Table of Contents

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Editorial Board

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Guidelines for Contributing Authors

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Expression of transcription factors in MEN1-associated pancreatic neuroendocrine tumors

Summary

MEN1-associated pancreatic neuroendocrine tumors (pNETs) may potentially express distinct hormones, but the mechanism has not been elucidated. Transcription factors such as MafA and Pdx1 have been identified to lead to beta cell differentiation, while Arx and Brn4 to alpha cell differentiation in developing pancreas. We hypothesized those transcription factors are important to produce specific hormones in pNETs, similarly to developing pancreas, and examined the expression of transcription factors in a case of MEN1 who showed immunohistological coexistence of several hormone-producing pNETs including insulinoma. A 70-year-old woman was found to manifest hypoglycemia with non-suppressed insulinemia and hypercalcemia with elevated PTH level. She was diagnosed as MEN1 based on the manifestation of primary hyperparathyroidism, pituitary adenoma and insulinoma, with genetic variation of MEN1 gene. She had pylorus-preserving pancreaticoduodenectomy because CT scan and SACI test indicated that insulinoma was localized in the head of the pancreas. Histopathological finding was MEN1-associated NET, G1. Interestingly, immunohistological examination of the resected pancreas revealed that two insulinomas, a glucagon-positive NET and a multiple hormone-positive NET coexisted. Hence, we examined the expression of transcription factors immunohistochemically to elucidate the role of the transcription factors in MEN1-associated hormone-producing pNETs. We observed homogeneous expressions of MafA and Pdx1 in insulinomas and Arx in glucagon-positive NET, respectively. Moreover, multiple hormone-positive NETs expressed several transcription factors heterogeneously. Collectively, our results suggested that transcription factors could play important roles in the production of specific hormones in MEN1-associated pNETs, similar to islet differentiation.

Learning points:

To date, it has been shown that different hormone-producing tumors coexist in MEN1-associated pNETs; however, the underlying mechanism of the hormone production in MEN1-associated pNETs has not been well elucidated.

Although this case presented symptomatic hypoglycemia, several hormone-producing pNETs other than insulinoma also coexisted in the pancreas.

Immunohistochemical analysis showed MafA and Pdx1 expressions distinctly in insulinoma, and Arx expression particularly in a glucagon-positive NET, while a multiple hormone-positive NET expressed MafA, Pdx1 and Arx.

Collectively, clinicians should consider that several hormone-producing pNETs may coexist in a MEN1 case and examine both endocrinological and histopathological analysis of pNETs, regardless of whether symptoms related to the excess of hormones are observed or not.

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Sclerosing thymoma-like thymic amyloidoma with nephrotic syndrome: a case report

Primary localized amyloidosis presenting as an isolated mediastinal mass is extremely rare, especially in the thymus. Sclerosing thymoma is also an extremely rare anterior mediastinal tumor, pathologically cha...

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Sudden sensorineural hearing loss in children and adolescents: Clinical characteristics and age-related prognosis

Publication date: Available online 6 September 2017
Source:Auris Nasus Larynx
Author(s): Jin Youp Kim, Jae Joon Han, Woong Sang Sunwoo, Ja-Won Koo, Seung-Ha Oh, Min-Hyun Park, Young Ho Kim
ObjectiveAlthough many studies have investigated sudden sensorineural hearing loss (SSNHL) in adults, there were few studies on SSNHL in the pediatric population; especially research on treatment and prognosis of pediatric SSNHL was limited. The aim of this study was to evaluate clinical characteristics, treatment outcomes and prognostic factors in children and adolescents with SSNHL.MethodsA retrospective review of medical records of 67 pediatric patients (67 ears) who had diagnosed with SSNHL at our hospitals was performed to analyze patients' clinical manifestations and audiograms. All patients were treated with high-dose systemic prednisolone (1mg/kg), and 17 of them underwent intratympanic steroid injection therapy. Audiological evaluation was carried out before and after treatment, and hearing recovery was defined as complete recovery and partial recovery according to Siegel's criteria. Patients were divided into two groups: childhood group (ages between 4 and 12 years old) and adolescence group (age>12years), and clinical characteristics and treatment outcomes were investigated. In addition, patients were divided into two groups according to degree of hearing recovery, and evaluation was made regarding possible prognostic factors.ResultsThe recovery rate in total 67 patients was 55.2%. The recovery rate of the childhood group was significantly lower than that of the adolescence group (p=0.038). While the presence of vertigo did not significantly correlate with prognosis (p=0.219), the presence of tinnitus was significantly associated with hearing recovery (p=0.005). Audiological assessment revealed that a low initial hearing threshold, high speech discrimination score, and descending type of audiogram were positively associated with hearing recovery (p=0.002, p=0.003, and p=0.029, respectively).ConclusionThe childhood group had worse treatment outcomes than the adolescence group. High initial hearing threshold and absence of tinnitus were poor prognostic factors of hearing recovery. Active treatment is required for patients with these poor prognostic factors and childhood patients with SSNHL.



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Response to the letter to the editor of Lambros et al.

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Italian survey on benign paroxysmal positional vertigo.

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Italian survey on benign paroxysmal positional vertigo.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):328-335

Authors: Messina A, Casani AP, Manfrin M, Guidetti G

Abstract
Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. BPPV often relapses after the first episode, with a recurrence rate between 15% and 50%. To date both the aetiopathogenetic processes that lead to otoconia detachment and the factors that make BPPV a relapsing disease are still unclear, but recent epidemiological studies have shown a possible association with cardiovascular risk factors. The aim of the present study (Sesto Senso Survey) was to evaluate in the Italian population through an observational survey, the main demographic and clinical characteristics of patients with BPPV (first episode or recurrent) with particular focus on the potential cardiovascular risk factors. The survey was conducted in 158 vestibology centres across Italy on 2,682 patients (mean age 59.3 ± 15.0 years; 39.1% males and 60.9% females) suffering from BPPV, from January 2013 to December 2014. The results showed a high prevalence of cardiovascular risk factors such as high blood pressure (55.8%), hypercholesterolaemia (38.6%) and diabetes (17.7%), as well as a family history of cardiovascular disease (49.4%). A high percentage of patients also had hearing loss (42.9%), tinnitus (41.2%), or both (26.8%). The presence of hypertension, dyslipidaemia and pre-existing cardiovascular comorbidities were significantly related to recurrent BPPV episodes (OR range between 1.84 and 2.31). In addition, the association with diabetes and thyroid/autoimmune disease (OR range between 1.73 and 1.89) was relevant. The survey results confirm the significant association between cardiovascular comorbidities and recurrent BPPV and identify them as a potential important risk factor for recurrence of BPPV in the Italian population, paving the way for the evaluation of new therapeutic strategies in the treatment of this disease.

PMID: 28872163 [PubMed - in process]

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Conservative treatment of vestibular schwannoma: growth and Penn Acoustic Neuroma Quality of Life scale in French language.

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Conservative treatment of vestibular schwannoma: growth and Penn Acoustic Neuroma Quality of Life scale in French language.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):320-327

Authors: Oddon PA, Montava M, Salburgo F, Collin M, Vercasson C, Lavieille JP

Abstract
The aim of this study was to determine the natural history of growth and quality of life (QoL) outcomes for vestibular schwannoma (VS) managed conservatively, and to validate the disease-specific Penn Acoustic Neuroma Quality-of-Life (PANQOL) scale in French language. We retrospectively studied 26 patients with VS managed conservatively. Patient characteristics and radiological findings were collected. Two scales were used to measure QoL: the Short Form-36 Health Survey (SF-36) and the PANQOL scale translated into French. Internal consistency and scores were compared with previous studies. The mean follow-up was 25 months (range 6-72). We observed tumour growth in 14 patients (53.8%), no growth in 12 patients (46.2%) and no case of tumour shrinkage. The mean tumour growth was 2.22 mm/year. No predictive factor of growth was found. Patients with vertigo or dizziness experienced a poorer QoL according to the SF-36 (Social Functioning and Emotional Role Limitation dimensions) and to the PANQOL scale (Balance and Energy dimensions). Our results were comparable with the literature using the SF-36. With the PANQOL scale, our scores were not statistically different with those from Dutch and North American studies except in the field of hearing (p = 0.019). Quality of life becomes essential in the management of VS. According to these results, we support a non-conservative strategy associated with vestibular rehabilitation for patients with dizziness or vertigo. The PANQOL is a validated specific scale for VS, which can be useful in French.

PMID: 28872162 [PubMed - in process]

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Temporal changes in impedance of implanted adults for various cochlear segments.

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Temporal changes in impedance of implanted adults for various cochlear segments.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):312-319

Authors: Leone CA, Mosca F, Grassia R

Abstract
Electrode impedance (EI) is the first objective assessment carried out during the surgical procedure and follow-up of cochlear implanted patients. This measure provides information on the integrity of electrodes and on the surrounding environment. It is one of the main factors responsible for energy consumption of the cochlear implant (CI). The aim of our study is to investigate changes over time in EI in adult recipients implanted with the perimodiolar array by comparing differences in various cochlear segments. In addition, we explore the relationship between these objective measures and subjective measures such as T-level and C-level. We studied 28 adult patients. Impedance values (IVs) were calculated in "common-ground" (CG) and in monopolar (M1+2) mode for electrode groups in basal middle and apical segments. We found significant decreases in IVs between activation and 1 month. We obtained higher values for basal impedance, whereas lower IVs were found for apical electrodes at all observation times. Statistical pairing over time between impedance and T/C values showed significant correlation for both global impedance (GI) and T-C levels at CG and M1+2 mode up to 6 months. Segregated statistical analysis also showed a significant and prolonged correlation of basal IVs and fitting parameters. The higher basal impedance over time can be explained by the higher proportion of newly formed tissue in this region. The linear correlation of impedances with the fitting parameters become not significant after 3/6 months for the apical and middle segments and remained significant only for the basal region over time. This behaviour underlines the importance of persistence in intra-cochlear factors in influencing fitting parameters in the basal segment.

PMID: 28872161 [PubMed - in process]

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A mild phenotype of sensorineural hearing loss and palmoplantar keratoderma caused by a novel GJB2 dominant mutation.

