Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive–compulsive disorder: a case report

Comorbidity of bipolar disorder and obsessive–compulsive disorder is common in adolescence. Obsessive–compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific fea...

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Factors affecting the outcomes of direct pulp capping using Biodentine

Abstract

Introduction

This study aimed to evaluate the prognostic value of factors with regard to the treatment outcome of direct pulp capping using Biodentine (Septodont, Saint-Maur-des-Fossés, France), in permanent teeth in which the pulps were exposed during caries removal.

Methods

Between 2010 and 2014, 112 teeth with deep carious lesions underwent direct pulp capping. The patients were followed up at 2–3 months and 1–1.5 years with a routine examination on both recall visits. Periapical radiographs were taken at 1–1.5 years. Lack of patient complaints, positive reactions to cold and electric testing, no sensitivity to percussion, and no widening of the periapical ligament indicated success. The Fisher exact test was used for statistical analysis. The significance level was P = .05.

Results

Eighty-six teeth were available for 1–1.5 years follow-up. The overall success rate was 82.6%. Only age had a significant effect on the pulpal survival rate: the success rate was 90.9% in patients younger than 40 years and 73.8% in patients 40 years or older (P = .0480). Sex, initial or secondary caries treatment, occlusal or cervical/proximal caries, delayed placement of permanent filling, tooth position, and arch type did not influence the outcome.

Conclusions

A patient's age influenced the outcome of direct pulp capping using this new calcium silicate cement.

Clinical relevance

Asymptomatic vital permanent teeth with cariously exposed pulp can be treated successfully by direct pulp capping using Biodentine.

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Simple classifiers for molecular subtypes of colorectal cancer

Publication date: Available online 11 December 2017
Source:Arab Journal of Gastroenterology
Author(s): Woo Gyeong Kim, Joo Yeon Kim, Do Youn Park
Background and study aimColorectal cancer (CRC) is a heterogeneous disease entity with a diverse biological pathogenesis. This study aims to validate the two studies published in 2013 which established a separate CRC molecular subtype classification by utilizing a rapidly accessible miniclassifier, and verify a simplified version thereof.Patients and methodsParticipants diagnosed with CRC (n = 568) were subtyped in three classifications for characteristic, and prognostic purposes. Colorectal cancer subtypes (CCS) were classified as: i) CCS1 (CDX2+, microsatellite stable (MSS)/microsatellite instability (MSI)-low), ii) CCS2 (MSI-high), and iii) CCS3 (FRMD6/ZEB1/HTR2B +, CDX2-, MSS/MSI-low]. Simplified CCS (SiCCS) subtypes were grouped as: i) CDX2 (CDX2+, MSS/MSI-low, ZEB1 ≤ 2), ii) MSI-H (MSI-high, CDX2/FRMD6/ZEB1/HTR2B +/-), and iii) ZEB1 (ZEB1 ≥ 2, CDX2-, MSS/MSI-low). New molecular classification (NMC) subtypes were defined as: i) enterocyte (E-C) (MUC2 +), ii) goblet-like (G-L) (MUC2 + and TFF3 +), iii) transit-amplifying (T-A) (CFTR +), and iv) stem-like (S-L) (ZEB1 +).ResultsIn total, 53.5% (n = 304) CCS, 58.3% (n = 331) SiCCS, and 37.7% (n = 214) NMC tumours could be evaluated. CCS2 and MSI-H CRCs had the most favourable survival outcome, whereas the CCS3, ZEB1 and S-L subtypes showed the poorest prognosis. A significant overlap between CCS3, ZEB1, and S-L tumours was demonstrated.ConclusionThere is still a need for a consensus gene expression-based subtyping classification system for CRCs, thereby allowing the categorization of most CRC tumours. This study reveals that a simple and rapidly accessible process could replace the complicated, costly and mostly inapproachable methods clinical practices that have been introduced in the majority of previous studies.



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Prevalence and risk factors of hepatitis D virus infection in patients with chronic hepatitis B infection attending the three main tertiary hospitals in Libya

Publication date: Available online 11 December 2017
Source:Arab Journal of Gastroenterology
Author(s): Abdel-Naser Elzouki, Saleh M. Bashir, Omar Elahmer, Islam Elzouki, Fathi Alkhattali
Background and study aimsGlobally, More than 350 million individuals are chronically infected with hepatitis B virus (HBV), and >20 million of them are co-infected with hepatitis D virus (HDV). The aim of this study was to determine the pattern of HDV infection in patients with chronic hepatitis B in three main tertiary hospitals in Tripoli and Benghazi, Libya.Patients and methodsThis cross sectional and descriptive study was conducted on 162 patients with chronic hepatitis B positive for more than six months) who were followed up at hepatitis clinics of the three main tertiary hospitals in Tripoli city (88 patients from Tripoli Medical Centre and Tripoli Central Hospital) and Benghazi city (74 patients from Aljomhoria Hospital) during the period from January 2010 to June 2012. HBV and HDV markers were detected by enzyme linked fluorescent assay (ELFA) or enzyme-linked immunosorbent assay and HBV-DNA was quantified by real-time PCR techniques.ResultsThe mean age of patients was 36,92 ± 15,35. One hundred and three (63.6%) of them were males and 59 (36,4%) were females. Four patients (2,5%) were tested positive for anti-HD antibodies, all of them have had clinical and/or histological diagnosis of cirrhosis. In multivariable regression analysis, age (p = .04), elevation of serum ALT (p = .03), elevation of serum AST (p = .04), and presence of cirrhosis (p = .003) were significantly related to HDV seropositivity.ConclusionAlthough the study demonstrated that Libya has low to moderate prevalence of HDV (2,5%), it is important for policy makers and health care providers to continue the preventive measures for HDV spread, and HBV prevention program including utilization of HBV vaccine. Furthermore, it is imperative to screen chronic HBV patients for HDV for close observation for early diagnosis of subsequent development of liver cirrhosis. Moreover, further epidemiologic and genetic studies are needed to explore the trend for HDV infection in Libya.



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Value of water enema computed tomography in elderly symptomatic patients

Publication date: Available online 11 December 2017
Source:Arab Journal of Gastroenterology
Author(s): Heyfa Romdhane, Imen Marzouk, Zeineb Mzoughi, Meriem Cheikh, Meriem Dridi, Houcem Fadhl, Rym Ennaifer, Najet Belhadj
Background and study aimsColonoscopy remains the gold standard for the examination of the colon. However, its use in the elderly is not well tolerated, and there is often a need for general anaesthesia, thus increasing the risk, especially if there are co-morbidities. Water enema computed tomography has been suggested to be a satisfactory alternative as a non-invasive, fast and effective means for the diagnosis of colorectal supra-centimetric lesions.The aim of our study was to assess the performance of water enema computed tomography as first-line examination by calculating its negative predictive value (NPV) for the diagnosis of supra-centimetric lesions in symptomatic elderly referred to colonoscopy.Patients and methodsThis was a prospective study including 57 symptomatic patients older than 65 years. All patients were explored by water enema computed tomography at first, followed by colonoscopy, and responded to a questionnaire on the tolerance to the preparation and both procedures.ResultsThe mean age of patients was 73 years. The M:F sex ratio was 1.59. The most frequent indication for colonoscopy was bowel disorders associated with abdominal pain (30%). Water enema computed tomography allowed the diagnosis of tumours (n = 2), polyps (n = 6), diverticulosis (n = 7), inflammatory wall thickening (n = 1) and extra-colic lesions (n = 28). NPV of water enema computed tomography for supra-centimetric lesions was 96.5%. Sensitivity and specificity were 87.3% and 98%, respectively. However, for sub-centimetric lesions, water enema computed tomography had a low sensitivity estimated at 6%, specificity at 89.9%, positive predictive value at 91.9% and NPV at 27.7%.ConclusionWater enema computed tomography has proven to be a valuable and non-invasive method indicated as a first-line examination in case of colonic symptoms in the elderly to diagnose supra-centimetric lesions.



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Radiofrequency-assisted subcision for postacne scars

Subcision is a commonly performed procedure for depressed rolling scars of acne.1 Breaking up the fibrotic strands mechanically with a blade or needle leads to neocollagenosis and hematoma formation, resulting in elevation of the depressed scars. However, the excessive mechanical force often leads to trauma to the surrounding tissue, excessive bleeding, and large hematoma formation and fibrosis.

http://ift.tt/2yguvXM

Trends in US sunscreen formulations: Impact of increasing spray usage

To the Editor: Sunscreen is an important component of sun protection. Almost all dermatologists believe that sunscreen is safe, effective, and can reduce the risk of skin cancer.1 In the United States, many different sunscreen formulations exist, including balms, sprays, lotions, sticks, creams, foams, gels, and oils.

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Editorial Board

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Table of Contents

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Botulinum toxin type A for the treatment of localized recalcitrant chronic pruritus

To the Editor: Localized chronic pruritus is a common condition that significantly affects health-related quality of life. A variety of diseases result in localized chronic itch, which can be broadly classified as dermatologic, neuropathic, or psychogenic in nature. For patients with chronic pruritus that is refractory to conventional therapy, the burden of disease is substantial.

http://ift.tt/2yheUXT

Cantharidin for treatment of facial molluscum contagiosum: A retrospective review

To the Editor: Molluscum contagiosum (MC) papules are self-limited, resolving within months to years. Active nonintervention is a common management approach in children; caregivers, however, often seek treatment owing to the contagious nature of the virus, itch, embarrassment, pain, or other reasons (Fig 1). Cantharidin is a common treatment for pediatric MC, although some discourage its use on the face. We present caregiver-reported outcomes of cantharidin treatment for facial molluscum in our practice.

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Micromelanomas identified with time-lapse total body photography and dermoscopy

To the Editor: Secondary prevention efforts to detect malignant melanoma focus on lesions at an initial growth phase with diameters <6 mm; earlier detection correlates with improved survival rates.1 Two photographic approaches provide critical and complementary information in the differential diagnosis of malignant melanoma. Total body photography (TBP) traditionally provides baseline images from which macroscopic lesion changes can be detected, whereas digital epiluminescence (dermoscopic) microscopy reveals subtle changes in preexisting nevi.

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Romance, love, and sex in the dermatology department and residency program

Many businesses and academic organizations have policies that address the issue of workplace amorous relationships. Virtually all such policies forbid relationships between supervisors and those whom they supervise, or between employees of significantly different rank. Some even go so far as to prohibit relationships between employees in different departments or those reporting to different supervisors. The basis for such policies is to prohibit relationships that may affect the work environment for other employees, the productivity of the company, and to prevent the company from becoming entangled in sexual harassment suits.

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Vitamin D deficiency in patients with alopecia areata: A systematic review and meta-analysis

Alopecia areata (AA) is a T cell–mediated autoimmune disease that causes nonscarring hair loss.1 Some autoimmune diseases are associated with a vitamin D deficiency, including inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and vitiligo.2,3 Previous studies that evaluated vitamin D levels in patients with AA have reached inconsistent conclusions. This study aimed to perform a systematic review and meta-analysis on the association between vitamin D levels and AA.

http://ift.tt/2yhafW1

Innovative modification of the USB dermatoscope for mucoscopy

There have been a number of technological advancements in dermoscopy of cutaneous lesions1; However, dermoscopy of mucosae remains a challenge, primarily because existing dermatoscopes are not well designed to explore them. Contact magnifying endoscopes and oral mucoscopes have been used in the past for contact and noncontact mucoscopy.2 But the lack of availability and versatility of these instruments and lack of expertise in handling them make them unsuitable for routine use by dermatologists in clinical practice.

http://ift.tt/2l244E6

Health care utilization for psoriasis in the United States differs by race: An analysis of the 2001-2013 Medical Expenditure Panel Surveys

To the Editor: Racial/ethnic differences in general health care utilization exist in the United States.1 Little is known about health care utilization among racial/ethnic groups for skin diseases, including for psoriasis, the most prevalent immune-mediated disease.2 We aimed to evaluate health care utilization for psoriasis by race/ethnicity using population-based data derived from the Medical Expenditure Panel Surveys, the most complete source of information on health care utilization, cost, and health insurance coverage in the United States.

http://ift.tt/2iVJVeI

Hidradenitis suppurativa burden of disease tool: Pilot testing of a disease-specific quality of life questionnaire

To the Editor: Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting intertriginous areas of the body that dramatically impairs quality of life (QoL) and has a substantial psychosocial burden.1,2 Full remission of HS is rare, making improvements in QoL a critical goal of therapy. Currently, when investigating the impact of HS, we are limited to generic QoL questionnaires, none of which are specific for HS. We propose a disease-specific tool that would better capture the unique burden of disease caused by HS, which is necessary to determine the impact of therapeutic interventions in clinical trials and in the clinical setting.

