Objectives: Watching a talker's mouth is beneficial for speech reception (SR) in many communication settings, especially in noise and when hearing is impaired. Measures for audiovisual (AV) SR can be valuable in the framework of diagnosing or treating hearing disorders. This study addresses the lack of standardized methods in many languages for assessing lipreading, AV gain, and integration. A new method is validated that supplements a German speech audiometric test with visualizations of the synthetic articulation of an avatar that was used, for it is feasible to lip-sync auditory speech in a highly standardized way. Three hypotheses were formed according to the literature on AV SR that used live or filmed talkers. It was tested whether respective effects could be reproduced with synthetic articulation: (1) cochlear implant (CI) users have a higher visual-only SR than normal-hearing (NH) individuals, and younger individuals obtain higher lipreading scores than older persons. (2) Both CI and NH gain from presenting AV over unimodal (auditory or visual) sentences in noise. (3) Both CI and NH listeners efficiently integrate complementary auditory and visual speech features. Design: In a controlled, cross-sectional study with 14 experienced CI users (mean age 47.4) and 14 NH individuals (mean age 46.3, similar broad age distribution), lipreading, AV gain, and integration of a German matrix sentence test were assessed. Visual speech stimuli were synthesized by the articulation of the Talking Head system "MASSY" (Modular Audiovisual Speech Synthesizer), which displayed standardized articulation with respect to the visibility of German phones. Results: In line with the hypotheses and previous literature, CI users had a higher mean visual-only SR than NH individuals (CI, 38%; NH, 12%; p
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Τετάρτη 25 Οκτωβρίου 2017
Prevalence of and Risk Factors for Tinnitus and Tinnitus-Related Handicap in a College-Aged Population.
Objective: Tinnitus is a common otological condition that affects almost 10% of US adults. Research suggests that college students are vulnerable to tinnitus and hearing loss as they are exposed to traumatic levels of noise on a regular basis. Tinnitus and its influence in daily living continue to be underappreciated in the college-aged population. Therefore, the objective for the present study was to analyze prevalence and associated risk factors of tinnitus and tinnitus-related handicap in a sample of college-aged students. Design: A survey was administered to 678 students aged 18-30 years in a cross-section of randomly selected university classes. The survey was adopted from the National Health and Nutrition Examination Survey (2010). It inquired about demographic details, medical and audiological history, routine noise exposure, smoking, sound level tolerance, tinnitus, and tinnitus-related handicap in daily living. Tinnitus-related handicap was assessed by the Tinnitus Handicap Inventory (THI). Participants were divided into four groups: chronic tinnitus (bothersome tinnitus for >1 year), acute tinnitus (bothersome tinnitus for =18). A multinomial regression analysis revealed that individuals with high noise exposure, high sound level tolerance score, recurring ear infections, and self-reported hearing loss had high odds of chronic tinnitus. Females showed higher prevalence of acute tinnitus than males. Individuals with European American ethnicity and smoking history showed high odds of reporting subacute tinnitus. Almost 10% of the subjects reported that they were music students. The prevalence of chronic, acute, and subacute tinnitus was 11.3%, 22.5%, and 32.4%, respectively, for musicians, which was significantly higher than that for nonmusicians. Music exposure, firearm noise exposure, and occupational noise exposure were significantly correlated with tinnitus. Temporal characteristics of tinnitus, self-reported tinnitus loudness, and sound level tolerance were identified as major predictors for the overall THI score. Conclusions: Despite the reluctance to complain about tinnitus, a substantial portion of college-aged individuals reported tinnitus experience and its adverse influence in daily living. It was concluded that environmental and health-related factors can trigger tinnitus perception, while self-reported psychoacoustic descriptors of tinnitus may explain perceived tinnitus-related handicap in daily living by college-aged individuals. Future research is required to explore effects of tinnitus on educational achievements, social interaction, and vocational aspects of college students. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.
http://ift.tt/2zErMs3
http://ift.tt/2zErMs3
Case–control study of mandibular canal branching and tooth-related inflammatory lesions
Abstract
Objectives
Morphological variations of mandibular canals increase the risk of neurovascular damage and bleeding during surgical procedures by decreasing the predictability of the inferior alveolar neurovascular bundle location. To improve the predictability with such variations, the present study aimed to verify the possibility of a relationship between mandibular canal branches (MCBs) and tooth-related inflammatory lesions, using trough cone-beam computed tomography (CBCT) examinations.
Methods
The sample comprised 150 age and sex-matched examinations (50 cases and 100 controls) from two databases. The CBCT examinations were grouped by the presence of MCBs starting in the mandibular body regions as the outcome variable. Tooth-related inflammatory lesions and measurements of gray levels in the posterior region of the alveolar ridge were assessed in both groups. A multiple logistic regression analysis was applied to verify the relationships between MCBs and independent variables (p < 0.05).
Results
Occurrence of tooth-related inflammatory lesions increased the risk of MCBs in the mandibular body regions (p < 0.001; OR 11.640; 95% CI 4.327–31.311). High-contrast images had a weaker association with MCBs (p = 0.002; OR 1.002; 95% CI 1.002–1.003). The most frequent tooth-related inflammatory lesions in both groups were endodontic (34 lesions; 45.94% of the total lesions). Most of the tooth-related inflammatory lesions related to MCBs were endodontic (20 cases) and combined endodontic and periodontal inflammation (20 cases).
Conclusions
An association was observed between MCBs in the mandibular body regions and tooth-related inflammatory lesions. Inflammatory lesions of endodontic origin are most often associated with MCBs.
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An Autistic-Like Profile of Attention and Perception in Synaesthesia
Source:Cortex
Author(s): Jamie Ward, Paris Brown, Jasmine Sherwood, Julia Simner
Synaesthesia and autism are two neurodevelopmental conditions that have been shown to co-occur more than expected by chance. The studies reported here test the hypothesis that increased sensory sensitivity and enhanced attention-to-detail are core cognitive features that are shared between them. In Study 1, we administer self-report measures of sensory sensitivity and autistic traits (the Autism Spectrum Quotient, AQ) to a large heterogeneous sample of synaesthetes. Both sensory sensitivity and the attention-to-detail subscale of the AQ show a "dose-like" relationship with synaesthesia: namely, more kinds of synaesthesia is related to a greater shift up the autistic spectrum. Study 2 uses two objective measures of visual perception/attention linked to autistic traits: change blindness and detection of local embedded figures. Both measures are shown here to be sensitive to the attention-to-detail subscale of the AQ, and synaesthetes outperformed controls on both tasks. Synaesthetes appear to occupy a specific cognitive niche of having autistic-like traits linked to enhanced perception and attention. Whilst these typically occur in the absence of the traditional impairments that define autism, they may carry the cost of increased vulnerability to clinical levels of autism (Odds Ratio=2.07).
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Seymour Aubrey Papert (1928-2016)
Source:Artificial Intelligence in Medicine
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Comparative one- and two-photon uncaging of MNI-glutamate and MNI-kainate on hippocampal CA1 neurons
Source:Journal of Neuroscience Methods, Volume 293
Author(s): Stefan Passlick, Graham C.R. Ellis-Davies
BackgroundThe light-induced release of neurotransmitters from caging chromophores provides a powerful means to study the underlying receptors in a physiologically relevant context. Surprisingly, most caged neurotransmitters, including the widely used 4-methoxy-7-nitroindolinyl (MNI)-glutamate, show strong antagonism against GABA-A receptors. Kainate has been shown to exhibit a higher efficacy at glutamate receptors compared to glutamate itself. Thus, uncaging of kainate might allow the application of the caged compound at lower, less antagonistic concentrations.New methodsThis study provides a detailed comparison of MNI-glutamate and MNI–kainate uncaging by different modes of one- and two-photon irradiation on hippocampal CA1 pyramidal neurons in acute brain slices.Results/Comparison with existing methodsUnexpectedly, the data revealed that currents in response to MNI-glutamate uncaging were larger compared to MNI-kainate with local one-photon laser uncaging at the soma and two-photon uncaging at the same spines. Furthermore, the direct comparison demonstrates the influence of type of caged agonist and light delivery conditions used for uncaging on the amplitude and kinetic properties of the current response.ConclusionThese findings highlight the importance of experimental design for uncaging experiments and provide a basis for future studies employing one- and two-photon uncaging to understand glutamate-dependent processes. It further provides the first example of two-photon uncaging of kainate at single spines in acute brain slices.
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Long-Term Effect of Pulsed Nd-YAG Laser Combined with Exercise on Bone Mineral Density in Men with Osteopenia or Osteoporosis: 1 Year of Follow-Up
Photomedicine and Laser Surgery , Vol. 0, No. 0.
