Transoral robotic retropharyngeal node dissection in oropharyngeal squamous cell carcinoma: Patterns of metastasis and functional outcomes

Abstract

Background

Assessment of the retropharyngeal lymph nodes is essential in the treatment for oropharyngeal squamous cell carcinoma (SCC). Transoral robotic retropharyngeal lymph node dissection (RPLND) may provide valuable staging information and guide selection of adjuvant therapy in a transoral robotic surgery (TORS) treatment paradigm.

Methods

Outcomes were compared between 30 patients with oropharyngeal SCC with tonsillar primaries undergoing RPLND and 37 stage-matched cases without RPLND.

Results

Retropharyngeal metastasis was confirmed in 6 patients undergoing RPLND. Compared with 37 stage-matched controls, there were no differences in length of stay, length of feeding tube dependence, net change in perioperative weight, or rates of hemorrhage and postoperative complications. RPLND altered adjuvant treatment recommendations in 1 of 30 patients.

Conclusion

RPLND is technically feasible by a purely transoral robotic approach. Its performance is not associated with worse swallowing outcomes or rates of complication. In select patients, RPLND may provide valuable staging information and guide the selection of adjuvant therapy.

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Eccrine Chromhidrosis in an Adolescent with Sickle Cell Disease

Abstract

Eccrine chromhidrosis can occur secondary to hyperbilirubinemia. We report an adolescent with sickle cell disease who presented with eccrine chromhidrosis on his palmar and plantar surfaces. He had extremely high levels of conjugated bilirubin but no fever. This is the youngest known reported patient with eccrine chromhidrosis and the first in a patient with sickle cell disease.

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Acanthosis Nigricans and Its Response to Metformin

Abstract

Acanthosis nigricans (AN) is the most common cutaneous manifestation of insulin resistance (IR) and is commonly seen in non-Caucasian populations. Variable benefits of metformin in the treatment of AN have been reported in the literature. We report an adolescent Caucasian boy with IR and extensive AN who showed complete resolution of AN after 2 years of metformin, despite persistence of IR.

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Pulsed-Dye Laser Treatment of Port-Wine Stains in Children: Useful Tips to Avoid General Anesthesia

Abstract

Pulsed dye laser (PDL) treatment of port-wine stains (PWSs) in children is a common procedure performed in most laser units. Pain assessment in our younger patients is a major concern, especially in those with extensive PWSs. The use of general anesthesia (GA) results in pain-free treatment, but its effects on the developing brain are far from totally understood. Thus we propose some tips that avoid the use of GA in most of our young patients, including the use of topical anesthetics and cooling systems, large laser spot size and high frequencies, early and frequent treatment with parents present, and the "introduction" and "pressure" techniques, among others.

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Keratoacanthoma management: results of a survey of UK dermatologists and surgeons

Abstract

Distinction of keratoacanthoma (KA) from squamous cell carcinoma (SCC) is challenging. Management is controversial, with some advocating prompt surgical excision and others monitoring to allow for spontaneous resolution¹. The controversy is compounded by rare reports of metastasis². And yet the benign natural history of KA is supported by various studies, including a systematic review of 455 cases with no cases of metastasis or death¹, and observational studies confirming spontaneous resolution¹.

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Enterogenous cyst of pediatric testis: a case report

An enterogenous cyst is a rare entity categorized as an intestinal cyst. In most cases, enterogenous cysts are seen in the mediastinum, peritoneal cavity, spinal canal, subarachnoid space, and cerebral ventricle.