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A mild phenotype of sensorineural hearing loss and palmoplantar keratoderma caused by a novel GJB2 dominant mutation.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):308-311

Authors: Stanghellini I, Genovese E, Palma S, Falcinelli C, Presutti L, Percesepe A

Abstract
Dominant GJB2 mutations are known to cause a syndromic form of sensorineural hearing loss associated with palmo-plantar skin manifestations. We present the genotype/phenotype correlations of a new GJB2 mutation identified in three generations of an Italian family (proband, mother and grandfather) whose members are affected by sensorineural hearing impairment associated with adult-onset palmoplantar keratoderma. In all affected members we identified a new heterozygous GJB2 mutation (c.66G > T, p.Lys22Asn) whose segregation, population frequency and in silico prediction analysis have suggested a pathogenic role. The p.Lys22Asn GJB2 mutation causes a dominant form of hearing loss associated with variable expression of palmoplantar keratoderma, representing a model of full penetrance, with an age-dependent effect on the phenotype.

PMID: 28872160 [PubMed - in process]

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Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre.

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Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):303-307

Authors: Zhang C, Ding X, Lu Y, Hu L, Hu G

Abstract
The aim of this study was to elucidate the risk factors for cerebrospinal fluid (CSF) rhinorrhoea following transsphenoidal surgery and discuss its prevention and treatments. We retrospectively reviewed 474 consecutive cases of pituitary adenoma treated with 485 transsphenoidal surgical procedures from January 2008 to December 2011 in our department. We analysed the incidence of intra- and post-operative CSF leakage and outcomes of various repair strategies. Intra-operative CSF leakage was encountered in 85 cases (17.9%), and post-operative CSF rhinorrhoea in 13 cases (2.7%). Seven of the 13 patients with post-operative CSF rhinorrhoea did not experience intra-operative CSF leakage; three of these patients had adrenocorticotropic hormone-secreting adenomas. Of the remaining 6 patients with both intra- and post-operative CSF leakage, 2 were treated for giant invasive prolactinomas, and 2 had previously undergone transsphenoidal surgery. In eight patients, the leak was resolved by lumbar puncture, lumbar external drainage, resting in a semi-reclining position, or other conservative treatment. Two CSF leaks were repaired with gelatine foam and fibrin glue using a transsphenoidal approach, and two with autologous fat graft and sellar floor reconstruction using a transnasal endoscopic approach. After undergoing two transnasal endoscopic repairs, one patient with post-operative CSF rhinorrhoea was successfully treated by further lumbar subarachnoid drainage. In conclusion, procedures using gelatine foam, fibrin glue and autologous fat graft are common and effective techniques for the management of CSF rhinorrhoea after transsphenoidal surgery. When a CSF leak is detected during transsphenoidal surgery, thorough sellar reconstruction and long-term follow-up are necessary.

PMID: 28872159 [PubMed - in process]

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Stabilometric findings in patients affected by organic dysphonia before and after phonomicrosurgery.

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Stabilometric findings in patients affected by organic dysphonia before and after phonomicrosurgery.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):286-294

Authors: Nacci A, Romeo SO, Berrettini S, Matteucci J, Cavaliere MD, Mancini V, Panicucci E, Ursino F, Fattori B

Abstract
The purpose of this study is to understand if there is any alteration in the posture of patients affected by organic dysphonia and describe possible postural modifications after phonomicrosurgery on the vocal folds. Forty subjects (22 males, 18 females; mean age 32.6 ± 7.5 years) suffering from organic dysphonia (15 cases of polyps, 11 submucosal retention cysts, 10 bilateral fibrous vocal fold nodules and 4 bilateral Reinke's oedema) were examined by open-eye and closed-eye posturography while breathing spontaneously before surgery, 24 hours after surgery and after 6 months. The variables taken into account were: the coordinates of the centre of pressure on both frontal and sagittal planes, length and surface of the track, mean velocity of the oscillations and relative standard deviations, spectral analysis of oscillation frequency, statokinesigram and stabilogram values. No characteristic pathological pattern was seen in basal stabilometry in any of the subgroups (polyps, cysts, Reinke's oedema). Only the subgroup of patients with fibrous vocal fold nodules (8/10; 80%) showed a slight forward shift from the centre of gravity when analysed in both open-eye and closed-eye posturography. A comparison performed within the same subgroup using open-eye and closed-eye posturography before and after surgery revealed no significant difference in any of the parameters being studied. The use of static stabilometry in this study demonstrates the absence of characteristic postural alterations in patients affected by organic dysphonia and also excludes that simple removal of the vocal fold lesion can change posture.

PMID: 28872158 [PubMed - in process]

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Laryngectomy: what is the impact of the type of surgery on life quality and sexual function?

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Laryngectomy: what is the impact of the type of surgery on life quality and sexual function?

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):276-280

Authors: Akil F, Yollu U, Toprak SF, Ayral M

Abstract
The purpose of this study is to compare total and partial larygectomy on private life functions and sexuality in patients with laryngeal cancer. The study included 31 partial laryngectomy patients (Group 1) and 51 total laryngectomy patients (Group 2) who were operated for laryngeal cancer. European Organization for Research and Treatment of Cancer (EORTC) head and neck cancer module (QLQ-H&N35) and Arizona Sexual Experiences Scale (ASEX) forms were filled in by interviewing face to face with patients. HNSW (swallowing), HNSE (senses), HNSP (speech), HNSO (social eating), HNSX (sexuality), HNTE (problems with teeth), HNOM (problems with opening mouth) and HNCO (coughing) scores of EORTC QLQ-H&N35 were significantly higher in group 2 than in group 1. However, according to Arizona test results, there were no significant difference between the two groups.

PMID: 28872157 [PubMed - in process]

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Indications of cone beam CT in head and neck imaging in children.

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Indications of cone beam CT in head and neck imaging in children.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):270-275

Authors: Walliczek-Dworschak U, Diogo I, Strack L, Mandapathil M, Teymoortash A, Werner JA, Güldner C

Abstract
For imaging of bony structures, especially for the anterior and lateral skull base in ORL medicine, cone beam computed tomography (CBCT) is an increasingly used alternative to CT, with a lower exposition to plain radiography that makes its use for imaging, particularly in children, very interesting. The aim of this study was to analyse possible indications and settings for CBCT in children and compare them to those of adults. A total of 554 patients (age range 0-18 years, mean age 10.36 years), who underwent CBCT between 01/2004-06/2013 in the ENT department at the university clinic of Marburg were enrolled in this retrospective analysis to evaluate technical parameters and indications. Data on CBCT of all children were compared with previously published data collected from 1730 adults who were diagnosed with the help of CBCT in the ENT department at the university clinic of Marburg, during the years 2012-2013. The most frequent indications of CBCT in children vs. adults were in the anterior skull base region: mid-facial trauma (60.4%) vs. chronic rhinosinusitis (54.8%), disturbed nasal breathing (13.9% vs. 13.0%) and chronic rhinosinusitis (12%) vs. mid-facial trauma (10.8%). For the lateral skull base the main indications were cholesteatoma (20.3%) vs. position control of cochlear implant (CI) electrode (31.2%), chronic otorrhoea (17.5%) vs. cholesteatoma (20.9%), and position control of CI electrode (11.8%) vs. chronic otitis media mesotympanalis (6.8%). CBCT is a suitable imaging modality for bony structures in adults and children. Settings mainly depend on the region of interest. One aim should also be to reduce exposure to radiation in both adults and children.

PMID: 28872156 [PubMed - in process]

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The rising incidence of parotid metastases: our experience from four decades of parotid gland surgery.

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The rising incidence of parotid metastases: our experience from four decades of parotid gland surgery.

Acta Otorhinolaryngol Ital. 2017 Aug;37(4):264-269

Authors: Franzen A, Buchali A, Lieder A

Abstract
Secondary neoplasia in the parotid gland is increasingly frequent. We examined outcomes from 40 years of parotid surgery to analyse patterns for metastasis, review the staging procedure and discuss management. We retrospectively examined 772 consecutive cases of parotid surgery in a university hospital between 1975 and 2015 and assessed changes in incidence and management over four decades. In all, 71% percent of patients were male and 29% were female, with a mean age of 68 years, aged between 23 and 93 years. We diagnosed 683 parotid tumours of which 15.8% (n = 108) were malignant; 44% (n = 48) of all malignant lesions were metastases. The incidence of malignant tumours rose from 8% in the first decade, 14% in the second, 17% in the third to 21% in the fourth. The incidence increased even further from 10% in the first to 57% in the final decade. Most frequent tumours were metastases of squamous cell carcinoma (79%), and the majority of these lesions (87%) arose from above the clavicle, with 30 primary tumours in the skin. In most cases, the skin tumour had been excised between 6 and 24 months prior to parotid metastasis. Management consisted of surgery with neck dissection. 48 patients (67%) received adjuvant therapy, but despite aggressive multimodal treatment, disease progressed in the majority of cases, in 57% squamous cell carcinoma of the skin primaries, 67% of mucosal primaries above the clavicle and 83% of infraclavicular primaries. Parotid malignant tumours are increasing in incidence, mostly due to a rise in metastatic malignant tumours within the parotid gland, most of which are metastases of skin tumours, commonly squamous cell carcinoma. Despite multimodal therapy, their recurrence and progression rate remains high. We propose inclusion in head and neck follow-up in all cases of head and neck skin cancers.

PMID: 28872155 [PubMed - in process]

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Commentary on: Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study

We reviewed the paper entitled "Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study," by Tierney et al. [1] with interest. This is an excellent work. Use of the sleep positioning device constitutes a minimally invasive treatment approach, resulting in more comfortable sleep and an improvement in the symptoms of laryngopharyngeal reflux (LPR). However, the authors did not describe the symptoms of the upper gastrointestinal tract or the performance of gastroscopy or 24-hour oropharyngeal or esophageal pH monitoring.

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Intraoperative imaging during minimally invasive transoral robotic surgery using near-infrared light

The purpose of this study was to determine if the use of the FIREFLY imaging system could be an asset in transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). The system uses indocyanine green dye (ICG), which fluoresces when illuminated by near-infrared light from the Da Vinci robot. The system may improve visualization of tumor margins, highlight important vascular structures, and help identify the location of tumors and unknown primary head and neck cancers.

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Sudden sensorineural hearing loss in children and adolescents: Clinical characteristics and age-related prognosis

Although many studies have investigated sudden sensorineural hearing loss (SSNHL) in adults, there were few studies on SSNHL in the pediatric population; especially research on treatment and prognosis of pediatric SSNHL was limited. The aim of this study was to evaluate clinical characteristics, treatment outcomes and prognostic factors in children and adolescents with SSNHL.