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The Effect of Gender on Resident Autonomy in the Operating room
Publication date: Available online 25 October 2017
Source:Journal of Surgical Education
Author(s): Julia Lichtenstein
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Results of a Surgical Simulation Course Designed to Improve Surgery Clerkship Performance
Publication date: Available online 25 October 2017
Source:Journal of Surgical Education
Author(s): Joseph LaPorta, Tanner McClure, Michael E. Tieman
Background and ObjectivesDuring the 2015-2016 academic year, Rocky Vista University College of Osteopathic Medicine (RVUCOM) conducted a required 1-week surgical simulation course as the first week of students' 8-week surgical clerkship. This course was adapted from a pilot RVUCOM surgical simulation course and other surgical simulation courses identified in the literature. The objectives of this course were to teach surgical skills and clinical knowledge, aid students in adjusting to the stress of a surgical clerkship, and improve students' confidence and abilities during the clerkship.MethodsIn all, 148 students participated in the surgical simulation course. Subjective assessment of this course included each student completing a daily standardized stress survey and student feedback surveys at the end of the course and at the end of the surgical clerkship. Objective assessment of this course compared precourse and postcourse tests of surgical knowledge and instrument identification, as well as comparison of NBME Surgery Subject Assessment percentile ranks of this class with 3 prior classes.ResultsDaily stress surveys indicated decreased stress on day 5 compared to day 1 (p < 0.01). Students' confidence level increased significantly on day 5 compared to day 1 (p < 0.01). Student feedback surveys demonstrated students' perception that surgical skills and clinical skills had been learned during the course and that the course improved their performance during the surgical clerkship.NBME Surgery Subject Assessment percentile rank improved significantly (p < 0.01) from a mean percentile rank of 36.94 for 3 previous classes to a mean percentile rank of 43.82 for the class who completed the simulation course. Surgical knowledge improved significantly (p < 0.001) from a pretest mean score of 47.02% to a posttest mean score of 55.14%. Surgical instrument identification improved significantly (p < 0.001) from a pretest mean of 13.81% to a posttest mean of 95.28%.ConclusionThe RVUCOM surgery simulation course significantly improved student performance academically and helped students acclimate to stress, increase their confidence level, and acquire surgical skills needed during the third-year surgery clerkship.
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Clinical Thyroidology for the Public – Highlighted Article
From Clinical Thyroidology for the Public: There has been a steady rise of thyroid cancers over the past several decades. Some of this is likely due to the increased use of imaging such as CT scans. However, it is likely that other factors play a role as well, including chemicals in our environment. Read More….
We welcome your feedback and suggestions. Let us know what you want to see in this publication.
Feedback & SuggestionsThe post Clinical Thyroidology for the Public – Highlighted Article appeared first on American Thyroid Association.
http://ift.tt/2gJJt5L
Clinical Thyroidology for the Public – Highlighted Article
From Clinical Thyroidology for the Public: There has been a steady rise of thyroid cancers over the past several decades. Some of this is likely due to the increased use of imaging such as CT scans. However, it is likely that other factors play a role as well, including chemicals in our environment. Read More….
We welcome your feedback and suggestions. Let us know what you want to see in this publication.
Feedback & SuggestionsThe post Clinical Thyroidology for the Public – Highlighted Article appeared first on American Thyroid Association.
http://ift.tt/2gJJt5L
Anesthesia and Sleep Apnea
Due to its low rate of diagnosis, in the general population over half of those experiencing Obstructive Sleep Apnea (OSA) are unaware that they have the condition. However, any acute medical event may exacerbate OSA and could have serious health consequences. In this context the management of the perioperative period, from anesthesia through the surgery itself and into the postoperative period, is more problematic for patients with sleep disordered breathing than for others. There is prolific literature in this area although large randomized trials are few due to the high sample size needed and possible ethical difficulties of withholding OSA treatment in the perioperative period.
http://ift.tt/2gJJmHi
Tumor Necrosis Factor Alpha in Sleep Regulation
This review details tumor necrosis factor alpha (TNF) biology and its role in sleep, and describes how TNF medications influence sleep/wake activity. Substantial evidence from healthy young animals indicates acute enhancement or inhibition of endogenous brain TNF respectively promotes and inhibits sleep. In contrast, the role of TNF in sleep in most human studies involves pathological conditions associated with chronic elevations of systemic TNF and disrupted sleep. Normalization of TNF levels in such patients improves sleep.
http://ift.tt/2yMFcpi
Anti myelin oligodendrocyte glycoprotein associated immunoglobulin G (AntiMOG-IgG)-associated neuromyelitis optica spectrum disorder with persistent disease activity and residual cognitive impairment
Annals of Indian Academy of Neurology 2017 20(4):411-413
Antibodies targeting myelin oligodendrocyte glycoprotein (MOG) have been recently reported in association with idiopathic inflammatory central nervous system disorders. Initially believed to be a benign disorder, anti MOG-IgG was noted to cause steroid responsive recurrent optic neuritis and isolated longitudinally extensive myelitis. However, there is growing evidence that the disease may be predominantly relapsing, often producing severe visual loss and involving regions other than the spinal cord and optic nerve. We report an adolescent male with an aggressive disease course previously undescribed in anti MOG-IgG-associated disease that left him with residual cognitive dysfunction.
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A sibling pair with autosomal recessive Charcot–Marie–Tooth disease due to novel ganglioside-induced differentiation-associated protein 1 mutation
Annals of Indian Academy of Neurology 2017 20(4):434-435
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Efficacy and safety of tacrolimus in myasthenia gravis: A systematic review and meta-analysis
Annals of Indian Academy of Neurology 2017 20(4):341-347
Aims: This study was designed to determine whether treatments with tacrolimus would provide benefit for patients with myasthenia gravis (MG). Materials and Methods: The databases of Medline, EMBASE, the Cochrane Library, and four Chinese databases were searched for eligible studies. Weighted mean differences and standardized mean differences (SMD) with corresponding 95% confidence intervals (CIs) were used to summarize the primary outcome, namely, steroid-sparing effect of tacrolimus in maintaining minimal manifestations, and the secondary outcome, namely, the effect of tacrolimus in reducing the severity of MG, respectively. Results: After systematic retrieval, 13 researches with two randomized controlled trials (RCTs) and 11 prospective open-label single-arm clinical trials were included in the study. For the primary outcome of two RCTs, one RCT which was followed up for 1 year showed a positive effect and the other RCT which was associated with treatment duration of 28 weeks showed a negative result. For the secondary outcome, meta-analyses of other 11 trials showed a benefit effect, overall. For the quantitative MG (QMG) score, there were significant differences with high heterogeneity (SMD: 2.93; 95% CI: 1.14–4.73; I2 = 86%). In contrast, for MG activities of daily living (MGADL) score, it was reduced by tacrolimus with significant SMD and less heterogeneity (SMD: 0.59; 95% CI: 0.33–0.85; I2 = 7%). Adverse effects were mentioned as mild. Discussion: The opposite results of two RCTs showed that tacrolimus with enough treatment duration might have positive steroid-sparing effect. The most possible cause of heterogeneity in the outcome of QMG score between trials was the baseline severity of MG. Conclusion: The above finding suggests that there might be a potential beneficial role with no serious side effects of tacrolimus, and additional better RCTs including larger sample sizes and long-term study are needed to confirm or refute the results.
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Clinico-Electrophysiological and genetic overlaps and magnetic resonance imaging findings in Charcot–Marie– Tooth disease: A pilot study from Western India
Annals of Indian Academy of Neurology 2017 20(4):425-429
Background: Charcot–Marie–Tooth (CMT) disease is clinically and genetically heterogeneous. There are no published series describing clinical, electrophysiological, and genetic information on CMT from the Indian subcontinent. Magnetic resonance imaging (MRI) neurography technique provides useful information about the plexus and roots and can be employed in patients with CMT. Settings and Design: A prospective, observational study carried out at a tertiary care hospital in Western India. Subjects and Methods: CMT patients fulfilling the UK Genetic Testing Network criteria were included. They underwent clinical, electrophysiological, radiological, and multigene panel testing. Results: Totally 22 patients (19 males, 3 females; 18 sporadic and 4 familial cases) were studied. Pes cavus (19), hammer toes (16), and scoliosis was seen in 1 patient. Electrophysiology revealed motor predominant neuropathy with 15 demyelinating (10 uniform and 5 multifocal) and 7 axonal patterns. Thickened lumbosacral plexuses on MRI neurography were evident in 6/10 studied patients, all 6 having demyelinating neuropathy. Genetic analysis identified PMP22, GJB1, SH3TC2, HSPB1, SPTLC2, MPZ, AARS, and NEFH gene mutations. Conclusions: This small series documents the pattern of CMT neuropathies as seen in Western India. Clinico-electrophysiological and genetic diagnosis showed general concordance some overlaps and reiterated advantages of gene panel testing in this heterogeneous group of neuropathies. MRI neurography was useful as an additional investigation to detect nerve enlargement in patients with demyelinating neuropathies.
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Johann bernhard aloys von Gudden and the Mad King of Bavaria
Annals of Indian Academy of Neurology 2017 20(4):348-351
Bernhard von Gudden was a psychiatrist in Prussia and he was summoned in March 1886 to examine King Ludwig II for his apparently insane activities like, profligate spending and erratic behaviour. A team of four estimable psychiatrists pronounced that he was not capable ruling. Consequently, he was dethroned and kept in a castle under supervision of von Gudden. Gudden championed the idea of 'no restraint' and advocated free movement of insane persons and one evening in June, he accompanied the King during an evening stroll to a lake. A few hours later, the corpus of both of them were recovered under mysterious circumstances. Autopsy suggested that the King was drowned but no post-mortem examination was performed on von Gudden. There are plenty of controversies regarding their death like, murder, accidental death or even natural death from cardiac arrest following immersion in cold water, but no incontrovertible conclusion could be arrived at, even after scrupulous analysis by historians and even the diagnosis of insanity of the King has been doubted. Some even suggested that the opinion of psychiatrists were sought as a pretense in order to depose the King.