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A Challenging Diagnosis of IgG4-Related Disease When Understanding Limitations of Laboratory Testing Was Pivotal

A 76-year-old man was incidentally found on a CT scan to have lymphadenopathy and bilateral kidney enlargement suggestive of infiltrative renal disease. He was largely asymptomatic but had bilateral salivary and lacrimal gland enlargement. A grossly elevated serum IgG (>70 g/L) with concomitant suppression of other immunoglobulins, a small IgG restriction, and a parotid biopsy revealing lymphoplasmacytic infiltrate with slight kappa light chain excess all suggested a lymphoproliferative disorder (LPD). The diagnostic workup was further confounded by a normal serum IgG4 concentration. Moreover, bone marrow and renal biopsies did not reveal evidence of LPD. Discussion with the laboratory not only clarified that the markedly increased total IgG could not be accounted for by the small IgG restriction, but also identified a discrepancy in the IgG4 measurement. Repeat analysis of a follow-up sample revealed an elevated IgG4 of 5.94 (reference interval: 0.039–0.864) g/L, which prompted a repeat parotid biopsy that showed predominant IgG4+ lymphocytic infiltrates. Despite the deluding presentations, a final diagnosis of IgG4-related disease (IgG4-RD) was made based on elevated serum IgG4 concentrations and histopathological findings. This case highlights the importance of recognizing limitations of laboratory testing and the benefit of close communications among clinical subspecialties and the laboratory.

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Disease-specific quality of life after septoplasty and bilateral inferior turbinate outfracture in patients with nasal obstruction

Publication date: Available online 29 July 2017
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Lucas Resende Lucinda, Carolina do Carmo, Leão Mocellin, Rogério Pasinato, Marcos Mocellin
IntroductionSeptal deviations might cause nasal obstruction and impact on the quality of life of individuals. The efficacy of septoplasty for treatment of septal deviation and the predictors of satisfactory surgical outcomes remain controversial. Technical variability, heterogeneity of research samples and absence of a solid tool for clinical evaluation are the main hindrances to the establishment of reliable statistical data regarding the procedure.ObjectiveTo evaluate the clinical improvements in the disease-specific quality-of-life between patients submitted to septoplasty with bilateral outfracture of the inferior turbinate under sedation and local anesthesia in a tertiary hospital and to assess possible clinical–epidemiological variables associated with functional outcome.MethodsFifty-two patients consecutively submitted to septoplasty with bilateral outfracture of the inferior turbinate for treatment of nasal obstruction filled in forms regarding clinical and epidemiological information during enrollment and had their symptom objectively quantified using the Nose Obstruction Symptom Evaluation (NOSE) scale preoperatively and one and three months after the procedure. Statistical analysis aimed to determine overall and stratified surgical outcomes and to investigate correlations between the clinical–epidemiological variables with the scores obtained.ResultsStatistically significant improvement in the preoperative NOSE questionnaire compared to the scores obtained three months after surgery was demonstrated (p<0.001, T-Wilcoxon), with strong correlation between the preoperative score and the postoperative improvement during this period (r=−0.614, p<0.001, Spearman). After one month, patients reached in average 87.15% of the result obtained at the study termination. Smokers and patients with rhinitis and/or pulmonary comorbidity showed increased average preoperative NOSE scores, although without statistical significance (p>0.05). Gender, age, history of rhinitis and presence of pulmonary comorbidity did not influence significantly surgical outcomes (p>0.05). Smokers presented greater reduction in NOSE scores during the study (p=0.043, U-Mann–Whitney).ConclusionSeptoplasty with bilateral outfracture of the inferior turbinate has proven to significantly improve disease-specific quality-of-life and this favorable outcome seems to occur precociously.



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Objective assessment of hearing during second stage of tympanoplasty – surgical technique and measurement methodology presented in ten patients

Abstract

In this paper, a complete integrated method of intraoperative monitoring of hearing (IOMH) during ossiculoplasty performed via posterior tympanotomy is presented.

The method integrates auditory steady state responses (ASSR) with Laser-Doppler Vibrometry (LDV) and allows intraoperative optimization of ossicular prosthesis positioning and coupling.

Both ASSR and LDV are acquired simultaneously.

The results of the integrated measurements are analyzed and evaluated automatically on-line which makes this strategy unaffected by individual differences in interpretations of collected recordings.

The technique of intraoperative monitoring of hearing, presented in this paper, allows optimal placement of the prosthesis and replacement if needed as well as confirmation of the ossiculoplasty efficiency by intraoperatively defined hearing threshold and air-bone gap closure before the end of surgery.