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The renoprotective properties of xenon and argon in kidney transplantation

No abstract available

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Comparison of polyvinyl chloride and tin stylets for postoperative sore throat and hoarseness: A randomised trial

No abstract available

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Anaesthetic management of patients with myopathies

The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia. The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age. One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH. If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies. Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively.

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Microvascular reactivity monitored with near-infrared spectroscopy is impaired after induction of anaesthesia in cardiac surgery patients: An observational study

BACKGROUND: Induction of anaesthesia causes significant macrohaemodynamic changes, but little is known about its effects on the microcirculation. However, alterations in microvascular perfusion are known to be associated with impaired tissue oxygenation and organ dysfunction. Microvascular reactivity can be assessed with vascular occlusion testing, which evaluates the response of tissue oxygen saturation to transient ischaemia and reperfusion. OBJECTIVE: The aim of the current study was to evaluate the effects of an opioid-based anaesthesia induction on microvascular reactivity. We hypothesised that despite minimal blood pressure changes, microvascular function would be impaired. DESIGN: Prospective, observational study. SETTING: Single-centre, tertiary university teaching hospital, Belgium. PATIENTS: Thirty-five adult patients scheduled for elective coronary artery bypass grafting surgery. INTERVENTION: Microvascular reactivity was assessed before and 30 min after anaesthesia induction by means of vascular occlusion testing and near-infrared spectroscopy. MAIN OUTCOME MEASURES: Tissue oxygen saturations, desaturation rate, recovery time (time from release of cuff to the maximum value) and rate of recovery were determined. RESULTS: Data are expressed as median (minimum to maximum). Tissue oxygen saturation was higher after induction of anaesthesia [70 (54 to 78) vs. 73 (55 to 94)%, P = 0.015]. Oxygen consumption decreased after induction, appreciable by the higher minimum tissue oxygen saturation [45 (29 to 69) vs. 53 (28 to 81)%, P 

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Acute and chronic neuropathic pain after surgery: Still a lot to learn

No abstract available

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Effect of intravenous dextrose administration on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: A randomised controlled trial

No abstract available

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Early postoperative neuropathic pain assessed by the DN4 score predicts an increased risk of persistent postsurgical neuropathic pain

BACKGROUND: Acute neuropathic pain can occur in the postoperative period but any link with persistent post-surgical neuropathic pain remains unclear. OBJECTIVES: The objectives of this study were to prospectively describe the incidence of acute post-surgical neuropathic pain in a large population using the DN4 (clinician administered) questionnaire and to confirm the hypothetical link between acute and persistent neuropathic pain at 2 months after surgery in a large population using the DN2 (self administered) questionnaire. DESIGN: A multi-centre, prospective and observational trial. SETTING: Two consecutive days in 27 hospitals in France. PATIENTS: Six hundred and eight patients undergoing 13 different types of surgery. Fifteen patients were excluded as data were incomplete, and 229 (38.6%) and 260 (43.8%) were not contactable for assessment at 1 and 2 months after surgery, respectively. MAIN OUTCOME MEASURES: Pain was evaluated at least 2 h postoperatively on the same day (D0),on the second day (D2) and at 1 and 2 months after surgery (M1 and M2). Pain was assessed using a 10-point Numeric Rating Scale. If the Numeric Rating Scale score was greater than 0, neuropathic pain was assessed using a DN4 (clinician administered) questionnaire or using a DN2 (self-administered) questionnaire. Acute and persistent postsurgical neuropathic pain (PPSNP) were defined respectively by a DN4 score at least 4/10 on day 0 and/or day 2 and a DN2 score at least 3/7 at 2 months after surgery. RESULTS: Of the 593 patients included, 41.2% were in pain before surgery and 8.2% described neuropathic pain. Early after surgery, the majority of the 593 patients (72.2% on the day of surgery and 71.3% on day 2) experienced acute pain. It was neuropathic in nature in 5.6% of patients (95% CI, 3.6 to 8.3) on the day of surgery and 12.9% (95% CI, 9.7 to 16.7) on day 2. Two months after surgery, PPSNP was present in 33.3% of the 333 patients assessed. Multivariate analysis showed that a DN4 score at least 4/10 on the day of surgery or on day 2 was a significant risk factor for PPSNP [odds ratios 4.22 (95% CI, 2.19 to 8.12)]. CONCLUSION: Our results suggest that early acute postsurgical neuropathic pain significantly increases the risk of persistent post-surgical neuropathic pain. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NTC NCT02826317.

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Women awaken faster than men after electroencephalogram-monitored propofol sedation for colonoscopy: A prospective observational study

BACKGROUND: Sedation for colonoscopy using intravenous propofol has become standard in many Western countries. OBJECTIVE: Gender-specific differences have been shown for general anaesthesia in dentistry, but no such data existed for gastrointestinal endoscopy. DESIGN: A prospective observational study. SETTING: An academic teaching hospital of Hannover Medical School. PATIENTS: A total of 219 patients (108 women and 111 men) scheduled for colonoscopy. INTERVENTION: Propofol sedation using electroencephalogram monitoring during a constant level of sedation depth (D0 to D2) performed by trained nurses or physicians after a body-weight-adjusted loading dose. MAIN OUTCOME MEASURES: The primary end-point was the presence of gender-specific differences in awakening time (time from end of sedation to eye-opening and complete orientation); secondary outcome parameters analysed were total dose of propofol, sedation-associated complications (bradycardia, hypotension, hypoxaemia and apnoea), patient cooperation and patient satisfaction. Multivariate analysis was performed to correct confounding factors such as age and BMI. RESULTS: Women awakened significantly faster than men, with a time to eye-opening of 7.3 ± 3.7 versus 8.4 ± 3.4 min (P = 0.005) and time until complete orientation of 9.1 ± 3.9 versus 10.4 ± 13.7 min (P = 0.008). The propofol dosage was not significantly different, with some trend towards more propofol per kg body weight in women (3.98 ± 1.81 mg versus 3.72 ± 1.75 mg, P = 0.232). CONCLUSION: The effect of gender aspects should be considered when propofol is used as sedation for gastrointestinal endoscopy. That includes adequate dosing for women as well as caution regarding potential overdosing of male patients. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT02687568).

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Intraoperative magnesium sulphate decreases agitation and pain in patients undergoing functional endoscopic surgery: A randomised double-blind study

BACKGROUND: Postoperative agitation is harmful for the patient as it may be associated with removal of catheters, nasal packs, oxygen masks and self-injury, and pose a danger to operating theatre staff. OBJECTIVE: The current study investigated the potential role of magnesium sulphate in treatment of postoperative agitation following functional endoscopic sinus surgery. DESIGN: A randomised, double-blinded, placebo-controlled trial. SETTING: ENT operating room, Menofia University Hospitals, Egypt. PATIENTS: A total of 312 adult patients (171 men and 141 women) were enrolled in the study. Eighteen patients (10 men and eight women) were excluded; data from 294 patients were analysed. Inclusion criteria were age between 20 and 60 years, American Society of Anesthesiologists' physical status 1 or 2 scheduled for functional endoscopic sinus surgery. Exclusion criteria were hypertension, cardiac ischaemia, cerebrovascular insufficiency, neuromuscular diseases, pregnancy, prolonged treatment with calcium-channel blockers, diabetic neuropathy or a known allergy to magnesium compounds. INTERVENTIONS: Patients were allocated randomly to either the magnesium group (a magnesium infusion of 30 mg kg−1 in the first hour followed by 9 mg kg−1 h−1 until the end of the surgical procedure) or the control group (0.9% saline at the same volume and rate). Hypotensive anaesthesia was induced by nitroglycerine 5 to 20 μg kg−1 min−1. In the postanaesthetic care unit (PACU), patients were assessed for agitation and pain using the Richmond agitation-sedation scale and numerical rating scale, respectively. PRIMARY OUTCOME: The incidence and severity of agitation measured 5 min after admission to the PACU. RESULTS: Magnesium reduced postoperative agitation at time 0 (P = 0.009) and 5, 10, 15 and 30 min after PACU admission (P 

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Prophylactic atropine administration attenuates the negative haemodynamic effects of induction of anaesthesia with propofol and high-dose remifentanil: A randomised controlled trial

BACKGROUND: Induction of anaesthesia with propofol and remifentanil often induces unwanted bradycardia and hypotension, raising concerns regarding tissue oxygenation. The electrophysiological cardiac effects of remifentanil can be reversed by atropine. OBJECTIVE: To investigate if prophylactic administration of atropine can attenuate the negative haemodynamic effects of propofol and a high dose of remifentanil during induction of anaesthesia. DESIGN: A double-blind, randomised controlled trial. SETTING: Single-centre, University Medical Center Groningen, The Netherlands. PATIENTS: Sixty euvolaemic patients scheduled for surgery under general anaesthesia. INTERVENTIONS: Anaesthesia was induced and maintained with a target-controlled infusion of propofol with a target effect-site concentration (Ce) of 2.5 μg ml−1, remifentanil (target-controlled infusion), (Ce 8 ng ml−1) and cis-atracurium. Methylatropine (500 μg) or 0.9% saline was administered at immediately before induction of anaesthesia. MAIN OUTCOME MEASURES: The changes (Δ) in mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), rate pressure product, cerebral tissue oxygenation and peripheral tissue oxygenation between induction of anaesthesia (T0) and 10 min later (T10). RESULTS: Atropine significantly attenuated the changes in the outcome measures between T0 and T10. Median (inter-quartile range) changes were MAP, Δ = −24 (−40 to −21) vs. Δ = −37 mmHg (−41 to −31) (P = 0.02); HR, Δ = 0 ± 13 vs. −19 ± 11 bpm (P 

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Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND: Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES: Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN: A web-based prospective observational registry. SETTING: Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS: Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S): Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES: Experience of PPSP according to the type of peri-operative analgesia. RESULTS: Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION: Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02147730

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Transcutaneous monitoring of partial pressure of carbon dioxide during bronchoscopic procedures performed with jet ventilation: Role of the perfusion index

No abstract available

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The use of dipyrone in the ICU is associated with acute kidney injury: A retrospective cohort analysis