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Optical coherence tomography and subclinical optical neuritis in longitudinally extensive transverse myelitis
Annals of Indian Academy of Neurology 2017 20(4):358-362
Objective: The aim is to compare the retinal nerve fiber layer (RNFL) thickness of longitudinally extensive transverse myelitis (LETM) eyes without previous optic neuritis with that of healthy control subjects. Methods: Over 20 LETM eyes and 20 normal control eyes were included in the study and subjected to optical coherence tomography to evaluate and compare the RNFL thickness. Result: Significant RNFL thinning was observed at 8 o'clock position in LETM eyes as compared to the control eyes (P = 0.038). No significant differences were seen in other RNFL measurements. Conclusion: Even in the absence of previous optic neuritis LETM can lead to subclinical axonal damage leading to focal RNFL thinning.
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Simultaneous miliary lesions of brain and lungs: A diagnostic challenge
Annals of Indian Academy of Neurology 2017 20(4):431-432
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Rapid clinical score for the diagnosis of tuberculous meningitis: A retrospective cohort study
Annals of Indian Academy of Neurology 2017 20(4):363-366
Objective: The aim of our study was to retrospectively validate a previously described rapid clinical score (RCS) in distinguishing tuberculous meningitis (TBM) from viral meningitis (VM) in people who are at increased risk of tuberculosis, as well as from cryptococcal meningitis (CM) in HIV-infected patients. Methods: We performed a retrospective study of patients admitted with a diagnosis of aseptic meningitis between January 2012 and December 2015, to a referral hospital for infectious diseases. The variables included in RCS were duration of symptoms before admission, neurological stage, cerebrospinal fluid (CSF) to blood glucose ratio, and CSF protein. We included in this retrospective study 31 patients with definite or probable TBM including 14 HIV-infected patients, 62 HIV-noninfected patients with VM, and 18 HIV-infected patients with CM. Results: The sensitivity of RCS to distinguish TBM from VM was 96.7%, with a specificity of 81.1% and the area under the receiver operating characteristic (ROC) curve was 0.949 (0.90–0.99). When all four criteria from the RCS were present, the specificity increased at 100%. In HIV-infected patients, the sensitivity and specificity of RCS in differentiating TBM from CM were 86.6% and 27.7%, respectively, and the area under the ROC curve was 0.669 (0.48–0.85). Conclusion: This easy-to-use RCS was found to be helpful in differentiating TBM from VM, with a better sensitivity than molecular amplification techniques and a relatively good specificity. However, the RCS was not useful to differentiate between TBM and CM in HIV-infected patients.
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Cutaneous adverse drug reactions to lamotrigine and human leukocyte antigen typing in North Indian patients: A case series
Annals of Indian Academy of Neurology 2017 20(4):408-410
Cutaneous adverse drug reaction (cADR) has limited epidemiological data in India. The older antiepileptic drugs, i.e., carbamazepine, phenytoin, valproic acid, phenobarbitone, etc., induce severe cADRs that have a strong associated with human leukocyte antigen (HLA)-related genetic risk factors. There is also evidence of association of certain HLA alleles with lamotrigine (LTG)-induced cADRs, but this has not been reported in the Indian population. Here, we report case series of three patients with LTG-induced "Stevens-Johnson syndrome (SJS)." Their HLA-B typing was also performed which showed the presence of HLA-B*15:02 in one case with SJS.
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Treatment-related fluctuations in guillain barre syndrome and the conundrum of additional cycles of plasmapheresis
Annals of Indian Academy of Neurology 2017 20(4):372-377
Introduction: In Guillain Barre syndrome (GBS), worsening of weakness or disability after initial period of recovery or stabilization is described as treatment-related fluctuations (TRF). Aim: This study aims to describe the clinical characteristics and outcome of six patients with GBS and TRF. Patients and Methods: Six patients with GBS fulfilling NINCDS criteria, evaluated at a tertiary care university hospital during 2008–2017, were diagnosed to have TRF. They form the basis of this report. Results: All patients were men and their mean age was 40 years. At presentation, mean duration of illness was 15 days; the illness had plateaued in three and progressive in other three patients. Two of the four patients had variant GBS. Initially, five patients were treated with large volume plasmapheresis (LVPP) and one patient with methyl prednisolone. At 17–28 days after disease onset, three patients developed new neurologic deficits (bilateral facial paresis in two; paralytic ileus in one). Other three patients with worsening of limb weakness (medical research council sum score of >5) and disability (Hughes disability grade by ≥1) fulfilled Kleyweg's criteria for TRF. All the six patients were treated with the completion of five cycles or additional cycles of LVPP. Conclusion: Awareness about TRF is essential for correct diagnosis and management of patients with GBS.
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Subdural empyema in disseminated histoplasmosis
Annals of Indian Academy of Neurology 2017 20(4):414-415
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Atherosclerotic carotid plaques: Multimodality imaging with contrast-enhanced ultrasound, computed tomography, and magnetic resonance imaging
Annals of Indian Academy of Neurology 2017 20(4):378-386
Introduction: The imaging of carotid plaques has undergone a paradigm shift increasing importance being given to plaque characterization. Patients with "vulnerable" plaques are more prone to develop future neurovascular events. Purpose: The purpose of this study is to analyze the role of multimodality imaging techniques in the assessment of carotid atherosclerotic plaques. Materials and Methods: Twenty-six patients were prospectively enrolled in the study. Patients underwent multidetector computed tomography (CT) angiography, ultrasound, contrast-enhanced ultrasound, and high-resolution magnetic resonance imaging (MRI) of the carotid arteries with special emphasis on the carotid bifurcation. Results: The mean age of patients was 65.41 years. Twenty-one were males. Plaque neovascularization was seen in 10 of the 18 plaques studied (55.56%). Based on the predominant components of the plaque, plaques were characterized as lipid (3), lipid with recent hemorrhage (1), fibrous (7), fibrofatty (4), fibrofatty with some hemorrhagic components (3), and recent hemorrhage (2). Conclusions: Together, contrast-enhanced ultrasound, CT, and MRI provide complete information about the plaque characteristics.
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Female caregivers and stroke severity determines caregiver stress in stroke patients
Annals of Indian Academy of Neurology 2017 20(4):418-424
Background: Stroke is among the major causes of short- and long-term disability. This study aimed to understand the caregivers (CGs) stress in stroke survivors. Materials and Methods: A 22-item questionnaire was administered to 201 CGs of stroke survivors. The variables tested were physical and mental health, social support, financial, and personal problems. CGs were divided into Group A (Barthel index [BI] <75) and B (BI >75) according to patient's BI, according to gender (male and female CG) and relation; spouses (wife, husband), daughters, sons, daughter-in-law, grandchildren, and rest (father, mother, brother, sister, and in-laws). Data were analyzed using SPSS software version–21. Data were analyzed to determine which variables of the patient effects the CG stress. Results: Majority of the CGs (74.62%) were females. 65% of CGs graded their burden as moderate to severe. 81% of CGs had left their work for caregiving. More than half of the CGs felt sleep disturbance and physical strain. Psychological instability and financial burdens were reported in 3/4th of CGs. Group A CGs faced more sleep, financial, health, and social life disturbance. Patient's bladder and bowel problems, shoulder pain, patients noncooperative attitude for medication administration, and physiotherapy were more upsetting for Group A CGs. Female CGs were subjected to more sleep disturbance, physical and psychological stress, faced more difficulty regarding the patient's bladder, bowel, personal hygiene needs, and physiotherapy. Female CGs felt less motivated in caregiving than male CGs. Wives and daughters-in-law experienced more burden. Time spent and burden perceived was more by female CGs (χ2 = 15.199, P = 0.002) than males (χ2 = 11.931, P = 0.018); wives and daughters than other relations (χ2 = 32.184, P = 0.000), (χ2 = 35.162, P = 0.019). Conclusion: Our study showed that caregiving burden was predominantly shouldered by females CGs. CGs faced physical, psychological, and socioeconomic burden. The burden was more evident in female CGs and in patients with severe stroke.
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Risk factors, vascular lesion distribution, outcome and recurrence of strokes due to intracranial atherosclerosis: One year data from Hyderabad stroke registry
Annals of Indian Academy of Neurology 2017 20(4):387-392
Background: Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke in Asian countries and probably in India. Aim: The aim of this study was to describe the risk factors, distribution of vascular lesions, recurrence and outcome of stroke due to ICAS. Methodology: A total of 100 consecutive patients of ischemic stroke due to ICAS were enrolled prospectively from January 1, 2015, to December 31, 2015, and followed for 1 year for treatment compliance and recurrence. The details about demographics, risk factors, and vascular lesions were noted. Results: There were 68 males and 32 females. Hypertension (HTN), diabetes, alcohol, smoking, hyperlipidemia, and hyperhomocysteinemia was present in 82%, 52%, 34%, 33%, 28%, and 23%, respectively. The number of arteries involved were middle cerebral artery, 53 (37.3%); posterior cerebral artery, 24 (16.9%); internal cerebral artery, 21 (14.8%); vertebral artery, 18 (12.7%); basilar artery, 6 (4.2%); and anterior cerebral artery, 6 (4.2%). Seventeen (17%) patients had a recurrent stroke during 1 year follow-up. The presence of uncontrolled HTN and diabetes mellitus after discharge were significantly associated with stroke recurrence (P < 0.05). The use of dual antiplatelet agents and statins was found to have a significant effect in the prevention of recurrent stroke (P < 0.05). Severe stroke at presentation and presence of hemiparesis were the predictors for unfavorable outcome at 3 months (P < 0.05). Conclusion: Risk factors, distribution of vascular lesions and high recurrence of stroke due to ICAS in this study is similar to that reported from other Asian countries. Aggressive medical management and risk factor control remains the best strategy for preventing recurrence.