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DNA methylation of Th2 lineage determination genes at birth is associated with allergic outcomes in childhood

Abstract

Background

There is now increasing evidence that asthma and atopy originate in part in utero, with disease risk being associated with the altered epigenetic regulation of genes.

Objective and Methods

To determine the relationship between variations in DNA methylation at birth and the development of allergic disease, we examined the methylation status of CpG loci within the promoter regions of Th1/2 lineage commitment genes (GATA3, IL-4, IL-4R, STAT4 and TBET) in umbilical cord DNA at birth in a cohort of infants from the Southampton Women's Survey (n=696) who were later assessed for asthma, atopic eczema and atopy.

Results

We found that higher methylation of GATA3 CpGs -2211/-2209 at birth was associated with a reduced risk of asthma at ages 3 (median ratio [median methylation in asthma group/median methylation in non-asthma group] =0.74, p=0.006) and 6 (median ratio 0.90, p=0.048) years. Furthermore, we demonstrated that the GATA3 CpG loci associated with later risk of asthma lie within a NF-κB binding site, and that methylation here blocks transcription factor binding to the GATA3 promoter in the Human Jurkat T cell line. Associations between umbilical cord methylation of CpG loci within IL-4R with atopic eczema at 12 months (median ratio 1.02, p=0.028), and TBET with atopy (median ratio 0.98, p=0.017) at 6-7 years of age were also observed.

Conclusions and Clinical Relevance

Our findings provides further evidence of a developmental contribution to the risk of later allergic disorders, and suggests that involvement of epigenetic mechanisms in childhood asthma is already demonstrable at birth.

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Factors influencing the quality of Myrmecia pilosula (Jack Jumper) ant venom for use in in vitro and in vivo diagnosis of allergen sensitization and in allergen immunotherapy

Summary

Background

Allergen immunotherapy uses pharmaceutical preparations derived from naturally occurring source materials, which contain water-soluble allergenic components responsible for allergic reactions. The success of in vivo and in vitro diagnosis in allergen sensitization and allergen immunotherapy largely depends on the quality, composition and uniformity of allergenic materials used to produce the active ingredients, and the formulation employed to prepare finished products.

Objectives

We aimed to examine the factors influencing batch-to-batch consistency of Jack Jumper (Myrmecia pilosula) ant venom (JJAV) in the form of Active Pharmaceutical Ingredient (AI) and informed whether factors such as temperature, artificial light and container materials influence the quality of JJAV AIs. We also aimed to establish handling and storage requirements of JJAV AIs to ensure preservation of allergenic activities during usage in the diagnosis of allergen sensitization and in allergen immunotherapy.

Methods

The quality and consistency of JJAV AIs were analysed using a combination of bicinchoninic acid assay for total protein quantification, HPLC-UV for JJAV allergen peptides quantification, ELISA Inhibition for total allergenic potency, SDS-PAGE, AU-PAGE and Immunoblot for qualitative assessment of JJAV components, and Limulus Amebocyte Lysate assay for the quantification of endotoxin concentration. API-ZYM and Zymogram assays were used to probe the presence of enzymatic activities in JJAV.

Results

Pharmaceutical grade JJAV for allergen immunotherapy has good batch-to-batch consistency. Temporary storage at 4°C and light exposure does not affect the quality of JJAV. Exposure to temperature above 40°C degrades high MW allergens in JJAV. Vials containing JJAV must be stored frozen and in upright position during long-term storage.

Conclusions and Clinical relevance

We have identified factors which can influence the quality and consistency of JJAV AIs and provided a framework for appropriate handling, transporting and storage of JJAV to be used for the diagnosis of allergen sensitization and in AIT.

This article is protected by copyright. All rights reserved.

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Accurate quantification of five German cockroach (GCr) allergens in complex extracts using multiple reaction monitoring mass spectrometry (MRM MS)

Abstract

Background

German cockroach (GCr) allergen extracts are complex and heterogeneous products, and methods to better assess their potency and composition are needed for adequate studies of their safety and efficacy.