BACKGROUND: Use of dipyrone (metamizole) in perioperative and ICU pain therapy remains controversial due to a lack of solid evidence weighing dipyrone benefit against its potential life-threatening complications. Although dipyrone has known analgesic and antipyretic properties, its mechanisms of actions are incompletely understood. Although dipyrone effects on renal vasodilator prostaglandin synthesis are documented, little is known about its potential renal side effects, especially in the critical care environment. OBJECTIVE: Investigation of the perioperative nephrotoxic potential of dipyrone in patients prone to acute kidney injury (AKI). DESIGN: Retrospective cohort study. SETTING: Single centre study in a tertiary referral hospital from January 2013 until June 2013. PATIENTS: A total of 500 consecutive patients aged 18 years and older referred to the anaesthesia ICU. Patients were excluded if admitted from or discharged to other ICUs, if referred for post resuscitation care, or if repeatedly admitted to the ICU. MAIN OUTCOME MEASURES: Incidence of AKI, as defined by the Kidney Disease: Improving Global Outcomes Acute Kidney Injury Work Group criteria, and duration of vasopressor therapy. RESULTS: Use of dipyrone was associated with an increased incidence of AKI in a dose-dependent manner with a 1.6-fold increase in the incidence of AKI with each additional gram of intravenous dipyrone per day. Dipyrone dose of more than 2.5 g day−1 was the best risk predictive cut-off for AKI. Patients receiving dipyrone on the ICU presented with a prolonged duration of vasopressor therapy. CONCLUSION: Increasing dipyrone dosage is a potential independent risk factor for AKI in adult ICU patients and may prolong vasopressor therapy. Clinical evidence for a benefit of dipyrone therapy in the ICU is insufficient and needs further critical evaluation.

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Quality and Safety in Anesthesia and Perioperative Care

No abstract available

http://ift.tt/2gMYEe8

Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures.

Purpose of review: The primary purpose of this chapter is to define current recommendations for vascular work-up of patients with craniomaxillofacial (CMF) trauma with emphasis on imaging to include intraoperative fluorescence, angiography, and surgical exploration. The second goal is to review current management recommendations for observation versus surgical exploration based on the neck zones of injury. Recent findings: Over the past two decades, endovascular techniques are increasingly utilized, particularly in zones I and III of the neck. Additionally, modern advances in radiographic technology have allowed for selective exploration of penetrating zone II injuries. A high suspicion for blunt cerebrovascular injury should be maintained for patients with high-speed deceleration mechanisms of injury, with a majority of patients managed with medical therapy or conservative monitoring over surgical intervention. Summary: CMF fractures are associated with vascular injuries to the intracranial carotid system, extracranial carotid system, or vertebral artery system. A thorough understanding of at risk patients, optimal work-up, and timely treatment algorithms is imperative given the devastating sequellae of stroke and death. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults.

: Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures. The role of, and credentialing required by, anaesthesiologists and practitioners performing PSA has been debated for years in different guidelines. For this reason, the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria. A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method. The Taskforce selected 2248 articles. Where there was insufficiently clear and concordant evidence on a topic, the Rand Appropriateness Method with three rounds of Delphi voting was used to obtain the highest level of consensus among the taskforce experts. These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries. The final draft of the document was available to ESA members via the website for 4 weeks with the facility for them to upload their comments. Comments and suggestions of individual members and national Societies were considered and the guidelines were amended accordingly. The ESA guidelines Committee and ESA board finally approved and ratified it before publication. (C) 2017 European Society of Anaesthesiology

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Current opinion in otolaryngology: update on vascular injuries in craniomaxillofacial fractures.

Purpose of review: The primary purpose of this chapter is to define current recommendations for vascular work-up of patients with craniomaxillofacial (CMF) trauma with emphasis on imaging to include intraoperative fluorescence, angiography, and surgical exploration. The second goal is to review current management recommendations for observation versus surgical exploration based on the neck zones of injury. Recent findings: Over the past two decades, endovascular techniques are increasingly utilized, particularly in zones I and III of the neck. Additionally, modern advances in radiographic technology have allowed for selective exploration of penetrating zone II injuries. A high suspicion for blunt cerebrovascular injury should be maintained for patients with high-speed deceleration mechanisms of injury, with a majority of patients managed with medical therapy or conservative monitoring over surgical intervention. Summary: CMF fractures are associated with vascular injuries to the intracranial carotid system, extracranial carotid system, or vertebral artery system. A thorough understanding of at risk patients, optimal work-up, and timely treatment algorithms is imperative given the devastating sequellae of stroke and death. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

http://ift.tt/2eHwKfp

Recovery From Ropivacaine-Induced or Levobupivacaine-Induced Cardiac Arrest in Rats: Comparison of Lipid Emulsion Effects.

BACKGROUND: Lipid emulsion treatment appears to have application in the treatment of local anesthetic-induced cardiac arrest. To examine whether the efficacy of lipid resuscitation in the treatment of local anesthetic-induced cardiac arrest is affected by lipophilicity, the effects of lipid infusions were compared between levobupivacaine-induced (high lipophilicity) and ropivacaine-induced (lower lipophilicity) rat cardiac arrest model. METHODS: A total of 28 female Sprague-Dawley rats were anesthetized using sevoflurane, which subsequently underwent tracheostomy, followed by femoral artery and vein cannulation. Two hours after the discontinuation of sevoflurane, either levobupivacaine 0.2% (n = 14) or ropivacaine 0.2% (n = 14) was administered at a rate of 2 mg/kg/min to the awake rats. When the pulse pressure decreased to 0, the infusion of local anesthetic was discontinued, and treatment with chest compressions and ventilation with 100% oxygen were immediately initiated. The total doses of local anesthetics needed to trigger the first seizure and pulse pressure of 0 mm Hg were calculated. The 2 groups were each subdivided into a lipid emulsion group (n = 7) and a control group (n = 7). In the lipid emulsion group, 20% lipid emulsion was administered intravenously (5 mL/kg bolus plus continuous infusion of 0.5 mL/kg/min), while in the control group, the same volume of normal saline was administered. Chest compressions were discontinued when the rate-pressure product had increased by more than 20% of baseline. RESULTS: The cumulative doses of levobupivacaine and ropivacaine that produced seizures and 0 pulse pressure showed no significant difference. Mean arterial blood pressure (MAP) values were higher in the levobupivacaine group than in the ropivacaine group after resuscitation was initiated (P 20% baseline), while only 2 of 7 rats in the control group achieved spontaneous circulation at 10 minutes. In ropivacaine-induced cardiac arrest, there were no significant differences in heart rate and MAP between the lipid and control groups from the start of resuscitation to 10 minutes; spontaneous circulation returned in 6 of 7 lipid group rats, but in only 2 of 7 control group rats at 10 minutes. CONCLUSIONS: Lipid emulsion treatment was more effective for levobupivacaine-induced cardiac arrest than for ropivacaine-induced cardiac arrest. Although lipid therapy is also effective for ropivacaine-induced cardiac arrest, it takes more time than in levobupivacaine-induced cardiac arrest. This suggests that the lipophilicity of local anesthetics influences the efficacy of lipid infusion when treating cardiac arrest caused by these drugs. 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. (C) 2017 International Anesthesia Research Society

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Diagnostic Errors in Patients With Skin Findings

Dr Graeme Lipper presents five cases that typically present to primary care but aren't as straightforward as they initially seem.
Medscape Internal Medicine

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Synergistic Effects of Long Wavelength Ultraviolet A1 and Visible Light on Pigmentation and Erythema

Summary

Background

Visible light (VL) induces multiple cutaneous effects. Sunscreen testing protocols recommended by regulatory bodies throughout the world require the use of solar simulators with spectral output in ultraviolet (UV) domain only. However, sunlight contains VL and infrared radiation also.

Objective

This study aimed to evaluate the contributions of VL and UVA on pigmentation and erythema, and optimize parameters for in-vivo testing.

Methods

Ten subjects with Fitzpatrick skin phototype IV-VI were enrolled. Subjects were irradiated on their back with VL using two light sources: one containing pure VL and one containing VL with less than 0.5% UVA1 (VL+UVA1). Four different irradiances were administered to investigate reciprocity behaviour. Assessments, including photography, investigator's global assessment, colorimetry, and spectroscopy, were performed immediately, 24 hours, 7 days and 14 days post-irradiation.

Results

Pigmentation was observed with both light sources; however, pigment intensity was greater with VL+UVA1 than pure VL. Reciprocity was observed in pure VL sites, but not VL+UVA1. Variation in spectral output had greater impact on pigment intensity than irradiance. Clinical erythema was observed on the VL+UVA1 side, but not on the pure VL side. Protocol for testing photoprotection product efficacy against VL induced effects has been proposed.

Conclusions

The findings suggest a synergistic relationship between VL and UVA1 and emphasize the need for developing means of photoprotection against VL.

This article is protected by copyright. All rights reserved.

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Issue Information

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Violaceous, Photodistributed Cutaneous Eruption and Leg Ulcer

A 69-year-old woman presented for the evaluation of a progressive, asymptomatic cutaneous eruption on her hands and forearms, as well as an enlarging, painful ulcer on her left leg that developed 6 months earlier; her medical history was notable for essential thrombocytosis. What is your diagnosis?

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A Transgender Woman With Anogenital Lichen Sclerosus

This case report describes a transgender woman with anogenital lichen sclerosus.

http://ift.tt/2xPp9Uc

Incorrect P Value in Table 3

In the article titled "Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution," an incorrect P value in Table 3 has been corrected. Previously, the P value for the "Members in practice" characteristic incorrectly read ".08." The correct P value is ".008." The article was corrected online.

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Attempting to Define “Hypoallergenic”

The North American Contact Dermatitis Group (NACDG) commends Xu et al for bringing attention to challenges facing dermatologists and consumers. Their original approach of using sales data provides a snapshot of what consumers are actually using (lotions!), and their assessment of commonly used marketing terms and their connection to cost and product composition are innovative.

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Error in Affiliation

In the article by Albers et al titled "Treatment of Hailey-Hailey Disease With Low-Dose Naltrexone," published online August 2, 2017, there was an error in the affiliations. Dr Arbiser is also at the Atlanta Veterans Administration Medical Center, Decatur, Georgia. The error has been corrected online.

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Effect of Topical Fluorouracil Cream on Photodamage

This secondary analysis of a randomized clinical trial investigates the effect of topical fluorouracil, 5%, cream on photoaging using validated photonumeric scales.