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Low rate of positive bronchoscopy for suspected foreign body aspiration in infants
To describe our institution's low rate of positive bronchoscopy in infants suspected of inhaling a foreign body.
http://ift.tt/2gJR3NA
Adaptation and validation of Mandarin Chinese version of the pediatric Voice Handicap Index (pVHI)
The aim of this study was to adapt and validate the English version of pediatric voice handicap index (pVHI) into Mandarin Chinese.
http://ift.tt/2yMD5So
Fibroangioma nasofaríngeo juvenil. Experiencia de 15 años en el Hospital Barros Luco Trudeau
RESUMEN Introducción: El fibroangioma nasofaríngeo juvenil es un tumor vascular benigno localmente agresivo, que afecta casi exclusivamente la nasofaringe de adolescentes de sexo masculino. Su manejo es complejo dada su extensión, naturaleza vascular y sus frecuentes recurrencias. Objetivo: Mostrar la experiencia de 15 años en fibroangioma juvenil en nuestro centro. Material y método: Estudio descriptivo retrospectivo de los pacientes con diagnóstico de ingreso de fibroangioma nasofaríngeo juvenil al Servicio de Otorrinolaringología del Hospital Barros Luco Trudeau entre los años 1997 y 2011, caracterizando al grupo de estudio en cuanto a características clínico-demográficas, vasos aferentes, relación entre etapa tumoral y vascularización, manejo terapéutico, complicaciones y recurrencias. Resultados: Se obtuvo un total de 20 pacientes, todos de sexo masculino, con un promedio de edad de 13,9 años. El síntoma de presentación más frecuente fue la epistaxis a repetición y obstrucción nasal presente en el 90% y 80%, respectivamente. Todos los pacientes se estudiaron con tomografia computarizada y recibieron embolización arterial preoperatoria. La mayoría de los tumores fueron de tipo II (65%) y III (20%), según clasificación de Radkowski. La técnica quirúrgica más empleada fue abierta (57,8%). Radioterapia en un caso. El vaso aferente principal fue la maxilar interno ipsilateral en el 100%. Todos los fibroangiomas etapa III eran además irrigados por la arteria carótida interna. Se encontró 20% de persistencia y 15% de recidiva. Conclusión: Nuestros resultados concuerdan con la gran mayoría de las series publicadas en la literatura. Epistaxis recurrente, obstrucción nasal y tumor nasal unilateral deben hacernos sospechar de esta patología en un adolescente masculino. El tratamiento de elección es la cirugía con embolización preoperatoria. La vía de abordaje endoscópica presenta menor morbilidad posoperatoria en pacientes con estadios I y II de Radkowski. Todos los fibroangiomas con compromiso intracraneano, presentan irrigación también del sistema carotideo interno.
ABSTRACT Introduction: Nasopharyngeal Fibroangioma is a locally aggressive benign vascular tumor. Its management is complex given its size, vascular nature and its frequent recurrences. Aim: To show the experience of 15 years in Juvenile Fibroangioma in our center. Material and method: Retrospective descriptive study of patients admitted with a diagnosis of Juvenile Fibroangioma Nasopharyngeal in the Department of Otolaryngology Hospital Barros Luco Trudeau between 1997 and 2011. Results: A total of 20 patients was obtained. The most common presenting symptom was recurrent epistaxis and nasal obstruction present in 90% and 80% respectively. The most common surgical technique was open (57.8%). Radiotherapy in one case. The main afferent vessel was the ipsilateral internal maxillary in 100%. All Fibroangioma stage III were also supplied by the internal carotid artery. 20% of persistence and 15% of recurrence was found. Conclusion: Recurrent epistaxis, nasal obstruction and unilateral nasal tumor should raise the suspicion of this disease in a male teenager. The treatment of choice is surgery with preoperative embolization. The route of endoscopic approach has less postoperative morbidity in patients with stage I and II of Radkowski. All Fibroangioma with intracranial commitment, have also the internal carotid irrigation system.
http://ift.tt/2zGpFUF
Revestimiento interno en reconstrucción nasal: Estudio anatómico cadavérico
ABSTRACT Introduction: In the presence of a nasal anatomical defect, it is necessary to consider alternatives to restore a correct function and esthetic nasal result. The nasal osteocartilaginous structure must have an internal support or lining that provides a necessary vascularization. There are various techniques of intranasal flaps to achieve reconstitution of the nasal internal lining. Aim: To describe the surgical technique of the main internal lining flaps in nasal reconstruction and its application in ex vivo models. Material and method: We dissected 7 cadaver donor specimens. A broad nasal resection was performed simulating a loss of tissue from the three layers of the nasal anatomy for subsequent reconstruction. Results: It was possible to replicate the different alternatives of intranasal flap techniques described for nasal reconstruction. Conclusion: The inner lining is of paramount importance in nasal reconstruction. This is a first phase in the development and learning of nasal reconstruction.
http://ift.tt/2h8Ter9
Manejo endoscópico de osteoma etmoidal con extensión orbitaria: A propósito de un caso
ABSTRACT The osteoma is the most common tumor of the paranasal sinuses, is usually asymptomatic because of their slow growth, however, may develop symptoms depending on the size, location and extent, with potential compromise of orbit and brain. Surgery is indicated in symptomatic cases, with external, endoscopic or combined approach. We present a case of ethmoidal osteoma with orbital involvement managed by endoscopic image guided surgery.
http://ift.tt/2zF8Id9
Paroxismia vestibular: Reporte de un caso
ABSTRACT We present the case of a young patient, with a 9-month long history of 4 to 5 daily spells of spontaneous vertigo, each lasting only seconds. There is no positional trigger, and there is a complete lack of symptoms between attacks. As is discussed in the article, this matches the recently published criteria for Vestibular Paroxysmia, an entity allegedly secondary to neurovascular compression of the vestibular nerve. The patient responded immediately and completely to carbamazepine at low dosage, the preferred treatment for vestibular paroxysmia.
http://ift.tt/2zDJ3Sp
Carcinoma parotídeo epitelial-mioepitelial: Presentación de un caso y revisión de la literatura
ABSTRACT We present a case of a 53 years old female patient with a left parotid tumor, with slow evolution, progressive growth and ipsilateral otalgia during later months. She was previously studied by tomography of the neck with contrast and magnetic resonance, which showed the mass of the deep lobe to have benign imaging characteristics. A parotidectomy of deep lobe was performed, with tumoral resection, preserving the facial nerve with the exception of the marginal branch. The biopsy was informed as epithelial-myoephitelial carcinoma, a rare salivary gland tumor. We completed the parotidectomy with neck dissection and Radiotherapy complementary was made. Besides we presented a literature review.
http://ift.tt/2zDJ0WJ
Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea
ABSTRACT A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.
http://ift.tt/2h9WRx9
Revisión sobre los conocimientos actuales de dehiscencia del canal semicircular posterior
RESUMEN La dehiscencia del canal semicircular posterior es una patología rara y con baja incidencia, por ello hemos realizado una revisión de los conocimientos actuales de esta entidad. Se ha realizado una búsqueda bibliográfica desde 1998 hasta diciembre de 2016 de toda la literatura publicada sobre la misma en las bases de datos Allied and Complementary Medicine Database and the Embase, Health Management Information Consortium, Scopus, Consortium, Medline, PsycINFO y Scielo. Se han encontrado y revisado 53 trabajos relacionados con el tema. La dehiscencia del canal semicircular posterior presenta una prevalencia variable; 0,3%-4,5% en adultos y 1,2%-20% en niños. Su localización puede ser hacia el golfo de la yugular o fosa cerebral posterior. Los pacientes pueden ser asintomáticos o presentar clínica auditiva y/o vestibular. La tomografía computarizada y la prueba de potenciales vestibulares miogénicos evocados permiten establecer el diagnóstico de certeza. En el tratamiento quirúrgico la vía de abordaje de elección es la transmastoidea y las técnicas del cierre del canal son el "plugging" y el "resurfacing".