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Iotaderma #287

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Andrews' diseases of the skin clinical atlas

Andrews' Diseases of the Skin Clinical Atlas by William James, Dirk Elston, and Patrick McMahon is the first published atlas from the writers of Andrews' Diseases of the Skin, a renowned comprehensive dermatological text. It not only serves as a wonderful accompaniment to the Andrews text but also is a strong standalone atlas benefitting any reader, from student to practicing clinician. For a specialty that relies heavily on the physical exam, this text provides wonderful depictions of thousands of entities that help the reader learn the morphology and distribution of each diagnosis.

http://ift.tt/2l1Ur8o

Cancer risks among patients with alopecia areata: A population-based case-control study in Korea

To the Editor: Studies have shown the reduced incidence of skin cancer in patients with autoimmune dermatologic diseases, including alopecia areata (AA) and vitiligo.1,2 The aim of this study was to investigate the association between AA and several types of cancer. This study was a retrospective case-control study from the National Health Insurance Service–National Sample Cohort.3 Age, sex, location, income, and diagnostic codes based on the International Classification of Diseases, 10th edition were retrieved.

http://ift.tt/2iRwMDk

Reply to: “Updated diagnostic criteria for frontal fibrosing alopecia”

To the Editor: We thank Vaño-Galvan et al for their letter regarding criteria for frontal fibrosing alopecia (FFA).1 The differential diagnosis of FFA is broad, and diagnostic criteria can aid in identifying this entity. We agree with many of the suggestions to our diagnostic criteria proposed in our article on the Mayo Clinic cohort of FFA patients.2

http://ift.tt/2B7aBDy

Decreased risk of vitiligo in organ transplant recipients: A population-based cohort study

To the Editor: Vitiligo remains a major challenge in dermatology because there is no definitive cure.1 The autoimmune nature of vitiligo has been described,2 and the involvement of T cells in pathogenesis of vitiligo has also been shown in previous reports.3 While the therapeutic potential of immunosuppressants has often been raised, their role has not been well examined.

http://ift.tt/2BD70xY

Vitiligo-like lesions in patients receiving anti–programmed cell death-1 therapies are distinct from spontaneously occurring active vitiligo

To the Editor: We would like to thank Fukuda and Harris for their interest in our manuscript.1 Clinically, we have voluntarily characterized vitiligo-like lesions induced by anti–programmed cell death-1 (PD-1) as "multiple flecked depigmented macules" to differ from the description reported for active lesions in spontaneously occurring vitiligo (referred to as vitiligo). Indeed, in vitiligo, active lesions are associated with hypomelanotic appearance and poorly defined borders2 (as shown in Fukuda et al, Fig 1), a clinical sign completely absent in vitiligo-like lesions under anti–PD-1.

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Trends in Medicare spending on topical immunomodulators and chemotherapies

To the Editor: Actinic keratoses (AKs) and in situ/superficial carcinomas are common and costly dermatologic conditions that account for ≥5.2 million visits and $920 million in annual spending.1,2 Topical therapies are often used as field therapy for these conditions. In this study, we evaluate recent national trends in topical therapy use and costs for precancerous and in situ/superficial carcinomas in the Medicare population.

http://ift.tt/2BEjYM3

Acknowledging the pseudo “fringe sign” in frontal fibrosing alopecia has diagnostic and prognostic implications

To the Editor: A frontal band of scarring alopecia with eyebrow involvement in postmenopausal women (ie, frontal fibrosing alopecia [FFA]) evolved from a "recently described disease" to the status of "a growing epidemic" in less than 2 decades. Since the first report by Kossard,1 additional features and variants not contemplated in the original description have been incorporated into the clinical picture. For such, I read with great interest the paper by Rossi et al reporting 3 unusual clinical patterns of FFA.

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High riding of brachiocephalic artery: A rare case of pulsatile anterior neck mass

Publication date: Available online 11 December 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Bao Ling Wong, Shashi Gopalan, Muhammad Nasri Abu Bakar, Ming Huei Wong
Anterior neck swellings are common presentations that are seen in otorhinolaryngology clinics. We presented a rare diagnosis of pulsatile anterior neck swelling where a high riding brachiocephalic artery needs to be considered as a differential diagnosis. This 54-year-old lady presented with anterior neck swelling for one year which appear to be pulsatile, soft and non-tender mass. Ultrasound and Doppler scan, contrast-enhanced computed tomography (CECT) scan revealed that the neck swelling corresponds to the high riding brachiocephalic artery. Hence, ultrasound scan is essential to detect any vascular lesion prior to biopsy or fine needle aspiration cytology as to avoid catastrophic hemorrhage.



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High riding of brachiocephalic artery: A rare case of pulsatile anterior neck mass

Publication date: Available online 11 December 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Bao Ling Wong, Shashi Gopalan, Muhammad Nasri Abu Bakar, Ming Huei Wong
Anterior neck swellings are common presentations that are seen in otorhinolaryngology clinics. We presented a rare diagnosis of pulsatile anterior neck swelling where a high riding brachiocephalic artery needs to be considered as a differential diagnosis. This 54-year-old lady presented with anterior neck swelling for one year which appear to be pulsatile, soft and non-tender mass. Ultrasound and Doppler scan, contrast-enhanced computed tomography (CECT) scan revealed that the neck swelling corresponds to the high riding brachiocephalic artery. Hence, ultrasound scan is essential to detect any vascular lesion prior to biopsy or fine needle aspiration cytology as to avoid catastrophic hemorrhage.



http://ift.tt/2jzIne6

Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis

BACKGROUND Guidance on pre-operative fluids fasting policy continues to evolve. Current European guidelines encourage the intake of oral fluids up to 2 h before the induction of general anaesthesia. From October 2014, Torbay Hospital Day Surgery Unit commenced an unrestricted fluid policy, encouraging patients to drink clear fluids up until the time of transfer to theatre. OBJECTIVE The aim of this study was to assess the incidence of postoperative nausea and vomiting before and after the change to the unrestricted pre-operative clear oral fluids. DESIGN Retrospective, before and after study. SETTING Single district general hospital between November 2013 and February 2016. PATIENTS A total of 11 500 patients on the day case pathway who were receiving either sedation, general anaesthesia, regional anaesthesia or their combination. The data from these patients were collected routinely. This number of patients represents approximately 78% of all patients before the change in fluids policy and 74% after the change. Exclusions were patients undergoing a termination of pregnancy, or patients undergoing community dental procedures, from whom patient experience data are not collected. INTERVENTION Introduction of a change to the day surgery pathway policy permitting unrestricted clear oral fluids preoperatively until transfer to theatre (from October 2014). MAIN OUTCOME MEASURES Incidence of postoperative nausea and vomiting. RESULTS The rates of nausea within 24 h postoperatively were 270/5192 (5.2%) when patients could not drink within 2 h of surgery, and 179/4724 (3.8%) when patients could drink up until surgery, a relative rate (95% confidence interval) of 0.73 (0.61 to 0.88), P = 0.00074. The corresponding rates of vomiting were 146/5186 (2.8%) and 104/4716 (2.2%), a relative rate (95% confidence interval) of 0.78 (0.61 to 1.00), P = 0.053. CONCLUSION Our data suggest that the liberal consumption of clear fluids before the induction of scheduled day case anaesthesia reduced the rates of postoperative nausea and vomiting. Correspondence to Dr Graham C. McCracken, MB, BCh, BAO, Department of Anaesthetics, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay TQ2 7AA, Devon, UK E-mail: gmccracken@nhs.net © 2017 European Society of Anaesthesiology

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Knowledge Translation: the bridging function of Cochrane Rehabilitation

Publication date: Available online 12 December 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Stefano Negrini, Francesca Gimigliano, Chiara Arienti, Carlotte Kiekens
Cochrane Rehabilitation is aimed to ensure that all rehabilitation professionals can apply Evidence Based Clinical Practice and take decisions according to the best and most appropriate evidence in this specific field, combining the best available evidence as gathered by high quality Cochrane systematic reviews, with their own clinical expertise and the values of patients. This mission can be pursued through Knowledge Translation. The aim of this paper is to shortly present what Knowledge Translation is, how and why Cochrane (previously known as Cochrane Collaboration) is trying to reorganize itself in light of Knowledge Translation, and the relevance that this process has for Cochrane Rehabilitation and in the end for the whole world of Rehabilitation.It is well known how it is difficult to effectively apply in everyday life what we would like to do and to apply the scientific knowledge in the clinical field: this is called the "know-do gap". In the field of Evidence Based Medicine, where Cochrane belongs, it has been proven that high quality evidence is not consistently applied in practice. A solution to these problems is the so-called "Knowledge Translation". In this context, Cochrane Rehabilitation is organized to provide the best possible Knowledge Translation in both directions (bridging function), obviously toward the world of rehabilitation (spreading reviews), but also to the Cochrane community (production of reviews significant for rehabilitation). Cochrane is now strongly pushing to improve its KT activities, and this creates a strong base for Cochrane Rehabilitation work, focused not only on spreading the evidence, but also on improving its production to make it more meaningful for the world of rehabilitation.



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A Cost-Effective, In-House, Positioning and Cutting Guide System for Orthognathic Surgery

Abstract

Introduction

Technological advances in 3D printing can dramatically improve orthognathic surgical planning workflow. Custom positioning and cutting guides enable intraoperative reproduction of pre-planned osteotomy cuts and can result in greater surgical accuracy and patient safety.

Objectives

This short paper describes the use of freeware (some with open-source) combined with in-house 3D printing facilities to produce reliable, affordable osteotomy cutting guides.

Methods

Open-source software (3D Slicer) is used to visualise and segment three-dimensional planning models from imported conventional computed tomography (CT) scans. Freeware (Autodesk Meshmixer ©) allows digital manipulation of maxillary and mandibular components to plan precise osteotomy cuts. Bespoke cutting guides allow exact intraoperative positioning. These are printed in polylactic acid (PLA) using a fused-filament fabrication 3D printer. Fixation of the osteotomised segments is achieved using plating templates and four pre-adapted plates with planned screw holes over the thickest bone. We print maxilla/ mandible models with desired movements incorporated to use as a plating template.

Results

A 3D printer capable of reproducing a complete skull can be procured for £1000, with material costs in the region of £10 per case. Our production of models and guides typically takes less than 24 hours of total print time. The entire production process is frequently less than three days. Externally sourced models and guides cost significantly more, frequently encountering costs totalling £1500–£2000 for models and guides for a bimaxillary osteotomy.

Conclusion

Three-dimensional guided surgical planning utilising custom cutting guides enables the surgeon to determine optimal orientation of osteotomy cuts and better predict the skeletal maxilla/mandible relationship following surgery. The learning curve to develop proficiency using planning software and printer settings is offset by increased surgical predictability and reduced theatre time, making this form of planning a worthy investment.

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Efficacy and Safety of Photoselective Vaporization of the Prostate with 120 W 532 nm Laser in Patients with Benign Prostatic Hyperplasia on Anticoagulation or Antiplatelet Therapy: Observations on Long-Term Outcomes

Photomedicine and Laser Surgery , Vol. 0, No. 0.


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Placental abruption leading to hysterectomy

A 32-year-old multigravid patient at 21 weeks gestation presents with major concealed placental abruption and subsequent fetal demise. During an eventually failed misoprostol regime aiming for vaginal delivery she develops severe disseminated intravascular coagulopathy. Subsequent hysterotomy reveals Couvelaire uterus with major haemorrhage and requires subtotal hysterectomy for haemostasis. This case highlights the severity of the systemic response to abruption and fetal demise in utero and the multifactorial nature of its management.