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Performance Characteristics of and Allergens in Best-Selling Moisturizers

This cohort study examines the product performance characteristics and ingredients of best-selling moisturizers.

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The Learning Curve in Surgical Practice and Its Applicability to Rhinoplasty

Abstract

The learning curve as a concept has been considered, discussed and debated in medical education and healthcare for over two decades. The precise usage has been recognised in surgical disciplines both broad specialties and sub-specialties. Rollin Daniel in his book stated that, rhinoplasty is the most difficult of all cosmetic operations for three reasons, (a) nasal anatomy is highly variable, (b) the procedure must correct form and function and (c) the final result must meet the patients expectations. With this in mind a study was carried on the perception of learning curve in rhinoplasty based on a surgeon questionnaire at Marien Hospital, Stuttgart, Germany under Prof. Gubisch. Aims of the study were, (1) to extract the perception of learning curve of Rhinoplasty from surgeons across a spectrum of experience, i.e. less experienced to experienced, (2) To calculate the perception of learning curve in rhinoplasty as for other surgical procedures i.e. minimum number, interquartile range, surgical time, accelerators, (3) To chart-out a road-map for a novice rhinoplasty surgeon for continued improvement in surgical skills and ability. The conclusion derived was the concept of learning curve in rhinoplasty cannot be applied to the operation of Septo-Rhinoplasty as a whole because the two factors i.e. interquartile range and minimum number to achieve proficiency have a wide range and cannot be generalized. It is thought that each type of Rhinoplasty should be dealt with separately and learning curve calculated accordingly, i.e. hump reduction, crooked nose and augmentation rhinoplasty.

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Etiology of Noise-Induced Hearing Loss (NIHL) and its Symptomatic Correlation with Audiometry Observations in Type II Diabetes

Abstract

Type II diabetic mellitus (DM) is a chronic metabolic disease that impairs normal insulin production and glucose transport to the liver and muscles. In the India, about 1–5% population suffer from diabetes or related complication. So there is need to cure this disease. DM chronic auditory complications may include spiral ganglia atrophy, degeneration of the vestibulocochlear nerve myelin sheath, reduction of the number of spiral lamina nerve fibres, and thickening of the capillary walls of the stria vascularis and small arteries. This study aims to know the incidence of common parameters, blood sugar levels, levels of lipids and the hearing thresholds of individuals. It is a Noise-Induced Hearing Loss research study featuring hearing impairment in transport workers diagnosed as type II diabetic. All individuals were interviewed by various questioners related to listening ability of subjects and underwent a physical examination, blood investigations and audiometry. Hearing impairment was more prevalent among adults with diabetes. Sensory neuron hearing loss is predominant in both study groups. Mixed Bilateral Hearing Loss showed significant p value in (>.001) by audiometry. The percentage of hearing loss in diabetes (ranges 5.3–28.1%) and in non-diabetics (ranges 3.4–24.1%) and risk factors in diabetes (ranges 22.8–35.1%) over nondiabetics (ranges 17.2–20.1%) which is eye opener. The correlation between type II diabetes and hearing impairment was independent of known risk factors for hearing impairment, such as noise exposure, build-up wax, ototoxic medication, smoking, tobacco chewing etc.

http://ift.tt/2xb2kx2

Anatomical Correlation Between Nasal Vascularisation and the Design of the Endonasal Pedicle Flaps

Abstract

Arteries that supply the nasal septum and the lateral nasal wall include vessels that originate from the external carotid artery and from the internal carotid artery. A variety of local endonasal pedicle flaps can be used in different anatomical areas for endoscopic skull base reconstruction. The main flaps are based on terminal branches of the sphenopalatine artery and on anterior ethmoidal artery. This study will describe the anatomy of these vessels and their relationship with the main flaps.

http://ift.tt/2wHmRq1

Etiology of Noise-Induced Hearing Loss (NIHL) and its Symptomatic Correlation with Audiometry Observations in Type II Diabetes

Abstract

Type II diabetic mellitus (DM) is a chronic metabolic disease that impairs normal insulin production and glucose transport to the liver and muscles. In the India, about 1–5% population suffer from diabetes or related complication. So there is need to cure this disease. DM chronic auditory complications may include spiral ganglia atrophy, degeneration of the vestibulocochlear nerve myelin sheath, reduction of the number of spiral lamina nerve fibres, and thickening of the capillary walls of the stria vascularis and small arteries. This study aims to know the incidence of common parameters, blood sugar levels, levels of lipids and the hearing thresholds of individuals. It is a Noise-Induced Hearing Loss research study featuring hearing impairment in transport workers diagnosed as type II diabetic. All individuals were interviewed by various questioners related to listening ability of subjects and underwent a physical examination, blood investigations and audiometry. Hearing impairment was more prevalent among adults with diabetes. Sensory neuron hearing loss is predominant in both study groups. Mixed Bilateral Hearing Loss showed significant p value in (>.001) by audiometry. The percentage of hearing loss in diabetes (ranges 5.3–28.1%) and in non-diabetics (ranges 3.4–24.1%) and risk factors in diabetes (ranges 22.8–35.1%) over nondiabetics (ranges 17.2–20.1%) which is eye opener. The correlation between type II diabetes and hearing impairment was independent of known risk factors for hearing impairment, such as noise exposure, build-up wax, ototoxic medication, smoking, tobacco chewing etc.

http://ift.tt/2xb2kx2

Akute Hauterkrankungen im Kindesalter

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Anatomical Correlation Between Nasal Vascularisation and the Design of the Endonasal Pedicle Flaps

Abstract

Arteries that supply the nasal septum and the lateral nasal wall include vessels that originate from the external carotid artery and from the internal carotid artery. A variety of local endonasal pedicle flaps can be used in different anatomical areas for endoscopic skull base reconstruction. The main flaps are based on terminal branches of the sphenopalatine artery and on anterior ethmoidal artery. This study will describe the anatomy of these vessels and their relationship with the main flaps.

http://ift.tt/2wHmRq1

Ectopic Hamartomatous Thymoma: A Review Of The Literature With Report Of New Cases And Proposal Of A New Name: Biphenotypic Branchioma

Abstract

Ectopic hamartomatous thymoma (EHT) is a rare benign neoplasm of the lower neck suggesting branchial origin. Despite use of the term thymoma in the nomenclature, there is no evidence of thymic origin or differentiation. It affects middle-aged adults with a remarkable male predominance. To date less than 80 cases have been reported in the English literature. We present here two additional cases of EHT. The first is a benign case in a 31-year-old man, showing typical histological features. The second is a malignant case in a 70-year-old woman, showing intraductal carcinoma arising in intimate association with an EHT. These cases are presented in the context of a review of cases reported in the English literature. The exact origin has not been identified, but is considered to be of branchial apparatus, creating a quandary about the best terminology. Recently, the designation "branchial anlage mixed tumor" or "thymic anlage tumor" were proposed, but do not quite reflect the true nature of the neoplasm. To avoid taxonomic confusion, international consensus on terminology is desired. As this entity is a neoplasm that shows dual mesoderm and endoderm derivation/differentiation, we propose a new name "biphenotypic branchioma."

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Nivolumab Plus Ipilimumab in Patients With Renal Medullary Carcinoma

Conditions:   Renal Medullary Carcinoma;   Other Disorders of Kidney and Ureter
Interventions:   Drug: Nivolumab;   Drug: Ipilimumab
Sponsors:   M.D. Anderson Cancer Center;   Bristol-Myers Squibb
Not yet recruiting - verified September 2017

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Efficacy of Nasogastric Tube Application in Postoperative Care of Esophagectomy

Condition:   Esophageal Cancer
Intervention:   Procedure: Discharge the NG tube during the surgery
Sponsor:   Fudan University
Not yet recruiting - verified August 2017

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Adjuvant Radiotherapy for T3N0M0 Esophageal Squamous Cell Carcinoma With Positive Circumstantial Resection Margin

Conditions:   Esophageal Squamous Cell Carcinoma;   Positive Circumferential Resection Margin
Intervention:   Radiation: radiation
Sponsor:   Fudan University
Not yet recruiting - verified August 2017

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Efficacy and Safety of Apatinib for Recurrent or Metastatic Esophageal Squamous Cell Carcinoma

Condition:   Esophageal Neoplasms
Intervention:   Drug: Apatinib
Sponsor:   Fudan University
Recruiting - verified September 2017

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Whole Body Electromyostimulation and Nutritional Therapy for Patients With Esophageal and Bronchial Carcinoma

Conditions:   Cancer of Esophagus;   Cancer, Lung
Interventions:   Procedure: whole body electromyostimulation exercise;   Procedure: protein-rich nutrition therapy
Sponsor:   University of Erlangen-Nürnberg Medical School
Recruiting - verified September 2017

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A murine Ig light chain transgene reveals IGKV3 gene contributions to anti-collagen types IV and II specificities

Publication date: November 2017
Source:Molecular Immunology, Volume 91
Author(s): Amy G. Clark, Inge M. Worni-Schudel, Francesca M. Korte, Mary H. Foster
A subset of autoimmune diseases result from autoantibodies targeting epitopes on matrix collagen. The most extensively studied are anti-glomerular basement membrane glomerulonephritis (or its systemic counterpart Goodpasture's disease) that destroys kidneys and lungs, and rheumatoid arthritis that leads to disabling arthritis. Autoantibodies in these disorders bind evolutionarily conserved conformational epitopes on the noncollagenous domain 1 (NC1) of the alpha3 chain of type IV [alpha3(IV)NC1] collagen in glomerular and alveolar basement membranes, and on native or citrullinated type II collagen (CII) in joint cartilage, respectively. The genetic origins of pathogenic anti-collagen B cells in these diseases is unknown, but observations from murine models raise the possibility that they overlap despite distinct in vivo immunopathologies. Monoclonal autoantibodies isolated from mice immunized with alpha3(IV)NC1 collagen or CII show a biased use of Ig light chains (LC) encoded by genes of the IGKV3 subgroup (previously Vk21 family), paired with diverse Ig heavy chains. To further explore this relationship and determine if a single murine IGKV3 LC independently predisposes to both anti-collagen responses, we generated a novel transgenic (Tg) C57BL/6 mouse that expresses a productively rearranged IGKV3-encoded LC, termed mLCV3-Tg, in conjunction with endogenously rearranged Ig heavy chains. Tg mice are also genetically deficient in endogenous kappa chains to permit tracking of the mLCV3 transgene. We show that mLCV3-Tg mice are susceptible to humoral autoimmunity against both collagen chains. Anti-alpha3(IV)NC1 collagen, but not anti-CII, mLCV3-encoded Ig are detected in serum of unmanipulated Tg mice, while Toll-like receptor ligands induce secretion of mLCV3-Tg autoantibodies of both collagen specificities from splenocytes ex vivo. This indicates developmental survival of mLCV3-Tg B cells reactive with each antigen, and is consistent with production of the two anti-collagen autoIg from distinct B cell populations. Reduced B cell numbers, low serum Ig kappa levels, low cell surface Ig kappa density, and abundant endogenous lambda chain expression suggest that subsets of IGKV3-encoded B cells are regulated in vivo by mechanisms that include deletion, anergy, and LC editing. These results support the notion that murine IGKV3 LCs contribute structural fitness to antigen binding sites that support diverse anti-collagen autoimmune responses, that these responses are regulated in vivo, and that these cells can nonetheless readily escape immune regulation.