ABSTRACT The posterior semicircular canal dehiscence is a rare pathology and it has a low incidence. We have realized a review about the current knowledge of this entity. We have performed a bibliographic research from 1998 to 2016 December about the literature published in this subject, in the data basis Allied and Complementary Medicine Database and the Embase, Health Management Information Consortium, Scopus, Consortium, Medline, PsycINFO y Scielo. I thas been found and reviewed 53 papers about the topic. The posterior semicircular canal dehiscence has a variable prevalence: 0,3%-4-5% in adults and 1,2%-20% in children. The location can be in the jugular bulb or in the posterior brain fossa. Some patients can be asymptomatic, whereas others can have auditory and/or vestibular signs and symptoms. Computed tomography and test of vestibular evoked myogenic potentials allow the diagnosis of certainty. In the surgical treatment the approach of choice is transmastoid and techniques to close the canal are plugging and resurfacing.
http://ift.tt/2h9G0KS
Hipertrofia de amígdala lingual y apnea obstructiva del sueño en población pediátrica: Una asociación a considerar
RESUMEN Las amígdalas linguales (AL) forman parte del Anillo de Waldeyer (AW). La hipertrofia de amígdala lingual (HAL) se debe habitualmente a hiperplasia, generalmente asintomática. Su etiología no está precisada, pero se reconoce como causa de Apnea Obstructiva del Sueño (AOS) residual, posterior a adenoamigdalectomía (AA). Su identificación en el examen físico es dificultosa, por lo que resulta relevante la sospecha, junto con una nasofibroscopía. Según condiciones y sintomatología del paciente se puede complementar el estudio con otras técnicas diagnósticas, como polisomnograma (PSG) y resonancia magnética (RM). La cirugía es exitosa para el tratamiento de estos casos. Dentro de las complicaciones descritas para este procedimiento destacan: hemorragia, obstrucción de la vía área, dificultad en la intubación orotraqueal y dolor en el posoperatorio. Actualmente no existe una técnica quirúrgica de elección. Debido a la morbilidad asociada a AOS resulta fundamental el diagnóstico de esta patología, ya que es susceptible de tratamiento.
ABSTRACT Lingual tonsils are part of Waldeyer`s Ring. The hypertrophy of the lingual tonsils is generally due to hiperplasia, without symptoms. The etiology is not clear, but it is a known cause of residual Obstructive Sleep Apnea (OSA), after adenotonsilectomy. Their identification during the physical exam results dificult, so the suspicious and the nasofibroscopy are relevant. Acording to the particular patient it is posible realize additional exams, like polisomnography and magnetic nuclear resonance. Surgery is succesful for this cases. The complications include: bleeding, airway obstruction, anestesia dificulties and pain. Currently there is not a particular techniqe of choice. OSA is associated to morbidity, therefore it is fundamental to diagnose this pathology, because it is posible to treat it through surgery.
http://ift.tt/2zDILeh
Crisis otolítica de Tumarkin. Revisión de la literatura
RESUMEN Las crisis de Tumarkin consisten en caídas bruscas al suelo sin pródromos previos ni pérdida de conciencia y de segundos de duración que pueden ocurrir con frecuencia relativa en pacientes con enfermedad de Ménière. Si bien pueden presentarse de manera aislada durante la evolución de la enfermedad, existen casos con crisis recurrentes que comprometen significativamente la calidad de vida de los pacientes. Se postula que las crisis se producen por una alteración de la función del órgano otolítico, específicamente del sáculo. El tratamiento puede ser desde el manejo expectante hasta el uso de laberintectomía química o quirúrgica.
ABSTRACT Tumarkin´s otolithic crisis is a sudden fall that comes with no loss of consciousness, and without warning or prodrome. It has a short duration and can occur with relative frequency in patients with Meniere disease. When it is present, it significantly compromises life quality of patients. There is no certainty about its mechanism, but it is assumed that the crises are caused by an otolithic organ disfunction, specifically a collapse of the saccule. Treatment can range from observation to chemical or surgical labyrinthectomy.
http://ift.tt/2zGj3pc
Diagnóstico en la patología del olfato: Revisión de la literatura
RESUMEN La patología del olfato es una afección común en la población, principalmente en adultos mayores, que puede alterar de manera significativa la calidad de vida del paciente, pudiendo ser la manifestación inicial de enfermedades neurológicas como la enfermedad de Parkinson. A pesar de su relevancia, el sentido del olfato continúa siendo poco estudiado en clínica, no obstante la existencia de métodos simples validados para su evaluación. En este articulo realizamos una revisión y análisis de la literatura actual sobre el estudio clínico del olfato, con el objetivo de establecer las herramientas diagnósticas disponibles en la práctica clínica para su estudio.
ABSTRACT Olfactory diseases are common to find in the population, mainly in older people, and it can affect significantly life quality. It can also be the first manifestation of neurological diseases, such as Parkinson disease. Despite its relevance, the sense of smell is still not studied although there are simple and validated methods available in the clinical practice. In this article, we make a review and analysis of the actual literature related to smell studies, so that we can establish available diagnosis tools in the clinical practice.
http://ift.tt/2zFmAEp
Quistes de cuerda vocal: Experiencia en 44 pacientes del Centro de Voz del Departamento de Otorrinolaringología de la Pontificia Universidad Católica de Chile
ABSTRACT Introduction: Vocal cord cysts are a relatively frequent cause of dysphonia. Their origin is still controversial, and their diagnosis and management continue to be a clinical challenge. Aim: To describe and analyze the clinical characteristics of vocal cord cysts in our series of patients. Material and method: Descriptive retrospective study of patients with diagnosis of vocal cord cyst attended in our center between June 2012 and December 2015. Results: 44 patients had the diagnosis of vocal cord cyst, which represents 4.32% of the patients that attended our Voice Center during that period. Most of the patients were adults, and among them 68.29% corresponded to women. 34.1% of the patients were submitted to surgical treatment with microphonosurgery technique. 75% of the surgical patients presented an improvement in the pattern of the videolaryngostroboscopic mucosal wave. All the patients in which pre and postsurgical subjective voice assessment polls were available, showed a significant voice improvement. Conclusion: Vocal cord cysts are lesions that affect both children and adults. The videolaryngostroboscopy evaluation is key in the diagnosis of these lesions, and the surgical treatment with microphonosurgery is effective in terms of anatomical and functional vocal results.
http://ift.tt/2zGpUPz
Sinus Tympani y recidiva en cirugía de colesteatoma
ABSTRACT Introduction: Sinus tympani (ST) is one of the areas with the most residual cholesteatoma. Recently it has been classified in 3 types according to its morphology. Aim: To determine the type of ST in patients undergoing cholesteatoma surgery and to analyze its impact as a relapse factor. Material and method: Review of clinical files of patients submitted to cholesteatoma surgery between 2004 and 2015 at the Regional Hospital of Concepción. Preoperative computed axial tomography (CT) analysis and subsequent clinical evaluation of patients operated by canal wall down mastoidectomy (CWD). Results: In the described period 271 ears were operated. 60% of the cases analyzed had ST type A and 40% ST type B. Twelve cases of relapse were identified, 3 ST type B and 9 ST type A, with no statistically significant difference between the two. Discussion: Unlike to what is reported in the literature, the most common ST type in our study was type A, which could correspond to an ethnic variable. Conclusion: The preoperative study with CT is a useful tool to evaluate the type and commitment of ST. The anatomical differences between ST type A and B seems not to be a determinant factor of relapse in CWD mastoidectomies.
http://ift.tt/2zGpNU9
Fibroangioma nasofaríngeo juvenil. Experiencia de 15 años en el Hospital Barros Luco Trudeau
RESUMEN Introducción: El fibroangioma nasofaríngeo juvenil es un tumor vascular benigno localmente agresivo, que afecta casi exclusivamente la nasofaringe de adolescentes de sexo masculino. Su manejo es complejo dada su extensión, naturaleza vascular y sus frecuentes recurrencias. Objetivo: Mostrar la experiencia de 15 años en fibroangioma juvenil en nuestro centro. Material y método: Estudio descriptivo retrospectivo de los pacientes con diagnóstico de ingreso de fibroangioma nasofaríngeo juvenil al Servicio de Otorrinolaringología del Hospital Barros Luco Trudeau entre los años 1997 y 2011, caracterizando al grupo de estudio en cuanto a características clínico-demográficas, vasos aferentes, relación entre etapa tumoral y vascularización, manejo terapéutico, complicaciones y recurrencias. Resultados: Se obtuvo un total de 20 pacientes, todos de sexo masculino, con un promedio de edad de 13,9 años. El síntoma de presentación más frecuente fue la epistaxis a repetición y obstrucción nasal presente en el 90% y 80%, respectivamente. Todos los pacientes se estudiaron con tomografia computarizada y recibieron embolización arterial preoperatoria. La mayoría de los tumores fueron de tipo II (65%) y III (20%), según clasificación de Radkowski. La técnica quirúrgica más empleada fue abierta (57,8%). Radioterapia en un caso. El vaso aferente principal fue la maxilar interno ipsilateral en el 100%. Todos los fibroangiomas etapa III eran además irrigados por la arteria carótida interna. Se encontró 20% de persistencia y 15% de recidiva. Conclusión: Nuestros resultados concuerdan con la gran mayoría de las series publicadas en la literatura. Epistaxis recurrente, obstrucción nasal y tumor nasal unilateral deben hacernos sospechar de esta patología en un adolescente masculino. El tratamiento de elección es la cirugía con embolización preoperatoria. La vía de abordaje endoscópica presenta menor morbilidad posoperatoria en pacientes con estadios I y II de Radkowski. Todos los fibroangiomas con compromiso intracraneano, presentan irrigación también del sistema carotideo interno.