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A novel technique for superior-based pharyngeal flaps: 10-year results with formal speech outcomes assessment

Publication date: Available online 11 December 2017
Source:American Journal of Otolaryngology
Author(s): Ryan Winters, John Carter, J. Lindhe Guarisco
PurposeDescribe a novel technique for superior-based pharyngeal flaps allowing restoration of bulk to the soft palate and intraoperative fine-tuning of lateral port size, while avoiding midline palate-splitting. Validated speech assessment tools are employed for quantitative analysis.MethodsRetrospective review of all patients who underwent superior-based pharyngeal flap in a 10-year period by a single surgeon. Pittsburgh Weighted Values for Speech Symptoms Associated with VPI and the Goldman-Fristoe Test of Articulation were used for formal speech assessment.Results78 patients met inclusion criteria with clinical data up to 10years postoperatively. 31 patients had congenital velopharyngeal insufficiency (VPI), and the remainder acquired VPI after cleft palate repair or adenoidectomy. 37 patients had a recognized syndrome. All patients noted subjective improvement in nasality, and evaluation with the validated speech assessment tools demonstrated statistically significant improvement in speech. Only one flap takedown was required in a patient with severe midface hypoplasia who developed sleep apnea several years postoperatively.ConclusionsThis technique is successful in congenital and acquired VPI, and in patients with complex craniofacial syndromes. Customization of lateral ports based on preoperative nasopharyngoscopy, and avoidance of a midline palate splitting incision, make this an attractive option for superior-based flap surgery.



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Gastro-pharyngeal reflux and total laryngectomy. Increasing knowledge about its management

Publication date: Available online 11 December 2017
Source:American Journal of Otolaryngology
Author(s): Giuditta Mannelli, Roberto Santoro, Francesco Segala, Elisabetta Surrenti, Oreste Gallo
PurposeInvestigate the incidence, the degree and the effect of gastro-pharyngeal reflux (GPR) in laryngectomised patients.Materials and methodsBehavioral and 24-hour pH- and impedance-monitoring data were prospectively analyzed for 25 laryngectomised patients with no previous history of GER in outpateints' setting. Reflux detected was characterized as either acid, weakly acidic or nonacid. Proximal reflux was found at 15cm above the LES.Results40% of patients presented a pathological number of reflux episodes in the upright position (p<0.0001); 9 of them presented a pathologic bolus exposure time. Bolus exposure at the proximal sphincter was one fourth-fold lower than 5cm above the LES (p=0.3593). There was a prevalence of acid reflux at both sphincters (p<0.0001); liquid reflux was prevalent at the LES (p=0.003) and mixed reflux at the UES (p=0.0001). Median REs was higher than time acid exposure (p=0.0013).ConclusionsPre- and post-surgical reflux investigation could identify preexisting reflux severity and screen potential high-risk cancer patients for postoperative complications. This might allow the early onset of acid suppressive therapy in presence of pathologic findings in high-complication risk cancer patients.



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Characterizing the impact of adaptive planning on image-guided perineal interstitial brachytherapy for gynecologic malignancies

Publication date: Available online 11 December 2017
Source:Brachytherapy
Author(s): Adam Gladwish, Ananth Ravi, Lisa Barbera, Lucas Mendez, Melanie Davidson, Laura D'Alimonte, David D'Souza, Matt Wronski, Eric Leung
PurposeTo determine the dosimetric impact of organ and implant motion/deformation in the context of adaptive planning in image-guided gynecologic brachytherapy using a 3-fraction transperineal approach.Methods and materialsTwenty-six patients were analyzed. Each patient was treated with three fractions given over a 24-h period using a single insertion. A planning CT scan (±MRI) was acquired before the first fraction. A verification scan was taken within 1 h following the second fraction. A single plan was delivered for Fractions 1 and 2 with an adaptive plan delivered for Fraction 3. Two evaluation frameworks were established. Framework 1 investigated the effects of motion/deformation from both implant and organs. Framework 2 investigated the impact of implant motion/deformation alone. Differences in high-risk clinical target volume (HRCTV) D90%, V100%, and bladder/rectum D2cc were assessed.ResultsFrom implant to verification, the HRCTV D90% and V100% decreased significantly (5.0%, p < 0.01; 3.1%, p < 0.01) and rectal D2cc was significantly higher (12.2%, p = 0.02). Adaptive planning recouped these changes. Implant changes resulted in a reduction in HRCTV dose and coverage, but no significant effect was seen in the bladder or rectum.ConclusionsAdaptive planning represents an important aspect of perineal-based interstitial image-guided brachytherapy given in three fractions; its absence would result in plan degradation.



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Development and characterization of an anthropomorphic breast phantom for permanent breast seed implant brachytherapy credentialing

Publication date: Available online 11 December 2017
Source:Brachytherapy
Author(s): Michael Roumeliotis, Sarah Quirk, Matthew Skarsgard, Tiana Trumpour, Elizabeth Watt, Tyler Meyer
PurposeTo develop an anthropomorphic breast phantom for use in credentialing of permanent breast seed implant brachytherapy.Methods and MaterialsA representative external contour and target volume was used as the basis of mold manufacturing for anthropomorphic breast phantom development. Both target and normal tissue were composed of gel-like materials that provide suitable computed tomography and ultrasound contrast for brachytherapy delivery. The phantoms were evaluated for consistency in construction (target location) and Hounsfield unit (computed tomography contrast). For both target and normal tissue, the speed of sound was measured and compared to the image reconstruction algorithm's expectation value. Five phantoms were imaged preimplant and postimplant to assess interphantom similarity as well as to evaluate the uncertainty in quantifying seed position.ResultsThe average Hounsfield units of the target and normal tissue gels is −146 ± 5 and 23 ± 1, respectively. The average speed of sound of the target and normal tissue gels is 1485 ± 7 m/s and 1558 ± 9 m/s, respectively, resulting in an estimated 0.4 mm uncertainty in image guidance. The registration/deformation uncertainty was determined to be 0.8 mm. The standard combined uncertainty in assessing seed position spatial accuracy, also including a 0.9 mm estimate based on literature for seed localization, is estimated to be 1.3 mm.ConclusionsThe development of the anthropomorphic breast phantom and evaluation of both the consistency as well as overall seed position uncertainty illustrates the suitability of this phantom for use in brachytherapy end-to-end delivery and implant accuracy evaluation. When evaluating a user's implant accuracy, we estimate a standard combined uncertainty of 1.3 mm.



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Placement of an absorbable rectal hydrogel spacer in patients undergoing low-dose-rate brachytherapy with palladium-103

Publication date: Available online 11 December 2017
Source:Brachytherapy
Author(s): Amandeep S. Taggar, Tomer Charas, Gil'ad N. Cohen, Keeratikarn Boonyawan, Marisa Kollmeier, Sean McBride, Nitin Mathur, Antonio L. Damato, Michael J. Zelefsky
PurposeRates of rectal toxicity after low-dose-rate (LDR) brachytherapy for prostate cancer are dependent on rectal dose, which is associated with rectal distance from prostate and implanted seeds. Placement of a hydrogel spacer between the prostate and rectum has proven to reduce the volume of the rectum exposed to higher radiation dose levels in the setting of external beam radiotherapy. We present our findings with placing a rectal hydrogel spacer in patients following LDR brachytherapy, and we further assess the impact of this placement on dosimetry and acute rectal toxicity.Methods and MaterialsBetween January 2016 and April 2017, 74 patients had placement of a hydrogel spacer, immediately following a Pd-103 seed-implant procedure. Brachytherapy was delivered as follows: as a monotherapy to 26 (35%) patients; as part of planned combination therapy with external beam radiotherapy to 40 (54%) patients; or as a salvage monotherapy to eight (11%) patients. Postoperative MRI was used to assess separation achieved with rectal spacer. Acute toxicity was assessed retrospectively using Radiation Oncology Therapy Group radiation toxicity grading system. Rectal dosimetry was compared with a consecutive cohort of 136 patients treated with seed implantation at our institution without a spacer, using a 2-tailed paired Student's t test (p < 0.05 for statistical significance).ResultsOn average, 11.2-mm (SD 3.3) separation was achieved between the prostate and the rectum. The resultant mean rectal volume receiving 100% of prescribed dose (V100%), dose to 1 cc of rectum (D1cc), and dose to 2 cc of rectum (D2cc) were 0 (SD 0.05 cc), 25.3% (SD 12.7), and 20.5% (SD 9.9), respectively. All rectal dosimetric parameters improved significantly for the cohort with spacer placement as compared with the nonspacer cohort. Mean prostate volume, prostate V100 and dose to 90% of gland (D90) were 29.3 cc (SD 12.4), 94.0% (SD 3.81), and 112.4% (SD 12.0), respectively. Urethral D20, D5cc, and D1cc were 122.0% (SD 17.27), 133.8% (SD 22.8), and 144.0% (SD 25.4), respectively. After completing all treatments, at the time of first the followup, 7 patients reported acute rectal toxicity—6 experiencing Grade 1 rectal discomfort and 1 (with preexisting hemorrhoids) experiencing Grade 1 bleeding.ConclusionsInjection of rectal spacer is feasible in the post-LDR brachytherapy setting and reduces dose to the rectum with minimal toxicity. Prostate and urethral dosimetries do not appear to be affected by the placement of a spacer. Further studies with long-term followup are warranted to assess the impact on reduction of late rectal toxicity.



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Central Mound Mastopexy for the Correction of Tuberous/Tubular Breast Deformity

Summary: Tuberous and tubular breast deformity are well-recognized abnormalities in the plastic surgery community that incur severe physical and psychological consequences in affected patients. Current reconstructive options for the tuberous and tubular breasts favor the use of prosthetic implants and soft-tissue manipulation. We present a case of tuberous and tubular breast deformity treated with a central mound reduction technique and mastopexy with imbricating sutures without the use of prosthetic implants. The patient remained extremely pleased with her results at long-term follow-up. This represents a unique case of successful reconstruction in a patient with a tuberous and tubular breast deformity using a central mound reduction technique with mastopexy and without a prosthetic device.

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Gluteal Black Market Silicone–induced Renal Failure: A Case Report and Literature Review

Summary: Very few cases of successful surgical treatment for renal failure due to gluteal silicone injections have been reported in the literature. The silicone toxicity and subsequent renal failure seem to follow repetitive silicone injections and silicone injections in large quantities. This is a case of a 31-year-old woman who developed renal failure after 6 years of gluteal silicone injections who underwent radical resection of bilateral gluteal regions in an attempt to mitigate her impending complete renal failure. A systematic review of the literature was conducted using PubMed database and with assistance from medical library staff to conduct keyword searches for "Silicone," "Renal failure," "Silicone emboli syndrome," "Silicone granuloma," and "Silicone end organ toxicity." The search results were reviewed by the authors and selected based on the relevance to the case report presented. Extensive literature relating to silicone granulomas and their systemic effects supports the use of steroids for immediate treatment and eventual surgical resection for cure of the various silicone-related end-organ toxicities including renal failure.

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Cardiac function in pediatric patients with congenital adrenal hyperplasia due to 21 hydroxylase deficiency

Abstract

Background

Hyperandrogenism and exogenous glucocorticoid excess may cause unfavorable changes in the cardiovascular risk profile of patients with congenital adrenal hyperplasia (CAH).

Objective

To evaluate the cardiac function in pediatric patients with CAH.

Patients and methods

27 pediatric patients with CAH, aged 8-16 years, were evaluated by physical examination, electrocardiogram (ECG), conventional echocardiography, tissue Doppler imaging and two-dimensional (2D) myocardial strain (rate) imaging. Results were compared to 27 age and gender matched healthy controls.

Results

No signs of left ventricular hypertrophy or dilatation were detected on ECG and echocardiography. ECG revealed a high prevalence (25.9%) of incomplete right bundle branch block. Left ventricular posterior wall thickness in diastole (LVPWd) was significantly lower in patients with CAH compared to controls (5.55 vs 6.53 mm; p=0.009). The LVPWd Z-score was significantly lower in patients with CAH yet within the normal range (-1.12 vs -0.35; p=0.002). Isovolumetric relaxation time was significantly lower in patients with CAH (49 vs 62 ms; p=0.003). Global longitudinal, radial and circumferential strain were not significantly different compared to controls. Global radial strain rate was significantly higher compared to healthy controls (2.58 vs 2.06 1/s; p=0.046). Global longitudinal strain was negatively correlated with 24 hour blood pressure parameters.

Conclusion

Cardiac evaluation of pediatric patients with CAH showed no signs of left ventricular hypertrophy or ventricular dilatation. LVPWd was lower in patients with CAH than in controls, but within the normal range. A shorter isovolumetric relaxation time in patients with CAH may be a sign of mild left ventricular diastolic dysfunction.

