköya1

Main Articles

B F Van Escha1 c1, P P G Van Benthema1, H J Van Der Zaag-Loonena1 and TJ D Bruintjesa1

Highlights

Abstract

Background

Methods

Results

Conclusion

Key words:

Highlights

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Teaser

Highlights

Abstract

Background

Methods

Results

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Key words:

Highlights

Abstract

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Teaser

Αρχειοθήκη ιστολογίου

M Wierzbicka^a1 ^c1, M Tokarski^a1, M Puszczewicz^a2 and W Szyfter^a1

K Sato^a1 ^c1, S Chitose^a1, T Kurita^a1 and H Umeno^a1

A Harrison^a1 ^c1, J Montgomery^a2 and F B Macgregor^a3

A Ashman^a1 ^c1, O T Dale^a2 and D L Baldwin^a1

K A Peng^a1 and E P Wilkinson^a1 ^c1

W L Neo^a1 ^c1, N Durisala^a2 and E C Ho^a1

M Kara^a1 ^c1, H Erdoğan^a1, H B Altinişik^a2, H Aylanç^a3, O Güçlü^a1 and F S Dereköy^a1

B F Van Esch^a1 ^c1, P P G Van Benthem^a1, H J Van Der Zaag-Loonen^a1 and TJ D Bruintjes^a1