ABSTRACT Introduction: Nasopharyngeal Fibroangioma is a locally aggressive benign vascular tumor. Its management is complex given its size, vascular nature and its frequent recurrences. Aim: To show the experience of 15 years in Juvenile Fibroangioma in our center. Material and method: Retrospective descriptive study of patients admitted with a diagnosis of Juvenile Fibroangioma Nasopharyngeal in the Department of Otolaryngology Hospital Barros Luco Trudeau between 1997 and 2011. Results: A total of 20 patients was obtained. The most common presenting symptom was recurrent epistaxis and nasal obstruction present in 90% and 80% respectively. The most common surgical technique was open (57.8%). Radiotherapy in one case. The main afferent vessel was the ipsilateral internal maxillary in 100%. All Fibroangioma stage III were also supplied by the internal carotid artery. 20% of persistence and 15% of recurrence was found. Conclusion: Recurrent epistaxis, nasal obstruction and unilateral nasal tumor should raise the suspicion of this disease in a male teenager. The treatment of choice is surgery with preoperative embolization. The route of endoscopic approach has less postoperative morbidity in patients with stage I and II of Radkowski. All Fibroangioma with intracranial commitment, have also the internal carotid irrigation system.
http://ift.tt/2zGpFUF
Causas de rinoplastía secundaria: Análisis de 277 casos
ABSTRACT Introduction: Secondary rhinoplasty is becoming increasingly common due to the growing popularity of cosmetic surgery and also by higher expectations of the patient and the surgeon. Secondary rhinoplasty has become an evolving field with unique challenges. To repair the surgeon must properly analyze and understand the specific concerns of the patient and the anatomical causes of why you need a new operation. Aim: To identify anatomical problems most frequently found in 277 secondary and systematize rhinoplasty for better preoperative evaluation and surgical planning. Material and method: Retrospective analysis of 1160 rhinoplasty operated by otolaryngologist Dr. Luis Villarroel between January 1006 and March 31, 2015, of which 277 are secondary rhinoplasty (24%). In this study we found 1197 problems or deformities (average 4.3), They were classified into upper, middle, bottom third ,and endonasal, with an individual deformities subdivision within each group. The results are compared if the primary surgery was another surgeon (secondary rhinoplasty of others) or by the same author (revision rhinoplasty). Results: 85% of patients had problems in the lower third. The most common individual problems identificated were deviated septum (56%), drop tip (47%), bone dorsum deviation (34%), and cartilaginous dorsum desviation (30%). The author presents a higher percentage of insufficient bone resection and less cartilaginous dorsum narrow. Conclusion: There are different reasons why a patient seeks a secondary rhinoplasty. It is important to know the most frequent causes in order to identify the mistakes made in the first instance and avoid them. It's preferable one conservative primary surgery because it avoids difficult problems. This classification helps us to systematize the preoperative analysis and better results.
http://ift.tt/2h9Xd6K
Revestimiento interno en reconstrucción nasal: Estudio anatómico cadavérico
ABSTRACT Introduction: In the presence of a nasal anatomical defect, it is necessary to consider alternatives to restore a correct function and esthetic nasal result. The nasal osteocartilaginous structure must have an internal support or lining that provides a necessary vascularization. There are various techniques of intranasal flaps to achieve reconstitution of the nasal internal lining. Aim: To describe the surgical technique of the main internal lining flaps in nasal reconstruction and its application in ex vivo models. Material and method: We dissected 7 cadaver donor specimens. A broad nasal resection was performed simulating a loss of tissue from the three layers of the nasal anatomy for subsequent reconstruction. Results: It was possible to replicate the different alternatives of intranasal flap techniques described for nasal reconstruction. Conclusion: The inner lining is of paramount importance in nasal reconstruction. This is a first phase in the development and learning of nasal reconstruction.
http://ift.tt/2h8Ter9
Manejo endoscópico de anomalías del cuarto arco branquial: Reporte de tres casos
RESUMEN Las anomalías de cuarto arco branquial corresponden a una entidad patológica infrecuente. Para su manejo existen distintas alternativas terapéuticas siendo una de ellas la cauterización endoscópica. Reportamos 3 casos de senos de cuarto arco branquial tratados mediante cauterización endoscópica en el Hospital Regional de Concepción luego de una revisión de fichas clínicas de todos los pacientes con diagnóstico de anomalías de cuarto arco branquial. Se identificaron tres casos de senos de cuarto arco branquial. Todos corresponden a pacientes de sexo masculino que presentaron cuadro de absceso cervical, diagnosticándose 2 de ellos al presentar recurrencia. Todos fueron tratados mediante cauterización endoscópica de la apertura fistulosa en seno piriforme. Estas anomalías representan vestigios de un trayecto que se origina desde el vértice del seno piriforme. La cauterización endoscópica presenta una serie de ventajas con tasas de recurrencia similares a la cirugía abierta de cuello, menores tasas de complicaciones y costo económico. Las anomalias de cuarto arco branquial constituyen una patología infrecuente y el diagnóstico requiere alta sospecha clínica. El manejo endoscópico ha demostrado ser una alternativa segura y efectiva con menor tasa de complicaciones.
ABSTRACT Anomalies of the fourth branchial arch correspond to an uncommon pathological entity. There are different therapeutic alternatives being one of them the endoscopic cauterization. We report 3 cases of fourth branchial arch anomalies treated by endoscopic cauterization in the Regional Hospital of Concepción. Review of clinical records of all patients with diagnosis of fourth branchial anomalies operated by endoscopic cauterization at the Regional Hospital of Concepción. Cases: Three cases of fourth branchial arch sinus were identified. All of them were male patients who presented with a cervical abscess, diagnosing 2 of them when they recurred. All 3 cases were treated by endoscopic cauterization of the fistulous opening in the piriform sinus. These anomalies represent vestiges of a path that originates from the apex of the piriform sinus. Endoscopic cauterization presents a number of advantages with recurrence rates similar to open neck surgery, with lower complication rates and economic cost. Fourth branchial anomalies constitute an uncommon pathology and the diagnosis requires high clinical suspicion. Endoscopic management has proven to be a safe and effective alternative with a lower rate of complications.
http://ift.tt/2hbiahT
Paroxismia vestibular: Reporte de un caso
ABSTRACT We present the case of a young patient, with a 9-month long history of 4 to 5 daily spells of spontaneous vertigo, each lasting only seconds. There is no positional trigger, and there is a complete lack of symptoms between attacks. As is discussed in the article, this matches the recently published criteria for Vestibular Paroxysmia, an entity allegedly secondary to neurovascular compression of the vestibular nerve. The patient responded immediately and completely to carbamazepine at low dosage, the preferred treatment for vestibular paroxysmia.
http://ift.tt/2zDJ3Sp
Carcinosarcoma de laringe: Reporte de dos casos
RESUMEN El carcinosarcoma de laringe es un tumor bifásico raro que representa menos del 1% de todos los tumores malignos de laringe. Debido a su doble naturaleza epitelial y mesenquimal esta neoplasia ha sido denominada de distintas maneras en la literatura, siendo indispensable el estudio mediante inmunohistoquímica para establecer un diagnóstico correcto. Se presentan 2 casos de carcinosarcoma de laringe, confirmados mediante estudio con inmunohistoquímica, ambos tratados mediante laringectomía total. Se elabora una discusión de los principales aspectos clínicos, histopatológicos y terapéuticos de esta infrecuente neoplasia.
ABSTRACT The larynx carcinosarcoma is a rare biphasic tumor that represents less than 1% of all malignant tumors of the larynx. Because of its biphasic epithelial and mesenchymal nature this neoplasm has been called in different ways in the literature being indispensable the study by immunohistochemistry to establish a proper diagnosis. We present 2 cases of larynx carcinosarcoma confirmed by immunohistochemical study, both treated with total laryngectomy. A discussion of the main clinical, histopathological and therapeutic aspects of this rare neoplasm is made.
http://ift.tt/2zDIWGt
Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea
ABSTRACT A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.
http://ift.tt/2h9WRx9
Tuberculosis como causa de adenopatías cervicales
ABSTRACT The tuberculosis (TB) is an infect-contagious worldwide distribution disease caused by Mycobacterium Tuberculosis and other atypical Mycobacteria. Lymph node involvement is late, and its associated clinical manifestations are usually unspecifics, therefore the diagnosis of tuberculosis lymph node is often delayed and is an unexpected finding in numerous occasions. This article aims to carry out a literature review of lymph node tuberculosis and to emphasize that TB must be taken into account as differential diagnosis in cervical masses, which often occur with few associated symptoms. In this article we present two cases of lymph node TB diagnosed in our department in last months, both cases presented exclusively as cervical mass of slow growth, without any accompanying pulmonary symptoms and were diagnosed as TB after the surgical removal of the lesion and its histopathological study.
http://ift.tt/2h9G2T0
Revisión sobre los conocimientos actuales de dehiscencia del canal semicircular posterior
RESUMEN La dehiscencia del canal semicircular posterior es una patología rara y con baja incidencia, por ello hemos realizado una revisión de los conocimientos actuales de esta entidad. Se ha realizado una búsqueda bibliográfica desde 1998 hasta diciembre de 2016 de toda la literatura publicada sobre la misma en las bases de datos Allied and Complementary Medicine Database and the Embase, Health Management Information Consortium, Scopus, Consortium, Medline, PsycINFO y Scielo. Se han encontrado y revisado 53 trabajos relacionados con el tema. La dehiscencia del canal semicircular posterior presenta una prevalencia variable; 0,3%-4,5% en adultos y 1,2%-20% en niños. Su localización puede ser hacia el golfo de la yugular o fosa cerebral posterior. Los pacientes pueden ser asintomáticos o presentar clínica auditiva y/o vestibular. La tomografía computarizada y la prueba de potenciales vestibulares miogénicos evocados permiten establecer el diagnóstico de certeza. En el tratamiento quirúrgico la vía de abordaje de elección es la transmastoidea y las técnicas del cierre del canal son el "plugging" y el "resurfacing".