This article is protected by copyright. All rights reserved.

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Unexpected Blooming Artifact in Brain Magnetic Resonance Imaging

Abstract Unexpected foreign bodies are occasionally discovered during magnetic resonance imaging (MRI). These are often present unknown to the patient, missed during routine pre-MRI screening and result in unnecessary delay during MRI. The authors present a patient with traumatically embedded foreign body in the scalp that escaped pre-MRI screening and caused susceptibility artifacts during brain MRI. The object was surgically removed to allow the imaging to be completed. Patients with suspicion or history of facial trauma or with dental restorations are referred to concerned specialists for compatibility of hardware, restorations and for assessing risks during MRI due to these. This patient is presented as a reminder for clinicians to probe further during anamnesis and have a high index of suspicion for foreign bodies that may be present even after trivial injuries. Address correspondence and reprint requests to Akilesh Ramasamy, MDS, Department of Dentistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India; E-mail: akident@gmail.com Received 22 April, 2017 Accepted 4 August, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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A Three-Dimensional Anthropometric Evaluation of Facial Morphology

Objectives: The aims of this study were to evaluate sexual dimorphism for facial features within Italian and Egyptian populations and to compare the facial morphology by sex between these 2 populations. Materials and Methods: Three-dimensional (3D) facial images were acquired by using the portable 3dMDface System, which captured 259 subjects from 2 population groups of Italian (n = 139) and Egyptian (n = 120). Each population was categorized into male and female groups for evaluation. All subjects in the groups were aged between 18 and 30 years and had no apparent facial anomalies. A total of 23 anthropometric landmarks were identified on the 3D faces of each subject. The independent t test was used to analyze each data set obtained within each subgroup. Results: Egyptian women tend to have distinct facial features when compared with Italian women; they had less prominent eyes, more nasal width, more height of upper and lower faces and more height of upper and lower vermilion lengths. Egyptian and Italian males demonstrated very close facial features. However, Egyptian males had more nasal width, length of alare, and mandibular height. Conclusions: Sexual dimorphism for facial features was presented in both the Italian and Egyptian populations. In addition, there were significant differences in facial morphology between these 2 populations, especially in females. Address correspondence and reprint requests to Dr. Chung How Kau, DDS, MSD, MBA, PhD, MOrth, FDS, FFD, FAMS, Department of Orthodontics, University of Alabama at Birmingham, School of Dentistry, 1919 Seventh Ave. S. Birmingham, AL 35294; E-mail: ckau@uab.edu Received 13 March, 2017 Accepted 14 August, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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The Hybrid Technical Management of Large and Complicated Traumatic Arteriovenous Fistula of Preauricular Region

Background: Arteriovenous fistula (AVF) is defined as an abnormal communication between the high flow arterial system and the low flow venous network, which directly connects the arterial feeding vessels and the near draining veins without normal intervening capillary bed. Arteriovenous fistula incurs in preauricular region is exceeding rare. Most of these fistulae occur as a result of an iatrogenic injury, the volume is small, feeding and draining vessels of feeding and draining are simple, and can be cured easily. However, the treatment of the large and complicated AVF after incidental trauma in preauricular region is a challenge even for senior neurosurgeon. In this study, the authors discuss the management of a traumatic AVF through combined therapeutic method of surgical ligation and transarterial embolization. It is fed by ipsilateral superficial temporal artery, internal maxillary artery, posterior auricular artery, and their accessory branches and is drained by ipsilateral common facial vein and external jugular vein. Also the etiology, clinical manifestations, pathology, diagnosis, and management are summarized. Conclusion: Large and complicated traumatic AVF in preauricular region is rare, often due from an injury in maxillofacial region, combined therapy needed. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://ift.tt/OBJ4xP Address correspondence and reprint requests to Jinlong Sun, Shandong Provincial Qianfoshan Hospital, Jinan, China; E-mail: jinlongsun@hotmail.com Received 16 July, 2017 Accepted 19 August, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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Differences in the Alignment Pattern of the Maxillary Dental Arch Following Fixed Orthodontic Treatment in Patients With Bilateral Cleft Lip and Palate: Anteroposterior-Collapsed Arch Versus Transverse-Collapsed Arch

Abstract The purpose of this study was to investigate differences in the alignment pattern of the collapsed maxillary arch following fixed orthodontic treatment (FOT) in bilateral cleft lip and palate (BCLP) patients according to collapse type. Fifteen BCLP patients were divided into Group 1 (anteroposterior-collapsed arch, n = 7) and Group 2 (transverse-collapsed arch, n = 8) according to maxillary arch shape before FOT. Linear and angular variables of lateral cephalograms and dental models were evaluated before (T1) and after FOT (T2), and statistical analysis was performed. In cephalometric measurements at T1, both the groups exhibited retrusive maxillae, a Class III relationship, and lingual inclination of U1-SN. At T2, significant improvement of U1-SN was observed in both the groups (P 

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Recurrent Lower Eyelid Ectropion After Graft Surgery Using Autogenous Palmaris Longus Tendon

Abstract A 78-year-old male experienced right lower eyelid ectropion following right facial trauma from a fall 5 years ago, for which he underwent autogenous palmaris longus tendon graft surgery at another clinic. Recurrence was noted 3 years after surgery. On first examination, there was outward turning of the lateral half of the right lower eyelid margin. We performed a lateral tarsal strip procedure with removal of the graft. Intraoperatively, the lateral part of the graft was located along the inferior tarsal border, whereas the medial part was located on the tarsal surface. The lateral stump had bifurcated; 1 branch had passed through a bony hole drilled at the base of the rim; and both branches had been ligated together on the rim surface. The medial side had been fixed to the medial canthal tendon. Postoperatively, the apposition of eyelid and ocular surface was good, and the patient experienced no recurrence after 1 year. Address correspondence and reprint requests to Hiromichi Matsuda, MD, Department of Ophthalmology, Daisan Hospital, The Jikei University School of Medicine, 4-11-1 Izumihonchou, Komae, Tokyo 201-8601, Japan; E-mail: thkmmm@yahoo.co.jp Received 21 June, 2017 Accepted 6 October, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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Intraoral Pleomorphic Adenoma in Young Patients

Background: Intraoral pleomorphic adenoma (PA) is rare in young individuals, with only single clinical reports or small patient series reported previously. Aim: The aim of this study was to describe the clinicopathological features of PA in 4 patients under 18 years of age, and to discuss the differential diagnosis of pediatric patients presenting with intraoral submucosal nodules. Methods: Between 2000 and 2015, all patients of intraoral PA in patients aged ≤18 years diagnosed in the Oral Pathology Laboratory of the Universidade Federal de Pernambuco, Brazil, were retrieved for the study. Clinical data were recorded from the clinical charts. Histopathological slides stained with hematoxylin and eosin were reviewed to confirm the diagnosis. Results: There were 4 cases of PA in patients aged ≤18 years. All patients in this patient series were males, with a mean age of 16.7 years. Three cases occurred in the palate, and in 1 case, the upper lip was affected. All PAs appeared as a painless, smooth surface, well-circumscribed, and submucosal nodule. All patients were surgically excised and subsequent histopathological analysis revealed well-circumscribed tumors composed of cells that were arranged in ducts within a fibromyxoid stroma. No signs of recurrence were observed in 3 patients after a mean follow-up of 30 months. One patient is lost to follow-up. Conclusion: Although PAs are unusual in young patients, they should be considered in the differential diagnosis of oral submucosal nodules. Address correspondence and reprint requests to Danyel Elias da Cruz Perez, PhD, 4a Travessa Professor Artur de Sá, Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, s/n—Cidade Universitária, CEP: 50740-521, Recife, Pernambuco, Brazil; E-mail: danyel.perez@ufpe.br Received 11 September, 2017 Accepted 8 October, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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Osseous Convexity at the Anterior Fontanelle: A Presentation of Metopic Fusion?

Background: Craniosynostosis, or a premature fusion of 1 or more cranial vault sutures, results in characteristic head shape deformities. In previous reports, an osseous prominence at the anterior fontanelle has been suggestive of adjacent suture fusion and local elevation in intracranial pressure (ICP). This prominence has been termed the "volcano" sign, and has been described in the anterior fusion of the sagittal suture and serves as an indication for surgery. Methods: Two patients presented for head shape evaluation with mild metopic ridging and anterior fontanellar osseous convexities consistent with the volcano sign. Low-dose computed tomography imaging was performed in both patients due to concern for underlying craniosynostosis with elevated locoregional ICP. Results: In both patients, imaging was significant for a localized, superior forehead metopic fusion, as well as a bony, convex prominence at the site of the ossified anterior fontanelle. There were no other clinical or radiologic signs or symptoms to suggest elevated ICP. Surgery was not indicated in either patient. Conclusions: Here the authors present 2 patients with osseous convexities at the site of the closed anterior fontanelle without signs or symptoms of elevated ICP, or classic signs of metopic synostosis. The authors hypothesize that this pattern may be due to a form of mechanically induced premature fusion of a normal metopic suture that is focused superiorly at the bregma, with minimal resultant restriction of overall skull growth. This is in contrast to metopic synostosis, which primarily has a sutural pathology and leads to characteristic findings of hypotelorism and trigonocephaly. Address correspondence and reprint requests to John A. Persing, MD, Yale Plastic Surgery, PO Box 208062, New Haven, CT 06510; E-mail: john.persing@yale.edu Received 25 February, 2017 Accepted 9 June, 2017 The authors report no conflicts of interest. © 2017 by Mutaz B. Habal, MD.

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Neoadjuvant radiotherapy combined with capecitabine and sorafenib in patients with advanced KRAS-mutated rectal cancer: A phase I/II trial (SAKK 41/08)

Publication date: January 2018
Source:European Journal of Cancer, Volume 89
Author(s): Roger von Moos, Dieter Koeberle, Sabina Schacher, Stefanie Hayoz, Ralph C. Winterhalder, Arnaud Roth, György Bodoky, Panagiotis Samaras, Martin D. Berger, Daniel Rauch, Piercarlo Saletti, Ludwig Plasswilm, Daniel Zwahlen, Urs R. Meier, Pu Yan, Paola Izzo, Dirk Klingbiel, Daniela Bärtschi, Kathrin Zaugg
BackgroundKRAS mutation occurs in ∼40% of locally advanced rectal cancers (LARCs). The multitarget tyrosine kinase inhibitor sorafenib has radiosensitising effects and might improve outcomes for standard preoperative chemoradiotherapy in patients with KRAS-mutated LARC.MethodsAdult patients with KRAS-mutated T3/4 and/or N1/2M0 LARC were included in this phase I/II study. The phase I dose-escalation study of capecitabine plus sorafenib and radiotherapy was followed by a phase II study assessing efficacy and safety. Primary end-points were to: establish the maximum tolerated dose of the regimen in phase I; determine the pathologic complete response (pCR) rate in phase II defined as Dworak regression grade 3 and 4.ResultsFifty-four patients were treated at 18 centres in Switzerland and Hungary; 40 patients were included in the single-arm phase II study. Recommended doses from phase I comprised radiotherapy (45 Gy in 25 fractions over 5 weeks) with capecitabine 825 mg/m² twice daily × 33 plus sorafenib 400 mg/d. Median daily dose intensity in phase II was radiotherapy 100%, capecitabine 98.6%, and sorafenib 100%. The pCR rate (Dworak 3/4) was 60% (95% CI, 43.3–75.1%) by central independent pathologic review. Sphincter preservation was achieved in 89.5%, R0 resection in 94.7%, and downstaging in 81.6%. The most common grade 3 toxicities during phase II included diarrhoea (15.0%), skin toxicity outside radiotherapy field (12.5%), pain (7.5%), skin toxicity in radiotherapy field, proctitis, fatigue and cardiac ischaemia (each 5%).ConclusionsCombining sorafenib and standard chemoradiotherapy with capecitabine is highly active in patients with KRAS-mutated LARC with acceptable toxicity and deserves further investigation. http://ift.tt/PmpYKN: NCT00869570.