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Human β-defensin 3 inhibits periodontitis development by suppressing inflammatory responses in macrophages

Publication date: November 2017
Source:Molecular Immunology, Volume 91
Author(s): Di Cui, Jinglu Lyu, Houxuan Li, Lang Lei, Tianying Bian, Lili Li, Fuhua Yan
Human β-defensin 3 (hBD3) is a cationic peptide with immunomodulatory effects on both innate and acquired immune responses. Periodontitis, an inflammatory disease that extends deep into periodontal tissues, causes the loss of supporting structures around the tooth. The present study assessed the effects of hBD3 as a monotherapy for periodontitis in mice and explored its potential mechanism. In vivo, hBD3 inhibited the levels of tumour necrosis factor (TNF)-α, interleukin-6, and matrix metalloprotease-9 in periodontium exposed to Porphyromonas gingivalis (P.g) in a mouse periodontitis model; reduced osteoclast formation and lower alveolar bone loss were also observed. In addition, hBD3 was related to the expression of polarization signature molecules in circulating monocytes. In vitro, hBD3 notably suppressed the production of TNF-α and interleukin-6 in RAW 264.7 cells stimulated by the lipopolysaccharide of P.g. Moreover, hBD3 attenuated polarization of RAW 264.7 cells into the M1 phenotype, with reduced activation of nuclear factor-κB signal transduction. In conclusion, hBD3 exhibits potent anti-periodontitis properties both in vitro and in vivo, and this effect may be correlated to inhibition of the nuclear factor-κB pathway and macrophage polarization.



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DAF in diabetic patients is subject to glycation/inactivation at its active site residues

Publication date: Available online 5 September 2017
Source:Molecular Immunology
Author(s): Rudolf Flückiger, Enzo Cocuzzi, Ram H. Nagaraj, Menachem Shoham, Timothy S. Kern, M. Edward Medof
Decay accelerating factor (DAF or CD55) is a cell associated C3 and C5 convertase regulator originally described in terms of protection of self-cells from systemic complement but now known to modulate adaptive T cell responses. It is expressed on all cell types. We investigated whether nonenzymatic glycation could impair its function and potentially be relevant to complications of diabetes mellitus and other conditions that result in nonenzymatic glycation including cancer, Alzheimer's disease, and aging. Immunoblots of affinity-purified DAF from erythrocytes of patients with diabetes showed pentosidine, glyoxal-AGEs, carboxymethyllysine, and argpyrimidine. HPLC/MS analyses of glucose modified DAF localized the sites of AGE modifications to K¹²⁵ adjacent to K¹²⁶, K¹²⁷ at the junction of CCPs2-3 and spatially near R⁹⁶, and R¹⁰⁰, all identified as being critical for DAF's function. Functional analyses of glucose or ribose treated DAF protein showed profound loss of its regulatory activity. The data argue that de-regulated activation of systemic complement and de-regulated activation of T cells and leukocytes could result from non-enzymatic glycation of DAF.



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Oropharyngeal lymphoma: A US population based analysis

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Hani M. Rayess, Michael Nissan, Amar Gupta, Michael A. Carron, S. Naweed Raza, Andrew M. Fribley
ObjectivesTo describe the epidemiology and analyze factors determinant of survival in patients with oropharyngeal lymphoma, using the Surveillance Epidemiology and End Results (SEER) database.Methods2504 patients with oropharyngeal lymphoma were identified using the most recent SEER database entry from 1976 to 2016. Demographic information, Ann Arbor stage, tumor histopathology and location were collected. Multivariate analysis was used to analyze patient and tumor characteristics associated with survival.ResultsThe mean age of the patients studied was 60.5years, 58.4% of the subjects were male and 81% were white. Diffuse large B cell lymphoma (DLBCL) was the most common histologic subtype involving 56.9% of cases. The most common subsite of origin was the tonsil, with 71% of lymphomas originating from there. The association of survival with stage, age, tumor location, presence of B symptoms, tumor pathology, gender and race was analyzed using multivariate regression. Decreased survival was significantly associated with patient age p<0.0001, Ann Arbor staging p=0.005, the presence of B symptoms p=0.003 and tumor histopathology (T cell tumors) p=0.01. Patients with tumors originating from the soft palate were significantly more likely to die asa result of their disease p=0.03.ConclusionOropharyngeal lymphoma most commonly originates from the tonsil. DLBCL is the most common subtype and has a good prognosis. The presence of B symptoms, tumors originating from the soft palate and patients with T cell tumors have the worst prognosis. This information can potentially be of great utility to the head and neck surgeon discussing prognosis with patients suffering from oropharyngeal lymphoma.



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Prevalence and clinical features of adverse food reactions in Portuguese children

The prevalence of adverse food reactions (AFR) has been increasing in the western world. Clinical manifestations are diversified and it may not be possible to clinically discriminate between IgE and non-IgE me...

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Analgesia nociception index for the assessment of pain in critically ill patients: a diagnostic accuracy study

Abstract

Background. Behavioural pain tools are used in Intensive Care Unit (ICU) patients unable to self-report their pain-intensity but need sustained efforts to educate and train the ICU team because of the subjective nature of these clinical tools. This study measured the validity and performance of an electrophysiological monitoring tool based on the spectral analysis of heart rate variability, the Analgesia Nociception Index (ANI) which varies from 0 (minimal parasympathetic tone, maximal stress-response and pain) to 100 (maximal parasympathetic tone, minimal stress-response and pain).Methods. Mean-ANI (ANIm) and Instant-ANI (ANIi) were continuously recorded then compared with the Behavioral Pain Scale (BPS) before, during and after routine care procedures in critically-ill non-comatose patients.Results. 969 assessments were performed in 110 patients. ANIi was the most discriminative pain tool. It was significantly correlated with BPS (r=–0.30; 95%CI –0.37 to –0.25; P<0.001). For an ANIi threshold of 42.5, the sensitivity, specificity, positive and negative predictive values were respectively 61.4%, 77.4%, 37.0%, and 90.4%. Compared with the BPS, ANIi had no significantly different ability to change during turning and tracheal-suctioning but changed significantly more during dressing change. ANIi increased independently with age, obesity and severity of illness, and controlled mechanical-ventilation, vasopressors use and analgesia. ANIi decreased independently when vigilance status and respiratory rate increased. ANIm demonstrated poor psychometric properties to detect pain.Conclusions. Despite low sensitivity/specificity, ANIi≥43 had a Negative-Predictive-Value of 90%. Hence ANIi may be of highest benefit for excluding significant pain. A randomized controlled trial should compare sedation-analgesia protocols based on ANIi to presently recommended behavioural-pain-tools.

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Benefit and harm of pregabalin in acute pain treatment: a systematic review with meta-analyses and trial sequential analyses

Abstract

Pregabalin has demonstrated anti-hyperalgesic properties and was introduced into acute pain treatment in 2001. Our aim was to evaluate the beneficial and harmful effects of pregabalin in postoperative pain management. We included randomized clinical trials investigating perioperative pregabalin treatment in adult surgical patients. The review followed Cochrane methodology, including Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and used trial sequential analyses (TSAs). The primary outcomes were 24 h morphine i.v. consumption and the incidence of serious adverse events (SAEs) defined by International Conference of Harmonisation Good Clinical Practice guidelines. Conclusions were based primarily on trials with low risk of bias. Ninety-seven randomized clinical trials with 7201 patients were included. The 24 h morphine i.v. consumption was reported in 11 trials with overall low risk of bias, finding a reduction of 5.8 mg (3.2, 8.5; TSA adjusted confidence interval: 3.2, 8.5). Incidence of SAEs was reported in 21 trials, with 55 SAEs reported in 12 of these trials, and 22 SAEs reported in 10 trials with overall low risk of bias. In trials with overall low risk of bias, Peto's odds ratio was 2.9 (1.2, 6.8; TSA adjusted confidence interval: 0.1, 97.1). Based on trials with low risk of bias, pregabalin may have a minimal opioid-sparing effect, but the risk of SAEs seems increased. However, the GRADE-rated evaluations showed only moderate to very low quality of evidence. Consequently, a routine use of pregabalin for postoperative pain treatment cannot be recommended.

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Association between intraoperative non-depolarising neuromuscular blocking agent dose and 30-day readmission after abdominal surgery

Abstract

Background. We hypothesised that intraoperative non-depolarising neuromuscular blocking agent (NMBA) dose is associated with 30-day hospital readmission.Methods. Data from 13,122 adult patients who underwent abdominal surgery under general anaesthesia at a tertiary care hospital were analysed by multivariable regression, to examine the effects of intraoperatively administered NMBA dose on 30-day readmission (primary endpoint), hospital length of stay, and hospital costs.Results. Clinicians used cisatracurium (mean dose [SD] 0.19 mg kg⁻¹ [0.12]), rocuronium (0.83 mg kg⁻¹ [0.53]) and vecuronium (0.14 mg kg⁻¹ [0.07]). Intraoperative administration of NMBAs was dose-dependently associated with higher risk of 30-day hospital readmission (adjusted odds ratio 1.89 [95% Confidence Interval (CI) 1.26–2.84] for 5th quintile vs 1st quintile; P for trend: P<0.001), prolonged hospital length of stay (adjusted incidence rate ratio [aIRR] 1.20 [95% CI 1.11–1.29]; P for trend: P<0.001) and increased hospital costs (aIRR 1.18 [95% CI 1.13-1.24]; P for trend: P<0.001). Admission type (same-day vs inpatient surgery) significantly modified the risk (interaction term: aOR 1.31 [95% CI 1.05–1.63], P=0.02), and the adjusted odds of readmission in patients undergoing ambulatory surgical procedures who received high-dose NMBAs vs low-dose NMBAs amounted to 2.61 [95% CI 1.11–6.17], P for trend: P<0.001. Total intraoperative neostigmine dose increased the risk of 30-day readmission (aOR 1.04 [1.0–1.08], P=0.048).Conclusions. In a retrospective analysis, high doses of NMBAs given during abdominal surgery was associated with an increased risk of 30-day readmission, particularly in patients undergoing ambulatory surgery.