Objective and Methods

The objective of this study was to develop an assay based on liquid chromatography and multiple reaction monitoring mass spectrometry (LC-MRM MS) for rapid, accurate, and reproducible quantification of five allergens (Bla g 1, Bla g 2, Bla g3, Bla g 4, and Bla g 5) in crude GCr allergen extracts.

Results

We first established a comprehensive peptide library of allergens from various commercial extracts as well as recombinant allergens. Peptide mapping was performed using high resolution MS and the peptide library was then used to identify prototypic and quantotypic peptides to proceed with MRM method development. Assay development included a systematic optimization of digestion conditions (buffer, digestion time, and trypsin concentration), chromatographic separation, and MS parameters. Robustness and suitability were assessed following ICH (Q2 (R1)) guidelines. The method is precise (RSD < 10%), linear over a wide range (r > 0.99, 0.01 -1384 fmol/μL), and sensitive (LLOD and LLOQ <1 fmol/μL). Having established the parameters for LC-MRM MS, we quantified allergens from various commercial GCr extracts and showed considerable variability that may impact clinical efficacy.

Conclusions and Clinical Relevance

Our data demonstrate that the LC-MRM MS method is valuable for absolute quantification of allergens in GCr extracts and likely has broader applicability to other complex allergen extracts. Definitive quantification provides a new standard for labeling of allergen extracts, which will inform patient care, enable personalized therapy, and enhance the efficacy of immunotherapy for environmental and food allergies.

This article is protected by copyright. All rights reserved.

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Optimal dose of rocuronium bromide undergoing adenotonsillectomy under 5% sevoflurane with fentanyl

Publication date: October 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 101
Author(s): Hyub Huh, Jeong Jun Park, Ji Yeong Kim, Tae Hoon Kim, Seung Zhoo Yoon, Hye Won Shin, Hye-Won Lee, Hye-Ja Lim, Jang Eun Cho
ObjectiveAdenotonsillectomy is a short surgical procedure under general anaesthesia in children. An ideal muscle relaxant for adenotonsillectomy would create an intense neuromuscular block while having a quick recovery time without postoperative morbidity. We compared the effect of different doses of rocuronium for the tracheal intubation in children under 5% sevoflurane and fentanyl.Materials and methods75 children (aged 3–10 years, ASA I) scheduled for adenotonsillectomy were enrolled. Anaesthesia was induced with propofol 2.5 mg/kg, followed by fentanyl 2 μg/kg. After mask ventilation with 5 vol% sevoflurane in 100% oxygen for 2 min, 2 ml of study drug was administered intravenously, i.e., either normal saline (S Group) or one of two doses (0.15 or 0.3 mg/kg) of rocuronium. We assessed conditions during tracheal intubation and also recorded the surgical condition, the time from discontinuation of sevoflurane to extubation and PAED scale, pain scores in PACU.ResultsRocuronium groups (96% and 100%, respectively; P < 0.01) showed statistically superior clinically acceptable intubating conditions than the saline group (72%). The 0.3 mg/kg rocuronium (80%) treatment clearly resulted in excellent intubating conditions compared with the 0.15 mg/kg group (44%; p = 0.028). There was no significant difference in the time to extubation and surgical condition, and in the postoperative measures of emergence delirium, pain, and recovery time among the three groups.ConclusionA dose of 0.3 mg/kg rocuronium may provide optimal intubating conditions without delayed recovery in 5% sevoflurane anaesthesia with fentanyl in children undergoing adenotonsillectomy.Clinical trials registry numberNCT02467595.



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Lymphoepithelial Cyst of Parotid in an Immunocompetent Patient with Chronic Otitis Media

Lymphoepithelial cysts of parotid are known to occur in HIV patients. In the present report, lymphoepithelial cyst of parotid was diagnosed in a middle aged immunocompetent patient, along with chronic otitis media. The source of infection and treatment options are summarized.

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