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Metastatic cutaneous apocrine adenocarcinoma responsive to the programmed cell death protein 1 inhibitor pembrolizumab

Publication date: Available online 11 December 2017
Source:European Journal of Cancer
Author(s): Max Rogatsch, Johannes Schmid, Sigurd Lax, Maximilian Uranitsch, Karin Schmid-Zalaudek, Roberta Giuffrida, Iris Zalaudek




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Haploinsufficiency of A20 causes autoinflammatory and autoimmune disorders

Publication date: Available online 11 December 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Tomonori Kadowaki, Hidenori Ohnishi, Norio Kawamoto, Tomohiro Hori, Kenichi Nishimura, Chie Kobayashi, Tomonari Shigemura, Shohei Ogata, Yuzaburo Inoue, Tomoki Kawai, Eitaro Hiejima, Masatoshi Takagi, Kohsuke Imai, Ryuta Nishikomori, Shuichi Ito, Toshio Heike, Osamu Ohara, Tomohiro Morio, Toshiyuki Fukao, Hirokazu Kanegane




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Long-term follow up of IPEX syndrome patients after different therapeutic strategies: an international multicenter retrospective study

Publication date: Available online 11 December 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Federica Barzaghi, Laura Cristina Amaya Hernandez, Benedicte Neven, Silvia Ricci, Zeynep Yesim Kucuk, Jack Bleesing, Zohreh Nademi, Mary Anne Slatter, Erlinda Rose Ulloa, Anna Shcherbina, Anna Roppelt, Austen Worth, Juliana Silva, Alessandro Aiuti, Luis Murguia-Favela, Carsten Speckmann, Magda Carneiro-Sampaio, Juliana Folloni Fernandes, Safa Baris, Ahmet Ozen, Elif Karakoc-Aydiner, Ayca Kiykim, Ansgar Schulz, Sandra Steinmann, Lucia Dora Notarangelo, Eleonora Gambineri, Paolo Lionetti, William Thomas Shearer, Lisa Forbes, Caridad Martinez, Despina Moshous, Stephane Blanche, Alain Fisher, Frank M. Ruemmele, Come Tissandier, M. Ouachee-Chardin, Frédéric Rieux-Laucat, Marina Cavazzana, Waseem Qasim, Barbarella Lucarelli, Michael H. Albert, Ichiro Kobayashi, Laura Alonso, Cristina Diaz De Heredia, Hirokazu Kanegane, Anita Lawitschka, Jong Jin Seo, Marta Gonzalez-Vicent, Miguel Angel Diaz, Rakesh Kumar Goyal, Martin G. Sauer, Akif Yesilipek, Minsoo Kim, Yesim Yilmaz-Demirdag, Monica Bhatia, Julie Khlevner, Erick .J. Richmond Padilla, Silvana Martino, Davide Montin, Olaf Neth, Agueda Molinos-Quintana, Justo Valverde-Fernandez, Arnon Broides, Vered Pinsk, Antje Ballauf, Filomeen Haerynck, Victoria Bordon, Catharina Dhooge, Maria Laura Garcia-Lloret, Robbert G. Bredius, Krzysztof Kałwak, Elie Haddad, Markus Gerhard Seidel, Gregor Duckers, Sung-Yun Pai, Christopher C. Dvorak, Stephan Ehl, Franco Locatelli, Frederick Goldman, Andrew Richard Gennery, Mort J. Cowan, Maria Grazia Roncarolo, Rosa Bacchetta
BackgroundImmunedysregulation Polyendocrinopathy Enteropathy X-linked (IPEX) syndrome is a monogenic autoimmune disease caused by FOXP3 mutations. Because it is a rare disease, the natural history and response to treatments, including allogeneic hematopoietic stem cell transplantation (HSCT) and immunosuppression (IS), have not been thoroughly examined.ObjectiveTo evaluate disease onset, progression and long-term outcome of the two main treatments in long-term IPEX survivors.MethodsClinical histories of 96 patients with a genetically proven IPEX syndrome were collected from 38 institutions worldwide and retrospectively analyzed. To investigate possible factors suitable to predict the outcome, an organ involvement (OI) scoring system was developed.ResultsWe confirm neonatal onset with enteropathy, type 1 diabetes (T1D), and eczema. In addition, we found less common manifestations in delayed onset patients or during disease evolution. There is no correlation between the site of mutation and the disease course or outcome, and the same genotype can present with variable phenotypes. HSCT patients (n=58) had a median follow-up of 2.7 years (range: 1 week - 15 years). Patients receiving chronic IS (n=34) had a median follow-up of 4 years (range: 2 months - 25 years). The overall survival (OS) after HSCT was 73.2% (95% confidence interval [CI], 59.4 to 83.0) and after IS was 65.1% (95 % CI, 62.8 to 95.8). The pre-treatment OI score was the only significant predictor of OS after transplant (p=0.035) but not under IS.ConclusionsPatients receiving chronic IS were hampered by disease recurrence or complications, impacting long-term disease-free survival. When performed in patients with a low OI score, HSCT resulted in disease resolution with better quality of life, independent of age, donor source or conditioning regimen.

Graphical abstract

Teaser

This international retrospective multicenter study of patients with long-term IPEX syndrome (n=96) provides data on onset, disease progression, and outcomes after different treatments to inform future therapeutic choices.


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Efficacy of lentiviral mediated gene therapy in an Omenn syndrome Rag2 mouse model is not hindered by inflammation and immune dysregulation

Publication date: Available online 11 December 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Valentina Capo, Maria Carmina Castiello, Elena Fontana, Sara Penna, Marita Bosticardo, Elena Draghici, Luigi P. Poliani, Lucia Sergi Sergi, Rosita Rigoni, Barbara Cassani, Monica Zanussi, Paola Carrera, Paolo Uva, Kerry Dobbs, Nicolò Sacchetti, Luigi D. Notarangelo, Niek P. van Til, Gerard Wagemaker, Anna Villa
BackgroundOmenn syndrome (OS) is a rare severe combined immunodeficiency associated with autoimmunity, caused by defects of the lymphoid-specific V(D)J recombination. Most patients carry hypomorphic mutations in recombination activating genes (RAG) 1 or 2. Hematopoietic stem cell (HSC) transplantation is the standard treatment, however gene therapy (GT) may represent a valid alternative, especially for patients lacking a matched donor.ObjectiveTo determine the efficacy of lentiviral vector (LV) mediated GT in the murine model of OS (Rag2^R229Q/R229Q) in correcting immunodeficiency and autoimmunity.MethodsOS Lin^- cells were transduced with a LV encoding the human RAG2 gene and injected into irradiated OS recipients. Control mice were transplanted with wild-type or OS untransduced Lin- cells. Immunophenotype, T-dependent and independent antigen challenges, immune spectratyping, autoantibodies detection and detailed tissue immunohistochemical analyses were performed.ResultsLV-mediated GT allowed immunological reconstitution, although suboptimal as compared to wild type bone marrow transplanted OS mice, in peripheral blood and hematopoietic organs, such as bone marrow, thymus and spleen. We observed in vivo variability in the efficacy of GT correlating with the levels of transduction achieved. Immunoglobulin levels and T cell repertoire normalized and gene corrected mice properly responded to challenges in vivo. Autoimmune manifestations, such as skin infiltration and autoantibodies, dramatically improved in GT mice with a vector copy number/genome higher than 1 in the bone marrow and 2 in the thymus.ConclusionsOur data show that LV-mediated GT for Omenn Syndrome significantly ameliorates the immunodeficiency even in an inflammatory environment.



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An actin cytoskeletal barrier inhibits lytic granule release from Natural Killer cells in Chediak-Higashi syndrome

Publication date: Available online 11 December 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Aleksandra Gil-Krzewska, Mezida B. Saeed, Anna Oszmiana, Elizabeth R. Fischer, Kathryn Lagrue, William A. Gahl, Wendy J. Introne, John E. Coligan, Daniel M. Davis, Konrad Krzewski
BackgroundChediak-Higashi syndrome (CHS) is a rare disorder caused by biallelic mutations in the LYST gene, resulting in formation of giant lysosomes or lysosome-related organelles in several cell types. The disease is characterized by immunodeficiency and a fatal hemophagocytic lymphohistiocytosis due to impaired function of cytotoxic lymphocytes, mainly Natural Killer (NK) cells.ObjectiveWe sought to determine the underlying biochemical cause of the impaired cytotoxicity of NK cells in CHS.MethodsWe generated a human cell model of CHS, using CRISPR technology. We used a combination of classical techniques to evaluate lysosomal function and cell activity in the model system, and super-resolution microscopy to visualize filamentous (F-)actin and lytic granules in normal and LYST-deficient NK cells.ResultsLoss of LYST function in a human NK cell line, NK92mi, resulted in inhibition of NK cell cytotoxicity and reproduced other aspects of CHS cellular phenotype, including the presence of significantly enlarged lytic granules with defective exocytosis, and impaired integrity of endo-lysosomal compartments. The large granules had an acidic pH, normal activity of lysosomal enzymes, and were positive for the proteins essential for lytic granule exocytosis. Visualization of the actin meshwork openings at the immunological synapse revealed that the cortical actin acts as a barrier for secretion of such large granules at the cell-cell contact site. Decreasing the cortical actin density at the immunological synapse, or decreasing the lytic granule size, restored the ability of LYST-deficient NK cells to degranulate and kill target cells.ConclusionThe cortical actin and granule size play significant roles in NK cell cytotoxic function. The periodicity of sub-synaptic actin is an important factor limiting the release of large lytic granules from CHS NK cells, and could be a novel target for pharmaceutical intervention.

Teaser

The large lytic granules in Chediak-Higashi syndrome NK cells are functional, but the actin meshwork at the immunological synapse is a barrier to their exocytosis, resulting in defective CHS NK cell degranulation and cytotoxicity. Decreasing the cortical actin density, or lytic granule size, restores the ability of LYST-deficient NK cells to degranulate and kill target cells..


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Associations between infant fungal and bacterial dysbiosis and childhood atopic wheeze in a nonindustrialized setting

Publication date: Available online 11 December 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Marie-Claire Arrieta, Andrea Arévalo, Leah Stiemsma, Pedro Dimitriu, Martha E. Chico, Sofia Loor, Maritza Vaca, Rozlyn C.T. Boutin, Evan Morien, Mingliang Jin, Stuart E. Turvey, Jens Walter, Laura Wegener Parfrey, Philip J. Cooper, Brett Finlay
BackgroundAsthma is the most prevalent chronic disease of childhood. Recently, we identified a critical window early in the life of both mice and Canadian infants during which gut microbial changes (dysbiosis) affect asthma development. Given geographic differences in human gut microbiota worldwide, we studied the effects of gut microbial dysbiosis on atopic wheeze in a population living in a distinct developing world environment.ObjectiveWe sought to determine whether microbial alterations in early infancy are associated with the development of atopic wheeze in a nonindustrialized setting.MethodsWe conducted a case-control study nested within a birth cohort from rural Ecuador in which we identified 27 children with atopic wheeze and 70 healthy control subjects at 5 years of age. We analyzed bacterial and eukaryotic gut microbiota in stool samples collected at 3 months of age using 16S and 18S sequencing. Bacterial metagenomes were predicted from 16S rRNA data by using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States and categorized by function with Kyoto Encyclopedia of Genes and Genomes ontology. Concentrations of fecal short-chain fatty acids were determined by using gas chromatography.ResultsAs previously observed in Canadian infants, microbial dysbiosis at 3 months of age was associated with later development of atopic wheeze. However, the dysbiosis in Ecuadorian babies involved different bacterial taxa, was more pronounced, and also involved several fungal taxa. Predicted metagenomic analysis emphasized significant dysbiosis-associated differences in genes involved in carbohydrate and taurine metabolism. Levels of the fecal short-chain fatty acids acetate and caproate were reduced and increased, respectively, in the 3-month stool samples of children who went on to have atopic wheeze.ConclusionsOur findings support the importance of fungal and bacterial microbiota during the first 100 days of life on the development of atopic wheeze and provide additional support for considering modulation of the gut microbiome as a primary asthma prevention strategy.