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Factors for a Successful Laparoscopic Hysterectomy in Very Large Uteri

Minimally invasive hysterectomy is a standard procedure. Different approaches, as laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy, and subtotal and total laparoscopic hysterectomy, have been described and evaluated by various investigations as safe and cost-effective methods. In particular, in comparison to abdominal hysterectomy, the minimally invasive methods have undoubted advantages for the patients. The main reason for a primary abdominal hysterectomy or conversion to abdominal hysterectomy during a minimal invasive approach is the uterine size. We describe our course of action in the retrospective analysis of five cases of total minimal-access hysterectomy, combining the laparoscopic subtotal hysterectomy and the vaginal extirpation of the cervix in uterine myomatosis with a uterine weight of more than 1000 grams, and discuss the factors that limit the use of laparoscopy in the treatment of big uteri. Trail Registration. The case report is registered in Research Registry under the UIN researchregistry743.

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Ectopic Hamartomatous Thymoma: A Review Of The Literature With Report Of New Cases And Proposal Of A New Name: Biphenotypic Branchioma

Abstract

Ectopic hamartomatous thymoma (EHT) is a rare benign neoplasm of the lower neck suggesting branchial origin. Despite use of the term thymoma in the nomenclature, there is no evidence of thymic origin or differentiation. It affects middle-aged adults with a remarkable male predominance. To date less than 80 cases have been reported in the English literature. We present here two additional cases of EHT. The first is a benign case in a 31-year-old man, showing typical histological features. The second is a malignant case in a 70-year-old woman, showing intraductal carcinoma arising in intimate association with an EHT. These cases are presented in the context of a review of cases reported in the English literature. The exact origin has not been identified, but is considered to be of branchial apparatus, creating a quandary about the best terminology. Recently, the designation "branchial anlage mixed tumor" or "thymic anlage tumor" were proposed, but do not quite reflect the true nature of the neoplasm. To avoid taxonomic confusion, international consensus on terminology is desired. As this entity is a neoplasm that shows dual mesoderm and endoderm derivation/differentiation, we propose a new name "biphenotypic branchioma."

http://ift.tt/2xa9rG3

Adenoid Cystic Carcinoma of the Oral Cavity: Radiology–Pathology Correlation

Abstract

Adenoid cystic carcinoma in the oral cavity is an uncommon salivary gland malignancy that has a propensity for perineural spread. A high-grade variant is evidenced by an abundance of pleomorphic cells, loss of the classic biphasic epithelial-myoepithelial growth pattern, and comedonecrosis, as well as elevated Ki-67. CT and MRI can both be useful for demonstrating the extent of invasion in oral cavity-associated adenoid cystic carcinoma, which can attain the inferior alveolar nerve for perineural spread by direct invasion through the mandible. Reflecting the aggressive nature of this high-grade malignancy, ¹⁸FDG-PET can demonstrate hypermetabolism and can be useful for staging. These features are exemplified in this sine qua non radiology–pathology correlation article.

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Encountering Chronic Sore Throat: How Challenging is it for the Otolaryngologists?

Abstract

Objective To explore and diagnose the underlying causes of chronic, recalcitrant sore throat. Methodology In this descriptive, cross-sectional study spanning 3 years (January 2014–December 2016), 1580 patients with chronic sore throat (>12 weeks duration, despite conventional medication) were evaluated for the possible cause(s) in a tertiary care teaching institute of eastern India, through proper history, appropriate investigations, and a self-designed algorithm. Results The common causes for chronic sore throat were chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder, respectively. Allergy, psychiatric illnesses, oral submucous fibrosis, systemic comorbidities (diabetes mellitus, hypothyroidism, uremia, arthritides), stylalgia, Koch's pneumonitis, recurrent aphthous ulcers, and dietary deficiencies formed the other major causes. There was a minimal female preponderance, the female: male ratio being 1.25. About 39% patients were chronic smokers, and 31% addicted to alcohol. Forty-three (2.72%) patients were reactive to HIV 1/2. Conclusion The study provided with a detailed account of the heterogeneous etiology of chronic sore throat, and an overall structured idea on how to approach to its work-up and diagnosis. Proper history taking and appropriate structured investigations are the keys. Chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder were the chief causes of chronic sore throat.

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The Learning Curve in Surgical Practice and Its Applicability to Rhinoplasty

Abstract

The learning curve as a concept has been considered, discussed and debated in medical education and healthcare for over two decades. The precise usage has been recognised in surgical disciplines both broad specialties and sub-specialties. Rollin Daniel in his book stated that, rhinoplasty is the most difficult of all cosmetic operations for three reasons, (a) nasal anatomy is highly variable, (b) the procedure must correct form and function and (c) the final result must meet the patients expectations. With this in mind a study was carried on the perception of learning curve in rhinoplasty based on a surgeon questionnaire at Marien Hospital, Stuttgart, Germany under Prof. Gubisch. Aims of the study were, (1) to extract the perception of learning curve of Rhinoplasty from surgeons across a spectrum of experience, i.e. less experienced to experienced, (2) To calculate the perception of learning curve in rhinoplasty as for other surgical procedures i.e. minimum number, interquartile range, surgical time, accelerators, (3) To chart-out a road-map for a novice rhinoplasty surgeon for continued improvement in surgical skills and ability. The conclusion derived was the concept of learning curve in rhinoplasty cannot be applied to the operation of Septo-Rhinoplasty as a whole because the two factors i.e. interquartile range and minimum number to achieve proficiency have a wide range and cannot be generalized. It is thought that each type of Rhinoplasty should be dealt with separately and learning curve calculated accordingly, i.e. hump reduction, crooked nose and augmentation rhinoplasty.

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Ectopic Hamartomatous Thymoma: A Review Of The Literature With Report Of New Cases And Proposal Of A New Name: Biphenotypic Branchioma

Abstract

Ectopic hamartomatous thymoma (EHT) is a rare benign neoplasm of the lower neck suggesting branchial origin. Despite use of the term thymoma in the nomenclature, there is no evidence of thymic origin or differentiation. It affects middle-aged adults with a remarkable male predominance. To date less than 80 cases have been reported in the English literature. We present here two additional cases of EHT. The first is a benign case in a 31-year-old man, showing typical histological features. The second is a malignant case in a 70-year-old woman, showing intraductal carcinoma arising in intimate association with an EHT. These cases are presented in the context of a review of cases reported in the English literature. The exact origin has not been identified, but is considered to be of branchial apparatus, creating a quandary about the best terminology. Recently, the designation "branchial anlage mixed tumor" or "thymic anlage tumor" were proposed, but do not quite reflect the true nature of the neoplasm. To avoid taxonomic confusion, international consensus on terminology is desired. As this entity is a neoplasm that shows dual mesoderm and endoderm derivation/differentiation, we propose a new name "biphenotypic branchioma."

http://ift.tt/2xa9rG3

Adenoid Cystic Carcinoma of the Oral Cavity: Radiology–Pathology Correlation

Abstract

Adenoid cystic carcinoma in the oral cavity is an uncommon salivary gland malignancy that has a propensity for perineural spread. A high-grade variant is evidenced by an abundance of pleomorphic cells, loss of the classic biphasic epithelial-myoepithelial growth pattern, and comedonecrosis, as well as elevated Ki-67. CT and MRI can both be useful for demonstrating the extent of invasion in oral cavity-associated adenoid cystic carcinoma, which can attain the inferior alveolar nerve for perineural spread by direct invasion through the mandible. Reflecting the aggressive nature of this high-grade malignancy, ¹⁸FDG-PET can demonstrate hypermetabolism and can be useful for staging. These features are exemplified in this sine qua non radiology–pathology correlation article.

http://ift.tt/2eF9sqi

Increased expression of interleukin-21 along colorectal adenoma-carcinoma sequence and its predicating significance in patients with sporadic colorectal cancer

Publication date: Available online 5 September 2017
Source:Clinical Immunology
Author(s): Guanglin Cui, Aping Yuan, Li Zhu, Jon Florholmen, Rasmus Goll
The role and significance of interleukin (IL)-21 in the development of sporadic CRC have not been well defined. The aim of this study is therefore to investigate the dynamics of the IL-21 along colorectal adenoma-carcinoma sequence and to evaluate the impact of IL-21 on clinicopathological parameters and CRC prognosis. The real-time PCR results showed that the level of IL-21 in adenomas (n=50) and sporadic CRC (n=50) were significantly higher than that in normal controls (n=18), which were predominately observed in the adenoma/CRC stroma. Analysis revealed that IL-21 level was correlated with the overall survival time in CRC patients. Double immunofluorescence observations confirmed that IL-21 positive cells were mostly natural killer cells and T lymphocytes in the tumor stroma. These results indicate that significant increased IL-21 expression present within the adenoma/CRC microenvironment might have a potential predicating significance for survival time in patients with CRC.



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Why Does Threshold Level Change in Transcranial Motor-evoked Potentials During Surgery for Supratentorial Lesions?