ABSTRACT The posterior semicircular canal dehiscence is a rare pathology and it has a low incidence. We have realized a review about the current knowledge of this entity. We have performed a bibliographic research from 1998 to 2016 December about the literature published in this subject, in the data basis Allied and Complementary Medicine Database and the Embase, Health Management Information Consortium, Scopus, Consortium, Medline, PsycINFO y Scielo. I thas been found and reviewed 53 papers about the topic. The posterior semicircular canal dehiscence has a variable prevalence: 0,3%-4-5% in adults and 1,2%-20% in children. The location can be in the jugular bulb or in the posterior brain fossa. Some patients can be asymptomatic, whereas others can have auditory and/or vestibular signs and symptoms. Computed tomography and test of vestibular evoked myogenic potentials allow the diagnosis of certainty. In the surgical treatment the approach of choice is transmastoid and techniques to close the canal are plugging and resurfacing.
http://ift.tt/2h9G0KS
Hipertrofia de amígdala lingual y apnea obstructiva del sueño en población pediátrica: Una asociación a considerar
RESUMEN Las amígdalas linguales (AL) forman parte del Anillo de Waldeyer (AW). La hipertrofia de amígdala lingual (HAL) se debe habitualmente a hiperplasia, generalmente asintomática. Su etiología no está precisada, pero se reconoce como causa de Apnea Obstructiva del Sueño (AOS) residual, posterior a adenoamigdalectomía (AA). Su identificación en el examen físico es dificultosa, por lo que resulta relevante la sospecha, junto con una nasofibroscopía. Según condiciones y sintomatología del paciente se puede complementar el estudio con otras técnicas diagnósticas, como polisomnograma (PSG) y resonancia magnética (RM). La cirugía es exitosa para el tratamiento de estos casos. Dentro de las complicaciones descritas para este procedimiento destacan: hemorragia, obstrucción de la vía área, dificultad en la intubación orotraqueal y dolor en el posoperatorio. Actualmente no existe una técnica quirúrgica de elección. Debido a la morbilidad asociada a AOS resulta fundamental el diagnóstico de esta patología, ya que es susceptible de tratamiento.
ABSTRACT Lingual tonsils are part of Waldeyer`s Ring. The hypertrophy of the lingual tonsils is generally due to hiperplasia, without symptoms. The etiology is not clear, but it is a known cause of residual Obstructive Sleep Apnea (OSA), after adenotonsilectomy. Their identification during the physical exam results dificult, so the suspicious and the nasofibroscopy are relevant. Acording to the particular patient it is posible realize additional exams, like polisomnography and magnetic nuclear resonance. Surgery is succesful for this cases. The complications include: bleeding, airway obstruction, anestesia dificulties and pain. Currently there is not a particular techniqe of choice. OSA is associated to morbidity, therefore it is fundamental to diagnose this pathology, because it is posible to treat it through surgery.
http://ift.tt/2zDILeh
Crisis otolítica de Tumarkin. Revisión de la literatura
RESUMEN Las crisis de Tumarkin consisten en caídas bruscas al suelo sin pródromos previos ni pérdida de conciencia y de segundos de duración que pueden ocurrir con frecuencia relativa en pacientes con enfermedad de Ménière. Si bien pueden presentarse de manera aislada durante la evolución de la enfermedad, existen casos con crisis recurrentes que comprometen significativamente la calidad de vida de los pacientes. Se postula que las crisis se producen por una alteración de la función del órgano otolítico, específicamente del sáculo. El tratamiento puede ser desde el manejo expectante hasta el uso de laberintectomía química o quirúrgica.
ABSTRACT Tumarkin´s otolithic crisis is a sudden fall that comes with no loss of consciousness, and without warning or prodrome. It has a short duration and can occur with relative frequency in patients with Meniere disease. When it is present, it significantly compromises life quality of patients. There is no certainty about its mechanism, but it is assumed that the crises are caused by an otolithic organ disfunction, specifically a collapse of the saccule. Treatment can range from observation to chemical or surgical labyrinthectomy.
http://ift.tt/2zGj3pc
Prueba de patrones de frecuencia y patrones de duración: Evaluación del ordenamiento auditivo temporal
RESUMEN Los aspectos temporales de la audición se consideran unos de los mecanismos claves del procesamiento auditivo, ya que resultarían críticos para el adecuado funcionamiento del resto de los procesos auditivos centrales. El ordenamiento auditivo temporal es una de las cuatro habilidades de los aspectos temporales de la audición y se refiere al procesamiento de dos o más estímulos auditivos según su orden de aparición u ocurrencia en el dominio temporal. Ha sido uno de los procesos más ampliamente estudiados debido a sus implicancias en el resto de las habilidades auditivas, así como también en numerosas actividades de la vida diaria, incluyendo la percepción y la discriminación de los sonidos del habla. Históricamente se han utilizado dos pruebas para evaluarlo: la prueba de patrones de frecuencia y la prueba de patrones de duración. Ambas pruebas cuentan con buena sensibilidad y especificidad para detectar lesiones del sistema nervioso auditivo central, incluyendo el hemisferio derecho, izquierdo y cuerpo calloso. En la actualidad, ambas pruebas son utilizadas con frecuencia debido a su eficiencia, su facilidad para ser administrada y la disponibilidad de valores normativos para un amplio rango de población. Se recomienda ampliamente su utilización en la práctica clínica considerando la obtención de valores normativos locales.
ABSTRACT The temporal aspects of audition are considered one of the key mechanisms of auditory processing, as they would be critical for the proper functioning of the rest of the central auditory processes. The auditory temporal ordering is referred to one of the four skills of the temporal aspects of audition and refers to the processing of two or more auditory stimuli in their order of appearance or occurrence in the time domain. It has been one of the most widely studied processes due to its implications for the rest of listening skills, as well as in numerous activities of daily life, including perception and discrimination of speech sounds. Historically, two test has been used to evaluate: the frequency pattern and duration pattern tests. Both tests have good sensitivity and specificity to detect lesions at the central auditory nervous system, such as right and left hemisphere and corpus callosum dysfunctions. Currently, both tests are commonly used clinically due to its efficiency, ease of administration and the availability of normative data in wide range of population. Their use is strongly recommended in clinical practice considering obtaining local normative values.
http://ift.tt/2h9FOeC
Diagnóstico en la patología del olfato: Revisión de la literatura
RESUMEN La patología del olfato es una afección común en la población, principalmente en adultos mayores, que puede alterar de manera significativa la calidad de vida del paciente, pudiendo ser la manifestación inicial de enfermedades neurológicas como la enfermedad de Parkinson. A pesar de su relevancia, el sentido del olfato continúa siendo poco estudiado en clínica, no obstante la existencia de métodos simples validados para su evaluación. En este articulo realizamos una revisión y análisis de la literatura actual sobre el estudio clínico del olfato, con el objetivo de establecer las herramientas diagnósticas disponibles en la práctica clínica para su estudio.
ABSTRACT Olfactory diseases are common to find in the population, mainly in older people, and it can affect significantly life quality. It can also be the first manifestation of neurological diseases, such as Parkinson disease. Despite its relevance, the sense of smell is still not studied although there are simple and validated methods available in the clinical practice. In this article, we make a review and analysis of the actual literature related to smell studies, so that we can establish available diagnosis tools in the clinical practice.
http://ift.tt/2zFmAEp
APRIL gene expression in a cohort of egyptian acute myeloid leukemia patients: clinical and prognostic significance
Source:Cancer Genetics
Author(s): Amira Ahmed Hammam, Shereen Mohamed Elhoseiny, Rania El-Sayed Sheir, Hisham Issa
BackgroundAPRIL (A Proliferation Inducing Ligand) is a member of the tumor necrosis factor (TNF) family. It is essential for the survival of normal and malignant B lymphocytes. Increased expression of APRIL is noted in most of hematological malignancies and auto immune diseases.Patients and methodsWe investigated the expression level of APRIL mRNA in 50 de novo acute myeloid leukemia (AML) patients, together with 20 healthy controls using a Real-Time Quantitative Reverse-Transcriptase Polymerase Chain Reaction (RTQ-PCR) with a specific aim of determining its relation to clinical features and laboratory findings at diagnosis and its impact on the response to therapy.ResultsAPRIL mRNA expression level was significantly higher in AML patients than in controls (p=< 0.001). APRIL expression level was significantly higher in patients who didn't achieve CR compared to those who achieved CR (p<0.001).Patients who didn't achieve CR also had higher TLC, lower platelets and older age than CR patients. The difference was statistically significant (p<0.001, p=0.047, p=0.019) respectively. APRIL levels showed significant positive correlation with TLC (r=0.743.p<0.001), with age (r=0.296,p=0.037)and a negative correlation with platelets count (r= -0.443,p=0.001) and no correlation with gender, Hb level, BM blast, HSM or LNs enlargement .ConclusionOur study has shown that APRIL is overexpressed in AML patients, its level might serve as an indicator for disease progression. APRIL might be an indicator for poor prognosis and treatment resistance in AML patient; therefore, APRIL antagonists may represent a novel therapeutic approach for the treatment of AML.