Graphical abstract

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Fertilizer effects of composted materials from different sources on cultivating Impatiens balsamina L. in municipal solid waste management

Abstract

At different stages of municipal solid waste management, several technologies such as home composting, industrial composting, and landfill mining could be used to recycle organic matters. Assessing the quality of composted material is crucial for determining where and how for recycling the organic fractions of municipal solid waste (OFMSW). Current studies mainly focused on comparing their biochemical characteristics and environmental impacts; however, comprehensive effects on cultivating plants were rarely compared with composted materials from different sources. Here, the final composting products from home composting (HC), industrial composting (IC), and landfill mining (LM), with different mixing ratios between OFMSW and soil (25, 50, 75, and 100%), were applied for cultivating Impatiens balsamina L. to examine the growing and flowering features under 195 days of observation. We found that all types of composted materials showed positive effects on growth of impatiens; however, their individual profiles were significant different. Generally, compost from HC showed the best comprehensive effects on the plant. Impatiens' dry weight biomass and maximum number of leaves and flowers of HC were1.5 and 2.8 times, 1.1 and 1.6 times, and 1.8 and 4.2 times than those of IC and LM, respectively. Compost from IC was superior in prolonging leaf-growing phase and increasing photosynthesis pigment contents of impatiens. Although comprehensive effect of fine fraction from landfill mining was much lower than HC and IC compost, it still improved impatiens growth and flowering compared to normal sandy soil. The results suggest that direct comprehensive effect on plants growth, flowering, and physiological influences could be introduced as an indicator when we compare different approach to recycle organics from MSW. Comprehensive effect on plants growth, flowering, and physiological influences could be introduced as a direct indicator for assessing organic waste recycling.

http://ift.tt/2nNnAoO

Environmental exposure to cadmium—a risk for health of the general population in industrialized countries and preventive strategies

Abstract

Cadmium (Cd) is a heavy metal belonging to the group of the main chemical pollutants of the natural and occupational environment in economically developed countries. The forecasts indicate that contamination of the environment with this toxic metal, and thus the exposure of the general population, will increase. Food (particularly plant products) is the main source of the general population exposure to this element. Moreover, an important, and often the main, source of intoxication with Cd is habitual tobacco smoking. Recent epidemiological studies have provided numerous evidence that even low-level environmental exposure to this toxic metal, nowadays occurring in numerous economically developed countries, creates a risk for health of the general population. The low-level lifetime exposure to this metal may lead to the damage to the kidneys, liver, skeletal system, and cardiovascular system, as well as to the deterioration of the sight and hearing. Moreover, it has been suggested that environmental exposure to this xenobiotic may contribute to the development of cancer of the lung, breast, prostate, pancreas, urinary bladder, and nasopharynx. Taking the above into account, the aim of this review article is to draw more attention to Cd as an environmental risk factor for the health of the general population and the need to undertake preventive actions allowing to reduce the risk of health damage due to a lifetime exposure to this toxic metal.

http://ift.tt/2C572f1

Response of energy microalgae Chlamydomonas reinhardtii to nitrogen and phosphorus stress

Abstract

Microalgae can effectively absorb nitrogen (N) and phosphorus (P) in wastewater, while growth characteristics can be affected by such nutrients. The influences of the N and P concentration on growth, biomass yield, protein yield, and cell ultrastructure of Chlamydomonas reinhardtii (C. reinhardtii) were investigated in this study. The results showed that, in the optimum conditions (24–72 mg/L for N and 4.5–13.5 mg/L for P), the final biomass and protein content of C. reinhardtii could reach maximum value, and the cell organelles (chloroplast, mitochondria,etc.) showed good structures with larger chloroplasts, and more and neater thylakoids. However, if the concentration of nutrients was much higher or lower than the optimal value, it would cause adverse effects on the growth of C. reinhardtii, especially in high nitrogen (1000 mg/L) and low phosphorus (0.5 mg/L) conditions. Under these extreme conditions, the ultrastructure of the cells was also damaged significantly as follows: the majority of the organelles were deformed, the chloroplast membrane became shrunken, and the mitochondria became swollen, even partial disintegrated (differing slightly under high-N and low-P conditions); furthermore, it is found that C. reinhardtii was more sensitive to low-P stress. On the basis of these results, our findings have general implications in the application of wastewater treatment.

http://ift.tt/2nQ7A5n

Exploiting the therapeutic potential of ready-to-use drugs: repurposing antibiotics against amyloid aggregation in neurodegenerative diseases

Publication date: Available online 11 December 2017
Source:Progress in Neurobiology
Author(s): Sergio B. Socias, Florencia Gonzalez-Lizarraga, Cesar L. Avila, Cecilia Vera, Leonardo Acuña, Julia E. Sepulveda-Diaz, Elaine Del-Bel, Rita Raisman-Vozari, Rosana N. Chehin
Neurodegenerative diseases are chronic and progressive disorders that affect specific regions of the brain, causing gradual disability and suffering that results in a complete inability of patients to perform daily functions. Amyloid aggregation of specific proteins is the most common biological event that is responsible for neuronal death and neurodegeneration in various neurodegenerative diseases. Therapeutic agents capable of interfering with the abnormal aggregation are required, but traditional drug discovery has fallen short. The exploration of new uses for approved drugs provides a useful alternative to fill the gap between the increasing incidence of neurodegenerative diseases and the long-term assessment of classical drug discovery technologies. Drug re-profiling is currently the quickest possible transition from bench to bedside. In this way, experimental evidence shows that some antibiotic compounds exert neuroprotective action through anti-aggregating activity on disease-associated proteins. The finding that many antibiotics can cross the blood-brain barrier and have been used for several decades without serious toxic effects makes them excellent candidates for therapeutic switching towards neurological disorders. The present review is, to our knowledge, the first extensive evaluation and analysis of the anti-amyloidogenic effect of different antibiotics on well-known disease-associated proteins. In addition, we propose a common structural signature derived from the antiaggregant antibiotic molecules that could be relevant to rational drug discovery.



http://ift.tt/2iU07NG

Is Instantaneous Wave-Free Ratio a New Standard of Care for Physiologic Assessment of Coronary Lesions?: More Questions Than Answers.

Author: Kern, Morton J. MD; Seto, Arnold H. MD

Page: 2295-2297

http://ift.tt/2C4Q0hf

Recent Evolution of the Treatment of Coronary Artery Disease in China: A Conversation With Ya-Ling Han, MD, PhD.

Author: Han, Ya-Ling MD, PhD; Rutherford, John D. MB ChB

Page: 2298-2302

http://ift.tt/2nRMp2P

Increase in Endovascular Therapy in Get With The Guidelines-Stroke After the Publication of Pivotal Trials.

Author: Smith, Eric E. MD, MPH; Saver, Jeffrey L. MD; Cox, Margueritte MSc, MGIST; Liang, Li PhD; Matsouaka, Roland PhD; Xian, Ying MD, PhD; Bhatt, Deepak L. MD, MPH; Fonarow, Gregg C. MD; Schwamm, Lee H. MD

Page: 2303-2310

http://ift.tt/2C6dt1k

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke).

Author: Froehler, Michael T. MD, PhD; Saver, Jeffrey L. MD; Zaidat, Osama O. MD; Jahan, Reza MD; Aziz-Sultan, Mohammad Ali MD; Klucznik, Richard P. MD; Haussen, Diogo C. MD; Hellinger, Frank R. Jr. MD, PhD; Yavagal, Dileep R. MD; Yao, Tom L. MD; Liebeskind, David S. MD; Jadhav, Ashutosh P. MD, PhD; Gupta, Rishi MD; Hassan, Ameer E. DO; Martin, Coleman O. MD; Bozorgchami, Hormozd MD; Kaushal, Ritesh MD; Nogueira, Raul G. MD; Gandhi, Ravi H. MD; Peterson, Eric C. MD; Dashti, Shervin R. MD, PhD; Given, Curtis A. II MD; Mehta, Brijesh P. MD; Deshmukh, Vivek MD; Starkman, Sidney MD; Linfante, Italo MD; McPherson, Scott H. MD; Kvamme, Peter MD; Grobelny, Thomas J. MD; Hussain, Muhammad S. MD; Thacker, Ike MD; Vora, Nirav MD; Chen, Peng Roc MD; Monteith, Stephen J. MD; Ecker, Robert D. MD; Schirmer, Clemens M. MD, PhD; Sauvageau, Eric MD; Abou-Chebl, Alex MD; Derdeyn, Colin P. MD; Maidan, Lucian MD; Badruddin, Aamir MD; Siddiqui, Adnan H. MD, PhD; Dumont, Travis M. MD; Alhajeri, Abdulnasser MD; Taqi, M. Asif MD; Asi, Khaled MD; Carpenter, Jeffrey MD; Boulos, Alan MD; Jindal, Gaurav MD; Puri, Ajit S. MD; Chitale, Rohan MD; Deshaies, Eric M. MD; Robinson, David H. MD; Kallmes, David F. MD; Baxter, Blaise W. MD; Jumaa, Mouhammad A. MD; Sunenshine, Peter MD; Majjhoo, Aniel MD; English, Joey D. MD; Suzuki, Shuichi MD; Fessler, Richard D. MD; Delgado Almandoz, Josser E. MD; Martin, Jerry C. MD; Mueller-Kronast, Nils H. MD; on behalf of the STRATIS Investigators

Page: 2311-2321

http://ift.tt/2nNjqNI

Optimizing Systems of Care for Endovascular Thrombectomy in Ischemic Stroke: Drip and Ship Versus Mothership.

Author: Campbell, Bruce C.V. PhD; Donnan, Geoffrey A. MD; Davis, Stephen M. MD

Page: 2322-2324

http://ift.tt/2C5qKYi

Integrated Noninvasive Physiological Assessment of Coronary Circulatory Function and Impact on Cardiovascular Mortality in Patients With Stable Coronary Artery Disease.

Author: Gupta, Ankur MD, PhD; Taqueti, Viviany R. MD, MPH; van de Hoef, Tim P. MD, PhD; Bajaj, Navkaranbir S. MD, MPH; Bravo, Paco E. MD; Murthy, Venkatesh L. MD, PhD; Osborne, Michael T. MD; Seidelmann, Sara B. MD, PhD; Vita, Tomas MD; Bibbo, Courtney F. MSc; Harrington, Meagan BS; Hainer, Jon BS; Rimoldi, Ornella MD; Dorbala, Sharmila MD; Bhatt, Deepak L. MD, MPH; Blankstein, Ron MD; Camici, Paolo G. MD; Di Carli, Marcelo F. MD

Page: 2325-2336

http://ift.tt/2nOjlcJ

cGMP-Elevating Compounds and Ischemic Conditioning Provide Cardioprotection Against Ischemia and Reperfusion Injury via Cardiomyocyte-Specific BK Channels.

Author: Frankenreiter, Sandra Dr rer nat; Bednarczyk, Piotr Dr hab; Kniess, Angelina; Bork, Nadja I. MSc; Straubinger, Julia Dr rer nat; Koprowski, Piotr Dr hab; Wrzosek, Antoni Dr; Mohr, Eva MSc; Logan, Angela PhD; Murphy, Michael P. PhD; Gawaz, Meinrad Dr med; Krieg, Thomas Dr med; Szewczyk, Adam Dr hab; Nikolaev, Viacheslav O. Dr rer nat; Ruth, Peter Dr rer nat; Lukowski, Robert Dr rer nat

Page: 2337-2355

http://ift.tt/2C6dqTc

Cardioprotection Is Alive But Remains Enigmatic: The Nitric Oxide-Protein Kinases-Mitochondria Signaling Axis.

Author: Heusch, Gerd MD

Page: 2356-2358

http://ift.tt/2nOiOrf

Pathologic Stimulus Determines Lineage Commitment of Cardiac C-kit+ Cells.

Author: Chen, Zhongming PhD *,,; Zhu, Wuqiang MD, PhD *,,; Bender, Ingrid BS; Gong, Wuming PhD; Kwak, Il-Youp PhD; Yellamilli, Amritha BS; Hodges, Thomas J.; Nemoto, Natsumi BS; Zhang, Jianyi MD, PhD; Garry, Daniel J. MD, PhD; van Berlo, Jop H. MD, PhD

Page: 2359-2372

http://ift.tt/2C3puVk

Stem Cell Therapy for Congenital Heart Disease: A Systematic Review.

Author: Tsilimigras, Diamantis I. MD; Oikonomou, Evangelos K. MD; Moris, Demetrios MD, MSc, PhD; Schizas, Dimitrios MD, PhD; Economopoulos, Konstantinos P. MD, PhD; Mylonas, Konstantinos S. MD

Page: 2373-2385

http://ift.tt/2nPjL2m

Regular Tachycardia With Abnormal QRS Axis.