Background: Rising threshold level during monitoring of motor-evoked potentials (MEP) using transcranial electrical stimulation (TES) has been described without damage to the motor pathway in the cranial surgery, suggesting the need for monitoring of affected and unaffected hemisphere. We aimed to determine the factors that lead to a change in threshold level and to establish reliable criteria for adjusting stimulation intensity during surgery for supratentorial lesions. Materials and Methods: Between October 2014 and October 2015, TES-MEP were performed in 143 patients during surgery for unilateral supratentorial lesions in motor-eloquent brain areas. All procedures were performed under general anesthesia using a strict protocol to maintain stable blood pressure. MEP were evaluated bilaterally to assess the percentage increase in threshold level, which was considered significant if it exceeded 20% on the contralateral side beyond the percentage increase on the ipsilateral side. Patients who developed a postoperative motor deficit were excluded. Volume of subdural air was measured on postoperative magnetic resonance imaging. Logistic regression was performed to identify factors associated with the intraoperative recorded changes in threshold level. Results: A total of 123 patients were included in the study. On the affected side, 82 patients (66.7%) showed an increase in threshold level, which ranged from 2% to 48% and 41 patients (33.3%) did not show any change. The difference to the unaffected side was under 20% in all patients. The recorded range of changes in the systolic and mean pressure did not exceed 20 mm Hg in any of the patients. Pneumocephalus was detected on postoperative magnetic resonance imaging scans in 87 patients (70.7%) and 81 of them (93.1%) had an intraoperative increase in threshold level on either sides. Pneumocephalus was the only factor associated with an increase in threshold level on the affected side (P

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Paediatric Patient With Acromegalic Features and Mallampati Class Zero Airway: A Rare Association

No abstract available

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Early Effects of Enteral Urea on Intracranial Pressure in Patients With Acute Brain Injury and Hyponatremia

Background: Hyponatremia occurs commonly after acute brain injury and is often due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Urea administration is 1 therapeutic option. Methods: In our Department, enteral urea is routinely administered to patients with acute brain injury who develop hyponatremia consistent with SIADH and do not respond to an initial sodium load. We reviewed the records of all patients over a 2-year period, who had acute brain injury, received enteral urea because of hyponatremia, and had intracranial pressure (ICP) monitoring using an intraventricular catheter. We recorded demographic, biological, and clinical data; mean ICP values during the 6 hours before and after the first dose of urea were also recorded. Results: We included 40 patients (23 subarachnoid hemorrhage, 8 traumatic brain injury, 6 intracranial hemorrhage, 2 postbrain tumor surgery, and 1 ischemic stroke); median age was 54 years (IQRs, 44 to 63 y) and median admission APACHE II score was 19 (13 to 19); 6-month survival was 63%. Median baseline sodium was 133 mEq/L (131 to 135 mEq/L). No patients received additional therapy to decrease ICP during the 6 hours following urea initiation. After the first urea dose (15 g), ICP decreased from 14 (13 to 18 mm Hg) to 11 mm Hg (8 to 13 mm Hg) (P

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Global and Cerebral Metabolism and Systemic and Cerebral Oxygenation During and After Intraoperative Seizures in a Patient Undergoing Brain Tumor Surgery

No abstract available

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Comparison of Ramosetron and Palonosetron for Preventing Nausea and Vomiting after Spinal Surgery: Association With ABCB1 Polymorphisms

Background: Adenosine triphosphate-binding cassette subfamily B member 1 (ABCB1) polymorphisms may influence 5-hydroxytryptamine receptor antagonist efficacy by altering their efflux transportation. We evaluated the influence of ABCB1 polymorphisms on the efficacy of ramosetron compared with palonosetron in managing postoperative nausea and vomiting (PONV) in patients who received intravenous patient-controlled analgesia after spinal surgery. Methods: Patients were randomly allocated to receive 2 boluses (20 min before the end of surgery and 24 h after surgery) of either ramosetron 0.3 mg (n=150) or palonosetron 0.075 mg (n=146). The incidence and severity of PONV, fentanyl consumption, and pain intensity were serially assessed for postoperative 48 hours. ABCB1 3435C>T and 2677G>T/A polymorphisms were assessed. Results: The incidences of nausea were similar between the 2 groups in patients with the 3435TT (50% vs. 56%, ramosetron and palonosetron group, respectively, P>0.999) or 2677TT (50% vs. 56%, ramosetron and palonosetron group, respectively, P>0.999). Mild PONV were more frequent in the ramosetron group than in the palonosetron group among patients with 3435TT (91% vs. 33%, P=0.034) and 2677TT (92% vs. 20%, P=0.002) genotypes. The intensity of nausea experienced by ramosetron-group TT genotype patients (1 [1 to 2], 3435TT; 1 [1 to 2.5], 2677TT) was lower than that experienced by ramosetron-group non-TT genotype patients (3 [1 to 6], 3435 non-TT, P=0.030; 3 [1 to 6], 2677 non-TT, P=0.038) and palonosetron-group TT genotype patients (6 [2 to 7], 3435TT, P=0.010; 6 [4 to 7], 2677TT, P=0.002). Conclusions: Compared with palonosetron, ramosetron may be superior for reducing PONV severity, especially in patients with ABCB1 3435TT or 2677TT genotype.

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2016 Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Annual Meeting Report

No abstract available

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A Comparison of Regional Versus General Anesthesia for Lumbar Spine Surgery: A Meta-Analysis of Randomized Studies

Background: General anesthesia (GA) is commonly used for lumbar spine surgery. The advantages of regional anesthesia (RA) for lumbar spine surgery, as compared with GA, remain unclear. The aim of this meta-analysis was to determine the impact of the type of anesthesia on intraoperative events, incidence of postoperative complications, and recovery time of patients undergoing lumbar spine surgery. Methods: Major databases (PubMed, EMBASE, Cochrane library, ISI Web of Science, and Google Scholar) were systematically searched for randomized clinical trials comparing regional versus GA for lumbar spine surgery. Study-level characteristics, intraoperative events, and postoperative complications were extracted from the articles. Meta-analysis was performed using random-effect models. Results: Fifteen randomized clinical trials comprising 961 patients were included in this meta-analysis. The use of RA for lumbar spine surgery was significantly associated with lower incidence of postoperative nausea and vomiting at 24 hours (risk ratio [RR]=0.42; 95% confidence interval [CI]=0.23-0.77, P=0.005), as well as lower length of stay (standardized mean difference [SMD]=−0.73; 95% CI=−1.17 to −0.29, P=0.001) and intraoperative blood loss (SMD=−1.24; 95% CI=−2.27 to −0.21, P=0.02). There was no statistically significant association with lower pain score (SMD=−0.47; 95% CI=−2.13 to 1.19, P=0.58), lower incidence of urinary retention (RR=1.16; 95% CI=0.73-1.86, P=0.53) or analgesic requirement (RR=0.87; 95% CI=0.64-1.18, P=0.37). Conclusions: In summary, RA has several advantageous characteristics, including lower incidence of postoperative nausea and vomiting, length of stay, and blood loss. Further well-designed studies with more sample size are needed to clarify the associations with possible neurological complications.

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We’re So Excited … We Just Can’t Hide It!

No abstract available

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Postoperative Delirium in Elderly Patients Undergoing Major Spinal Surgery: Role of Cerebral Oximetry

Background: Perioperative cerebral hypoperfusion/ischemia is a major inciting factor of postoperative delirium, which is coupled with adverse outcome in elderly patients. Cerebral oximetry enables noninvasive assessment of the regional cerebral oxygen saturation (rSO2). This study aimed to investigate whether perioperative rSO2 variations were linked to delirium in elderly patients after spinal surgery. Materials and Methods: Postoperative delirium was assessed for 48 hours postsurgery in 109 patients aged over 60 years without a prior history of cerebrovascular or psychiatric diseases by the Confusion Assessment Method for the intensive care unit and the intensive care delirium screening checklist. The rSO2 values immediately before and throughout surgery were acquired. The preoperative cognitive functions, patient characteristics, and perioperative data were recorded. Results: During the 48-h postoperative period, 9 patients (8%) exhibited delirium. The patients with delirium showed similar perioperative rSO2 values as those without, in terms of the median lowest rSO2 values (55% vs. 56%; P=0.876) and incidence (22%, both) and duration of decline of rSO2

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An Uncommon Cause of Hemorrhagic Stroke: The Marchiafava-Micheli Disease

No abstract available

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Postoperative Analgesia After Wound Infiltration With Tramadol and Dexmedetomidine as an Adjuvant to Ropivacaine for Lumbar Discectomies: A Randomized-controlled Clinical Trial

Introduction: Crippling postoperative pain linked with lumbar discectomies not only shackles patient's normal daily activities but also lengthens their hospital stay. So, allaying postoperative pain in these patients has become a substantive component in neuroanesthesia to expedite neurological recovery. Wound infiltration with local anesthetics is widely used to optimize postoperative pain. Different adjuvants like dexmedetomidine and tramadol when added to local anesthetics prolongs postoperative analgesia. The aim of this trial was to evaluate the analgesic efficacy of tramadol and dexmedetomidine when added to ropivacaine for wound infiltration in lumbar discectomies. Methodology: This study was prospective, randomized, double-blind, controlled in nature conducted among 45 adult patients belonging to American Society of Anesthesiologists' physical status 1 and 2, of either sex aged between 30 and 70 years undergoing elective lumbar discectomies. They were randomly allocated into 3 equal groups: group R received 100 mg of 0.5% ropivacaine (20 mL) and 2 mL normal saline, group RT received 100 mg of 0.5% ropivacaine (20 mL) and 2 mg/kg tramadol (2 mL), and group RD received 100 mg of 0.5% ropivacaine (20 mL) and 0.5 μg/kg dexmedetomidine (2 mL) (total volume, 22 mL). Visual analog scale at 0, 2, 4, 6, 12, 18, and 24 hours; time to first rescue analgesia, total supplemental analgesic consumption and side effects (if any) were assessed during first 24 hours postoperatively. Results: The median time to first rescue analgesia (median; 95% confidence interval [CI]) in group RD was 930 (854.3 to 1005.7) minutes. This was significantly longer (P=0.000) than group RT (420 [366.3 to 473.7] min) or group R (270 [243.2 to 296.8] min). Postoperative diclofenac consumed (median [interquartile range]) was 150 (150 to 200) mg in group R, 150 (75 to 150) mg in group RT and 75 (75 to 150) mg in group RD (P=0.008). Significant differences in mean visual analog scale scores were observed among the 3 groups at hours 0 (P=0.033), 2 (P=0.001), 4 (P=0.000), 6 (P=0.001), and 24 (P=0.013). No statistical significant side effects could be discerned among the groups. Conclusions: We concluded that wound infiltration with combined ropivacaine and dexmedetomidine found to be significantly superior for postoperative analgesia compared with either combined ropivacaine and tramadol or ropivacaine alone for lumbar discectomies.

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