http://ift.tt/2h9DsfM
Myeloid neoplasm with eosinophilia associated with isolated extramedullary FIP1L1/PDGFRA rearrangement
Source:Cancer Genetics
Author(s): Talal Hilal, Veena Fauble, Rhett P. Ketterling, Katalin Kelemen
Myeloid neoplasms with eosinophilia associated with PDGFRA rearrangement are very responsive to tyrosine kinase inhibitors (TKIs). Herein, we report a case of a 53-year-old man with eosinophilia and a well-differentiated extramedullary myeloid tumor with evidence of FIP1L1/PDGFRA rearrangement by fluorescent in situ hybridization in the extramedullary tissue. His bone marrow evaluation revealed a hypercellular marrow with eosinophilia but without evidence of a FIP1L1/PDGFRA rearrangement. The patient was treated with imatinib at a dose of 100 mg daily and responded with normalization of his peripheral eosinophil count. The case raises the possibility that an extramedullary myeloid tumor may represent a primary site for PDGFRA rearrangement, and highlights the importance of performing cytogenetic testing on extramedullary tissue. Detection of the chromosomal rearrangement is critical for initiation of effective targeted therapy that can improve patient outcomes.
http://ift.tt/2hbaqwd
Comprehensive BRCA mutation analysis in the greek population. Experience from a single clinical diagnostic center
Publication date: Available online 19 October 2017
Source:Cancer Genetics
Author(s): Angela Apessos, Konstantinos Agiannitopoulos, Georgia Pepe, Georgios N. Tsaousis, Eirini Papadopoulou, Vasiliki Metaxa-Mariatou, Angeliki Tsirigoti, Chrysoula Efstathiadou, Christos Markopoulos, Grigorios Xepapadakis, Vasileios Venizelos, Aris Tsiftsoglou, Ioannis Natsiopoulos, George Nasioulas
Germline mutations in the BRCA1 and BRCA2 genes are associated with hereditary predisposition to breast and ovarian cancer. Sensitive and accurate detection of BRCA1 and BRCA2 mutations is crucial for personalized clinical management of individuals affected by breast or ovarian cancer, and for the identification of at-risk healthy relatives.We performed molecular analysis of the BRCA1 and BRCA2 genes in 898 Greek families, using Sanger sequencing or Next Generation Sequencing for the detection of small insertion/deletion frameshift, nonsynonymous, truncating and splice-site alterations and MLPA for the detection of large genomic rearrangements.In total, a pathogenic mutation was identified in 12.9% of 898 families analyzed. Of the 116 mutations identified in total 9% were novel and 14.7% were large genomic rearrangements.Our results indicate that different types of mutational events in the BRCA1 and BRCA2 genes are responsible for the hereditary component of breast / ovarian cancer in the Greek population. Therefore the methodology used in the analysis of Greek patients must be able to detect both point and small frameshift mutations in addition to large genomic rearrangements across the entire coding region of the two genes.
http://ift.tt/2zGh2JE
B-cell acute lymphoblastic leukemia with +der(1)t(1;19) (p13;p13.1) arising in the setting of CALR exon 9 mutated essential thrombocythemia
Source:Cancer Genetics
Author(s): Talal Hilal, Christopher R. Conley
http://ift.tt/2z6jAVb
Advances in Environmental and Occupational Disorders 2016
In this review, we highlight recent studies that advance the knowledge and understanding of the effects of various environmental factors and the associated immune responses in patients with allergic diseases. This review will focus on new literature regarding allergic and immune responses to a variety of environmental factors including aeroallergens, stinging insects, fungi, pollutants, viral respiratory infections, climate change, and microbial exposures.
http://ift.tt/2z6i0md
T cell-mediated immune response to pneumococcal conjugate vaccine (PCV-13) and tetanus toxoid vaccine in patients with moderate to severe psoriasis during tofacitinib treatment
Psoriasis is often treated with immunomodulatory therapies that may affect immune response to common antigens. Tofacitinib is an oral Janus kinase inhibitor.
http://ift.tt/2yNYrwj
Preventing new sensitization and asthma onset by allergen immunotherapy: the current evidence
Purpose of review: Specific allergen immunotherapy is considered a key candidate for a successful preventive intervention in atopic diseases. The strong association of atopic manifestations such as rhinitis and asthma with atopic sensitizations (specific serum IgE) provide a rationale for early intervention in childhood and adolescence. Recent findings: Currently, the documentation of the disease-modifying intervention effects is limited to the secondary prevention of asthma symptoms in children with allergic rhinoconjunctivitis. These effects appear to be rather allergen specific than nonspecific. Summary: Documentation on disease modification including a reduction of asthma symptoms in children, particularly with grass pollen tablets has become quite robust. It is not clear up to now, if the new onset of allergic sensitizations can be modified. So far data on primary prevention are not conclusive.http://ift.tt/2iy0AYH
An update on gain-of-function mutations in primary immunodeficiency diseases
Purpose of review: Most primary immunodeficiencies described since 1952 were associated with loss-of-function defects. With the advent and popularization of unbiased next-generation sequencing diagnostic approaches followed by functional validation techniques, many gain-of-function mutations leading to immunodeficiency have also been identified. This review highlights the updates on pathophysiology mechanisms and new therapeutic approaches involving primary immunodeficiencies because of gain-of-function mutations. Recent findings: The more recent developments related to gain-of-function primary immunodeficiencies mostly involving increased infection susceptibility but also immune dysregulation and autoimmunity, were reviewed. Updates regarding pathophysiology mechanisms, different mutation types, clinical features, laboratory markers, current and potential new treatments on patients with caspase recruitment domain family member 11, signal transducer and activator of transcription 1, signal transducer and activator of transcription 3, phosphatidylinositol-4,5-biphosphate 3-kinase catalytic 110, phosphatidylinositol-4,5-biphosphate 3-kinase regulatory subunit 1, chemokine C-X-C motif receptor 4, sterile α motif domain containing 9-like, and nuclear factor κ-B subunit 2 gain-of-function mutations are reviewed for each disease. Summary: With the identification of gain-of-function mutations as a cause of immunodeficiency, new genetic pathophysiology mechanisms unveiled and new-targeted therapeutic approaches can be explored as potential rescue treatments for these diseases.http://ift.tt/2iBsy5L
NLRC4 inflammasomopathies
Purpose of review: The purpose of the review is to highlight developments in autoinflammatory diseases associated with gain-of-function mutations in the gene encoding NLR-family CARD-containing protein 4 (NLRC4), the NLRC4-inflammasomopathies. Recent findings: Three years since the identification of the first autoinflammation with infantile enterocolitis (AIFEC) patients, there is an improved understanding of how the NLRC4 inflammasome and interleukin 18 (IL-18) contribute to gut inflammation in myeloid and also intestinal epithelial cells. This information has opened new therapeutic avenues to treat AIFEC patients with targeted agents like recombinant IL-18 binding protein and antiinterferon-γ antibodies. Additional phenotypes traditionally associated with NLRP3 mutations like familial cold autoinflammatory syndrome and neonatal onset multisystem inflammatory disease (NOMID), have now also been associated with gain-of-function NLRC4 mutations. Finally, NLRC4 somatic mosaicism has now been identified in a NOMID and an AIFEC patient, a finding emphasizing nontraditional modes of inheritance in autoinflammatory diseases. Summary: The NLRC4 inflammasomopathies constitute a growing autoinflammatory disease category that spans a broad clinical spectrum from cold urticaria to NOMID and the often fatal disease AIFEC. Rapid case identification with biomarkers like elevated serum IL-18 concentrations and early intervention with targeted immunomodulatory therapies are key strategies to improving outcomes for AIFEC patients.http://ift.tt/2iCnSwR
Critical appraisal of the unmet needs in the treatment of chronic spontaneous urticaria with omalizumab: an Italian perspective
Purpose of review: The humanized anti-IgE antibody omalizumab has been available for patients with chronic spontaneous urticaria (CSU) in Italy since 2015. This review summarizes the unresolved issues and unmet therapeutic needs associated with omalizumab and discusses practical recommendations for its use in the management of CSU. Recent findings: Although modern second-generation H1-antihistamines are the standard of care for patients with CSU, adjunctive treatments (including omalizumab) may be required for effective control of symptoms in many patients. Evidence from clinical trials and experience from daily clinical practice suggest that the use of omalizumab in patients with CSU who have inadequate response to H1-antihistamines remains challenging. Summary: Based on current international guidelines, omalizumab labelling information and our experience in clinical practice, we provide treatment recommendations regarding the use of omalizumab in patients with CSU. These include: optimal treatment duration, the use of concomitant antihistamine therapy, the definition and management of disease relapse after treatment, and the management of patients with late or no response to treatment.http://ift.tt/2iCnSgl
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