Author: Choudhury, Rajin MD; Duytschaever, Mattias MD, PhD; Knecht, Sebastien MD, PhD; Vandekerckhove, Yves MD; Tavernier, Rene MD, PhD

Page: 2386-2388

http://ift.tt/2C531XZ

Meta-Analysis of Death and Myocardial Infarction in the DEFINE-FLAIR and iFR-SWEDEHEART Trials.

Author: Berry, Colin MBChB, PhD *,,; McClure, John D. PhD *,; Oldroyd, Keith G. MD(Hons)

Page: 2389-2391

http://ift.tt/2nPjpc2

Letter by Jin-Shan and Xue-Bin Regarding Article, "Fractional Flow Reserve and Cardiac Events in Coronary Artery Disease: Data From a Prospective IRIS-FFR Registry (Interventional Cardiology Research Incooperation Society Fractional Flow Reserve)".

Author: Jin-Shan, He MD; Xue-Bin, Li MD

Page: 2392

http://ift.tt/2C52wNB

Response by Ahn and Park to Letter Regarding Article, "Fractional Flow Reserve and Cardiac Events in Coronary Artery Disease: Data From a Prospective IRIS-FFR Registry (Interventional Cardiology Research Incooperation Society Fractional Flow Reserve)".

Author: Ahn, Jung-Min MD; Park, Seung-Jung MD

Page: 2393-2394

http://ift.tt/2nNX6Dy

Letter by Triantafyllou and Straub Regarding Article, "Thresholds for Ambulatory Blood Pressure Among African Americans in the Jackson Heart Study".

Author: Triantafyllou, Georgios A. MD; Straub, Adam C. PhD

Page: 2395-2396

http://ift.tt/2C525CX

Letter by Chi and Marszalek Regarding Article, "Composite End Points in Clinical Research: A Time for Reappraisal".

Author: Chi, Gerald MD; Marszalek, Jolanta MD

Page: 2397-2398

http://ift.tt/2nPj2OG

American Heart Association Principles on the Accessibility and Affordability of Drugs and Biologics: A Presidential Advisory From the American Heart Association.

Author: Antman, Elliott M. MD, FAHA, Chair; Creager, Mark A. MD, FAHA; Houser, Steven R. MD, FAHA; Warner, John J. MD, FAHA; Konig, Madeleine MPH; On behalf of the American Heart Association

Page: e441-e447

http://ift.tt/2C7ByF9

Late-Breaking Science Abstracts From the American Heart Association's Scientific Sessions 2017 and Late-Breaking Abstracts in Resuscitation Science From the Resuscitation Science Symposium 2017.

Author:

Page: e448-e467

http://ift.tt/2nTBm9C

Decisional balance and self-efficacy mediate the association among provider advice, health literacy and cervical cancer screening

Publication date: February 2018
Source:European Journal of Oncology Nursing, Volume 32
Author(s): Kyounghae Kim, Qian-Li Xue, Benita Walton-Moss, Marie T. Nolan, Hae-Ra Han
PurposeHealth literacy has emerged as a potential determinant of cancer screening, yet limited literature has investigated the pathways which health literacy influences Pap tests among immigrant women who experience a higher incidence of cervical cancer. This study aimed to test a health literacy-focused sociocognitive model which proposes motivational (knowledge, decisional balance) and volitional (self-efficacy) factors mediating the association between health literacy and triennial Pap tests.MethodsUsing structural equation modeling, we conducted a secondary analysis of baseline data obtained from a randomized controlled trial to promote breast and cervical cancer screenings among 560 Korean American women 21–65 years of age. They were interviewed on demographics such as education and English proficiency, provider advice, health literacy, knowledge of cervical cancer, decisional balance for Pap tests, self-efficacy, and Pap test use.ResultsHigher health literacy predicted high level of knowledge and high decisional balance score, and greater self-efficacy and then only decisional balance and self-efficacy affected Pap tests. High level of knowledge predicted Pap tests through its impact on the decisional balance score. Receiving provider advice both directly and indirectly predicted Pap tests through high level of health literacy, high level of decisional balance and greater self-efficacy.ConclusionsFindings from this study suggest possible pathways through which provider advice and health literacy affect Pap tests. Interventions targeting immigrant women with limited English proficiency should consider skill-based approaches such as health literacy training, promoting patient-provider communications and emphasizing decisional balance and self-efficacy as potentially sustainable ways of promoting Pap tests.



http://ift.tt/2iWiDoh

Decisional balance and self-efficacy mediate the association among provider advice, health literacy and cervical cancer screening

Publication date: February 2018
Source:European Journal of Oncology Nursing, Volume 32
Author(s): Kyounghae Kim, Qian-Li Xue, Benita Walton-Moss, Marie T. Nolan, Hae-Ra Han
PurposeHealth literacy has emerged as a potential determinant of cancer screening, yet limited literature has investigated the pathways which health literacy influences Pap tests among immigrant women who experience a higher incidence of cervical cancer. This study aimed to test a health literacy-focused sociocognitive model which proposes motivational (knowledge, decisional balance) and volitional (self-efficacy) factors mediating the association between health literacy and triennial Pap tests.MethodsUsing structural equation modeling, we conducted a secondary analysis of baseline data obtained from a randomized controlled trial to promote breast and cervical cancer screenings among 560 Korean American women 21–65 years of age. They were interviewed on demographics such as education and English proficiency, provider advice, health literacy, knowledge of cervical cancer, decisional balance for Pap tests, self-efficacy, and Pap test use.ResultsHigher health literacy predicted high level of knowledge and high decisional balance score, and greater self-efficacy and then only decisional balance and self-efficacy affected Pap tests. High level of knowledge predicted Pap tests through its impact on the decisional balance score. Receiving provider advice both directly and indirectly predicted Pap tests through high level of health literacy, high level of decisional balance and greater self-efficacy.ConclusionsFindings from this study suggest possible pathways through which provider advice and health literacy affect Pap tests. Interventions targeting immigrant women with limited English proficiency should consider skill-based approaches such as health literacy training, promoting patient-provider communications and emphasizing decisional balance and self-efficacy as potentially sustainable ways of promoting Pap tests.



http://ift.tt/2iWiDoh

AP-2{alpha} and AP-2{beta} cooperatively orchestrate homeobox gene expression during branchial arch patterning [RESEARCH ARTICLE]

Eric Van Otterloo, Hong Li, Kenneth L. Jones, and Trevor Williams

The evolution of a hinged moveable jaw with variable morphology is considered a major factor behind the successful expansion of the vertebrates. DLX homeobox transcription factors are critical to establish the positional code that patterns the mandible, maxilla and intervening hinge domain, but how these genes are regulated remains unclear. Herein, we demonstrate that the concerted action of the AP-2a and AP-2β transcription factors within the mouse neural crest is essential for jaw patterning. In the absence of these two genes the hinge domain is lost and there are alterations in the size and patterning of the jaws correlating with dysregulation of homeobox gene expression, with reduced levels of Emx, Msx and Dlx paralogs accompanied by an expansion of Six1. Moreover, detailed analysis of morphological features and gene expression changes indicate significant overlap with various compound Dlx mutants. Together, these findings reveal that the AP-2 genes have a major function in mammalian neural crest development, influencing patterning of the craniofacial skeleton via the DLX-code, a result that has implications for vertebrate facial evolution as well as for human craniofacial disorders.

http://ift.tt/2C4RCHS

Drosophila female-specific Ilp7 motoneurons are generated by Fruitless-dependent cell death in males and a double-assurance survival role for Transformer in females [RESEARCH ARTICLE]

Sarah Rose C. Garner, Monica C. Castellanos, Katherine Baillie, Tianshun Lian, and Douglas W. Allan

Female-specific Ilp7 neuropeptide-expressing motoneurons (FS-Ilp7 motoneurons) are required in Drosophila for oviduct function in egg-laying. Here, we uncover cellular and genetic mechanisms underlying their female-specific generation. We demonstrate that programmed cell death (PCD) eliminates FS-Ilp7 motoneurons in males, and that this requires male-specific splicing of the sex determination gene fruitless (fru) into the Fru^MC isoform. However, in females, fru alleles that only generate Fru^M isoforms failed to kill FS-Ilp7 motoneurons. This blockade of Fru^M-dependent PCD was not attributable to doublesex gene function but to a non-canonical role for transformer (tra), a gene encoding the RNA splicing activator of fru and dsx gene transcripts that is only functional in females and prevents splicing into the Fru^M protein isoform. However, in both sexes, we show that Tra prevents PCD even in the presence of constitutive Fru^M isoform generation. In addition, we found that Fru^MC eliminated FS-Ilp7 motoneurons in both sexes, but only when Tra is absent. Thus, Fru^MC-dependent PCD eliminates female-specific neurons in males, and Tra plays a double-assurance function in females to establish and reinforce the decision to generate female-specific neurons.

http://ift.tt/2BUTUIv

Hierarchical genetic interactions between FOXG1 and LHX2 regulate the formation of the cortical hem in the developing telencephalon [RESEARCH ARTICLE]

Geeta Godbole, Ashwin S. Shetty, Achira Roy, Leora D'Souza, Bin Chen, Goichi Miyoshi, Gordon Fishell, and Shubha Tole

During forebrain development, a telencephalic organizer called the cortical hem is critical for inducing hippocampal fate in adjacent cortical neuroepithelium. How the hem is restricted to its medial position is therefore a fundamental patterning question. Here, we demonstrate that Foxg1-Lhx2 interactions are critical for the formation of the hem. Loss of either gene causes a portion of the cortical neuroepithelium to transform into hem. We show that FOXG1 regulates Lhx2 expression in the cortical primordium. In the absence of Foxg1, the presence of Lhx2 is sufficient to suppress hem fate, and hippocampal markers appear selectively in Lhx2-expressing regions. FOXG1 also restricts the temporal window in which loss of Lhx2 results in a transformation of cortical primordium into hem. Therefore, Foxg1 and Lhx2 form a genetic hierarchy in the spatiotemporal regulation of cortical hem specification and positioning, and together ensure the normal development of this hippocampal organizer.

http://ift.tt/2C3mSXw

Rb1 promotes T cell maturation from premature apoptosis by inhibiting E2F1 [RESEARCH ARTICLE]

Zili Zhang, Wei Liu, Lingfeng Zhao, Zhibin Huang, Xiaohui Chen, Ning Ma, Jin Xu, Wenqing Zhang, and Yiyue Zhang

T lymphocytes are key cellular components of acquired immune system and play essential roles in cell-mediated immunity. T cell development occurs in the thymus where 95% of immature thymocytes are eliminated via apoptosis. It is known that mutation of Zeb1, one of RB1 target genes, resulted in immature T cell decrease in mice. E2F1, an RB1 interacting protein, has been shown to regulate mature T cell development by interfering with thymocyte apoptosis. However, whether Rb1 regulate thymocyte development in vivo is still need to be further investigated. Here we use zebrafish model to investigate the role of Rb1 in T cell development. We show that Rb1-deficient fish exhibit a significant reduction of T cells during early development and it is attributed to the accelerated apoptosis of immature T cell in a Caspase-dependent manner. We further show that E2F1 overexpression could mimic the reduced T lymphocytes phenotype of Rb1 mutants, and E2F1 knockdown could rescue the phenotype in Rb1-deficient mutants. Collectively, our data indicated that Rb1-E2F1-Caspase axis is crucial for protecting immature T cells from apoptosis during early T lymphocyte maturation.

http://ift.tt/2BWk65Q

Revealing age-related changes of adult hippocampal neurogenesis using mathematical models [RESEARCH ARTICLE]

Frederik Ziebell, Sascha Dehler, Ana Martin-Villalba, and Anna Marciniak-Czochra

New neurons are continuously generated in the dentate gyrus of the adult hippocampus. This continuous supply of newborn neurons is important to modulate cognitive functions. Yet, the number of newborn neurons declines with age. Increasing Wnt activity upon loss of the Dickkopf-1 can counteract both the decline of newborn neurons and the age-related cognitive decline. However, the precise cellular changes underlying the age-related decline or its rescue are fundamentally not understood. The present study combines a mathematical model and experimental data to address features controlling neural stem cell (NSC) dynamics. We show that available experimental data fit a model in which quiescent NSCs may either become activated to divide or may undergo depletion events, such as astrocytic transformation and apoptosis. Additionally, we demonstrate that old NSCs remain quiescent longer and have a higher probability of becoming re-activated than depleted. Finally, our model explains that high NSC-Wnt activity leads to longer time in quiescence while enhancing the probability of activation. Altogether, our study shows that modulation of the quiescent state is critical to regulate the pool of stem cells throughout the life of an animal.

http://ift.tt/2C2EuTw

Cytoplasmic polyadenylation-mediated translational control of maternal mRNAs directs maternal to zygotic transition [RESEARCH ARTICLE]

Cecilia Lanny Winata, Maciej Łapinski, Leszek Pryszcz, Candida Vaz, Muhammad Hisyam bin Ismail, Srikanth Nama, Hajira Shreen Hajan, Serene Gek Ping Lee, Vladimir Korzh, Prabha Sampath, Vivek Tanavde, and Sinnakaruppan Mathavan

In the earliest stages of animal development following fertilization, maternally deposited mRNAs direct biological processes to the point of zygotic genome activation (ZGA). These maternal mRNAs undergo cytoplasmic polyadenylation (CPA), suggesting translational control of their activation. To elucidate the biological role of CPA during embryogenesis, we performed genome-wide polysome profiling at several stages of zebrafish development. Our analysis revealed a correlation between CPA and polysome association dynamics, demonstrating a coupling of translation to the CPA of maternal mRNAs. Pan-embryonic CPA inhibition disrupted the maternal to zygotic transition (MZT), causing a failure of developmental progression past the MBT and changes in global gene expression that indicated a failure of ZGA and maternal mRNA clearance. Among the genes that were differentially expressed were those encoding chromatin modifiers and key transcription factors involved in ZGA, including nanog, pou5f3, and sox19b, which present distinct CPA dynamics. Our results establish the necessity of CPA to ensure progression of the MZT. The RNA-seq data generated in this study represents a valuable zebrafish resource for the discovery of novel elements of the early embryonic transcriptome.

http://ift.tt/2BSArID

Mannitol and the blood-labyrinth barrier

Characterization of the blood labyrinth barrier (BLB) is extremely important to determine whether the BLB can be manipulated pharmacologically. However, experiments to investigate the BLB are technically diffi...

http://ift.tt/2BD8rfW

Mannitol and the blood-labyrinth barrier

Characterization of the blood labyrinth barrier (BLB) is extremely important to determine whether the BLB can be manipulated pharmacologically. However, experiments to investigate the BLB are technically diffi...

http://ift.tt/2BD8rfW

Fibula osteomyocutaneous free flap in mandibular reconstruction: clinical experience in a community-based hospital

Abstract

Background

The fibula free flap (FFF) constitutes the gold standard surgical approach for mandibular reconstruction. Mandible reconstruction is routinely performed in high-volume academic centers. To our best knowledge, this is the first case series exclusively dedicated on FFF conducted in community hospitals. This study evaluates our 10-year experience with FFF mandible reconstruction in two community hospitals.

Methods

This is a retrospective review of all 12 patients who underwent partial or total mandibulectomy with concomitant mandible reconstruction using FFF from September 2005 through February 2015.

Results

The majority of the patients were men (75%) with a mean age of 61 years. Eleven (91.7%) patients had malignancies of the head and neck, and 10 (83.3%) received preoperative XRT. Overall flap survival was 100%, with no arterial/venous thrombosis or malunion. Partial flap failure (with skin paddle necrosis) was reported in only 1 patient, but the bone was viable and survived. Recipient-site wound infection, hardware exposure, and orocutaneous fistula occurred among previously irradiated patients, and in those who were suffering from osteoradionecrosis.

Conclusions

Our FFF outcomes were non-inferior to those reported in specialized university hospitals and are evidence that successful results can be obtained outside of high-volume academic centers. FFF represents a reliable surgical approach for mandible reconstruction in university and community hospitals.

Level of Evidence: Level IV, therapeutic study.

http://ift.tt/2AMsLZ4

The aetiopathogenesis of capsular contracture: a systematic review of the literature

Capsular contracture is the most frequent complication after breast augmentation or reconstruction with breast implants. The immune system plays a prominent role in capsular contracture formation, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for capsular contracture. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of capsular contracture.

http://ift.tt/2AMFcUM

Can you tell the difference: round vs anatomical implants – a real-time global ballot

Round and anatomical implants are used throughout the world for breast augmentation. However, controversy persists as to which provides the most aesthetically pleasing results, with a paucity of evidence comparing the cosmetic outcome of the two shapes. Many argue that in the majority of patients it is impossible to tell whether augmentation has been carried out using anatomical or round implants. We performed a live global ballot at the London Breast Meeting 2016 to determine whether delegates from around the world could determine the shape of implants used to augment 50 patients.

http://ift.tt/2BX1RNr

Project Rose Carries the Ball Forward in the Fight Against Sleep Apnea

David Gergen and NFL Legend Earl Campbell

Considerable money, expertise, and even star power has been poured into a new venture in the Texas cities of Tyler/Dallas/Houston/Austin and many more to come, all in an effort to fight sleep apnea and bring oral appliances to the forefront of treatment. Thanks to NFL greats Gary Baxter and Earl Campbell, the Project Rose Sports Science Center is now open in conjunction with Texas Spine & Joint.

 

Officials at the American Sleep & Breathing Academy (ASBA) are working closely with Baxter and Campbell to help stock the facility with top-notch dentists who are experts in the treatment of sleep apnea. And while all appropriate treatment modalities will be on the table, these dentists are well aware of the effectiveness (and excellent compliance rates) of oral appliances in the successful treatment of obstructive sleep apnea (OSA).

 

"By some studies, about 70% of people who get a CPAP machine are not wearing it in six months," says Harry Sugg, DDS, owner of Dallas-based Wheatland Dental, and a dentist at Project Rose. "That is too many people left untreated. Oral appliances can treat them."

 

Not all clinicians agree with Sugg, but Rebecca Lauck, DDS, believes that is mostly due to a lack of education. "Most medical professionals are not even aware of oral appliances," says Lauck, who owns a traditional dental practice, as well as a dental sleep practice. "They have never seen them or heard of them, and they are oblivious. They have only learned about CPAP."

 

In her area of Keller, Texas, Lauck does her part to spread awareness by speaking with physicians and educating them about her patients who are benefitting by wearing oral appliances. "But there are not many people like me around spreading the message," says Lauck, who will be treating Project Rose patients when the concept expands to her region of the Lone Star state. "They [physicians] would rather just refer their patients to a sleep doctor and be done with it."

 

The mere existence of Project Rose, as a facility-based sleep center with dentists on staff, will contribute to the increasing level of respect enjoyed by dental sleep medicine. When the "Rose" banner spreads to a planned 100 facilities across the nation, oral appliance awareness will only be that much higher.

 

Baxter and Campbell will no doubt boost that awareness among sports fans who remember Baxter as a star cornerback/safety on the stalwart defense of the Baltimore Ravens, while Campbell is a past Heisman Trophy winner and all pro running back with the Houston Oilers.

 

Both men care deeply about current and retired athletes, but Project Rose is designed to reach the entire patient demographic. David Gergen, CEO of the ASBA and Gergen's Orthodontic Lab, estimates that the ratio will likely be 99% general population to 1% premier athletes. "The ultimate goal," says Gergen, "is to integrate dentists into hospitals and make oral appliance therapy the true go-to line of defense for obstructive sleep apnea."

 

Coaches have long set curfews as a way of ensuring proper slumber and better performance on the field, but these days coaches are recognizing the importance of clinically proper sleep. It's not enough to be horizontal, because physical recovery depends on real sleep. Sugg points out that all of this applies to active and retired athletes.

 

"Some of those linemen at 300 pounds stop playing and they have a very high incidence of sleep apnea," he says. "Project Rose is an avenue that Campbell and Baxter see as an opportunity to create something positive and useful for athletes and the public. They are doing it in a top-notch way, because they have the backing of the former NFL legends and Olympians. If it's good enough for NFL greats, then it'll surely be good enough for us. The scope of what they are doing here is phenomenal. Texas was just the beginning."

 

NFL Legend Earl Campbell and Dr. Rebecca Lauck

Into the Hospital Setting

Project Rose in Tyler is firmly in the hospital environment, which streamlines billing, and more importantly, streamlines the treatment process. "The sleep beds are right there and take-home sleep studies are also there for mild to moderate cases," says Sugg. "Then the oral appliance gets made and it gets titrated over a couple of visits. The NFL stars, Eric Dickerson, Marcus Allen and Roy Green just to name  a few, will be helping with the promotion."

 

Encompassing about 25,000 square feet, the facilities include physical therapy and rehabilitation. For example, at the Tyler location, the top floor is the Texas Spine and Joint Hospital, recently bought out by Baylor University. "It's a whole new way of doing sleep medicine in a hospital environment," enthuses Sugg.

 

Project Rose is a "Center for Excellence" built with Texas Spine & Joint and partner Baylor Scott and White. Baxter told a local newspaper: "For Earl and myself, this is a dream come true. We've done a lot of hard work on this. We wanted to bring something special…We're raising money to do research in the field of sports. We want to make sure for the next generation that we are helping to prevent injuries and stop injuries through education. Then even after guys get hurt or injured, we want to be there to help them return to the field and/or return to normal life."

 

Phase 2 will feature a Bio-Mechanic Lab where researchers will work on everything from muscle tears to helping prevent and lessen the effects of concussions. "My hometown means the world to me, and to be able to give back is what life is all about," said Earl Campbell. "My goal for this non-profit is to help as many people as possible, while we contribute to the study of sports science. I am so thankful for the opportunity."

 

With the academic backing of ASBA and the promotional heft of NFL star power, Campbell's goal fits in with what ASBA member dentists believe is a nationwide trend toward greater acceptance of oral appliances in the fight against sleep apnea. Rebecca Lauck points out that sleep apnea is a relatively young field when compared to cardiology and other facets of pulmonology. As such, it's not surprising that acceptance is still not at particularly high levels—at least not yet.

 

"It's a shame, but dentists are not really trained extensively on sleep," says Lauck. "They might go to a quick course and learn how to do an appliance, and they may offhandedly make an appliance and not know how to really get it to work for a patient. We need to do more to help them. It needs to be a specialty within dentistry so that oral appliances are treated the way they should be."

 

Project Rose Team: Gary Baxter, Dr. Rebecca Lauck, Dr. Brandon Hedgecock, Isiah Robertson, Dr. Harry Sugg, D. Gergen, Dr. Ed Hobbs, Eric Dickerson

Assembling the Team

The Arizona-based ASBA has quickly made its mark as a zealous proponent of oral appliances for the treatment of sleep apnea. CEO David Gergen bristles at the "CPAP gold standard" comment, frequently pointing out that nothing can be a true gold standard if it's not being worn.

 

Harnessing the considerable popularity of the National Football League, Gergen and executive director Alan Hickey have been able to advance the cause beyond academic shows to encompass football fans, many of whom come to sleep apnea awareness via their gridiron heroes.

 

Project Rose is heavily dependent on expert clinicians such as Sugg, Lauck, Edward H. Hobbs, DDS, MS, and others. Hobbs echoes a familiar story about his initial involvement with the Project Rose endeavor. "Dave Gergen, who owns a dental lab out in Phoenix, called and wanted to discuss something," says Hobbs, owner of DENTACARE Dental Group, Longview, Texas. "He described their plans, and how it was set up to help a lot of people. The people involved were well known—Earl Campbell and Gary Baxter—and I said yes."

 

Like so many of his colleagues, Hobbs heard little about sleep medicine in the early days of the dental profession. About 20 years ago, however, he decided to "Go take a sleep course in Dallas and learn something about these 'sleep appliance' things." He learned from an experienced doc and this initial exposure led to mini residencies at prestigious universities. And yet, even in 2017, there is much work to be done.

 

"The level of respect for oral appliances has a long way to go among members of the medical community," laments Hobbs. "These people are so busy that they have a hard time keeping up with ancillary fields such as oral appliances. They are just overwhelmed. They don't totally understand the use of these appliances and the dentist's role—and how successful they are.

 

"The lack of compliance in the CPAP world shows us that patients are using it less than 7 hours," continues Hobbs. "The oral appliance has tremendous opportunity to help a lot of people in treating their sleep apnea and breathing disorders. The more we can get people to understand, the better for the patients, and that's what it's all about. Project Rose treatment centers will be instrumental in spreading this crucial awareness."

 

 

 

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