Removal of thyroid remnant for cancer in the previously operated central neck

Publication date: Available online 22 December 2017
Source:Operative Techniques in Otolaryngology-Head and Neck Surgery
Author(s): Vaninder K Dhillon, Ralph P Tufano
Reoperative central neck dissection requires a concise set of steps to complete a comprehensive dissection of recurrent lymphadenopathy seen in thyroid cancer. The main considerations take into account the recurrent laryngeal nerve and the parathyroid glands. This chapter specifies those steps from a preoperative evaluation to the pearls during dissection to ensure a complete reoperative dissection that removes all residual thyroid tissue and lymphadenopathy while ensuring the best outcomes.



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Recurrent laryngeal nerve preservation in thyroid cancer involving the ligament of berry

Publication date: Available online 22 December 2017
Source:Operative Techniques in Otolaryngology-Head and Neck Surgery
Author(s): Nathan W. Hales, Dipti Kamani, GregoryW. Randolph
The ligament of Berry is a dense consolidation of pretracheal vascular fascia or suspensory ligament which anchors the thyroid to the trachea and is located medial and deep to the tubercle of Zuckerkandl. The ligament of Berry is closely related to the distal 2cm of the extralaryngeal course of the recurrent laryngeal nerve and to the superior parathyroid gland. When thyroid cancer is present in the ligament of Berry, proper preoperative imaging, meticulous dissection with extra caution in the area of the ligament of Berry and use of intraoperative nerve monitoring are helpful tools in preservation of recurrent laryngeal nerve. Additionally, when thyroid cancer is preoperatively suspected to involve ligament of Berry, proper preoperative counseling, detailed consent, as well as communication regarding accurate patient expectations are essential.



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A rare cause of neonatal persistent jaundice

Description

A 22-year-old gravida 2, para 1 (G2P1) woman with immunoglobulin anti-D prophylaxis, insulin-treated gestational diabetes and first-trimester cytomegalovirus (CMV) infection vaginally delivered a 39-week boy weighing 3720 g (90th centile) and with Apgar scores of 8 and 10 at 1 and 5 min. Prenatal ultrasonographic assessment throughout gestation was normal. Nursery stay was uneventful. He was discharged on day 2, with a normal examination, except for the appearance of jaundice, with a transcutaneous bilirubin of 248 µmol/L (cut-off 250 µmol/L), not meeting the criteria for phototherapy. A follow-up clinic on day 4, arranged for bilirubin measurement and CMV testing, surprisingly revealed poor general appearance, lethargy, very icteric skin and a minor weight loss (9% of birth weight). Both liver and splenic edges were palpable. Vital signs were normal. Blood routine showed haemoglobin of 19 g/dL, haematocrit of 58%, white blood cells 11.6x10⁹/L and platelet count 128x10⁹/L. Biochemistry revealed total serum bilirubin...

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Maxillary chondrosarcoma mimicking torus palatinus

Description 

An 88-year-old man was referred to the head and neck surgery clinic for investigation of a painless hard palate lesion. The mass had been present for several months and was identified incidentally by the general practitioner. There were no oral or sinonasal symptoms. On examination, a 3x2 cm hard palatal swelling, covered by normal mucosa and resembling a torus palatinus was identified (figure 1). Flexible nasal endoscopy revealed the tumour to involve the floor of the nasal cavity bilaterally, displacing the inferior nasal turbinates. Examination of the neck was normal.

Figure 1

Midline palatal swelling covered by mucosa.

A biopsy was taken, and histological analysis described a welldifferentiated cartilaginous lesion consistent with a grade 1 chondrosarcoma. A CT scan was performed (figure 2). The regional head and neck and regional sarcoma multidisciplinary team meetings recommended surgical management. The patient underwent...

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Intractable hyperemesis gravidarum in a patient with type 1 diabetes

Hyperemesis gravidarum is not uncommon. Its pathogenies is multifactorial but not fully understood. We present a case of a middle class, Caucasian pregnant woman aged 24 years with coexisting type 1 diabetes, who had severe hyperemesis gravidarum from the sixth week of pregnancy and was resistant to all standard and off-the-label treatments raising questions about the pathogenesis of hyperemesis gravidarum. She was managed with a multidisciplinary approach and was supported with total parenteral nutrition till she had an emergency caesarean section in the 29th week of pregnancy. Her vomiting stopped as soon as a small for gestational age but otherwise healthy male baby was delivered.

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Intradural lumbar disc herniation detected by 3D CISS MRI

A 73-year-old man who presented with right lumbosciatic pain underwent a neurosurgical operation for a voluminous L2–L3 disc herniation, seen on conventional MRI images. No disc herniation was identified in the epidural space during the surgery. Just after the operation, the patient started to present pain in the left L3 territory and was not able to walk any more. A second MRI including three-dimensional (3D) high-resolution constructive interference in steady state (CISS) sequence showed that the voluminous L2–L3 disc split the posterior longitudinal ligament and the anterior dura mater, extended intradurally and compressed the cauda equina to the right. The patient underwent a second surgery, which permitted to cure the symptoms. 3D high-resolution CISS should be considered to accurately depict intradural disc herniation in order to optimally guide the surgical approach.

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Shah-Waardenburg syndrome: a case highlighting the importance of a holistic approach to assessing a child

We present the case of a 45-day-old child with the chief complaint of failure to pass stools for 10 days. After initial investigation, the patient was found to have Hirschsprung's disease. However, with further examination and analysis, the extremely rare diagnosis of type 4 Waardenburg syndrome was made (also known as Shah-Waardenburg syndrome or Waardenburg-Hirschsprung's disease).

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Solid pseudopapillary tumour (Frantzs tumour) of the pancreas in childhood: successful management of late liver metastases with sunitinib and chemoembolisation

The patient is a girl aged 17 years who originally presented at age 11 years with a solid pseudopapillary tumour (SPT) in the head of the pancreas treated by an R0 pylorus-preserving Whipple procedure. The patient underwent surveillance CT every 3 months for the first year followed by MRI every 6 months. She was noted to have a new liver lesion in Couinaud segment VI highly suspicious for metastasis at 30 months. Liver wedge biopsy confirmed metastatic SPT. Two months later two new lesions were noted in Couinaud segment VII. The family preferred medical management to surgery resulting in a treatment combination of the tyrosine kinase inhibitor sunitinib and hepatic artery embolisation. The patient developed a hepatic abscess following embolisation but recovered with antibiotics. The patient has subsequently been followed with serial MRIs every 3 months, and 20 months following chemoembolisation, she has no evidence of recurrence of the metastases.

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Unusual case of anxiety: trichloroethylene neurotoxicity

I present an uncommon case of recurrent, intractable anxiety that was presented acutely and slowly evolved into a chronic debilitating condition. A young previously fit and healthy 24-year-old patient presents with somewhat atypical symptoms of anxiety. Full medical work-up including examination, blood, ECG electrocardiogram, electroencephalogram and CT of the head was unremarkable. When the history was explored in detail, it was revealed he worked in the navy and was exposed to a neurotoxic solvent, trichloroethylene. This case highlights the importance of eliciting a detailed occupational history, particularly paying attention to patient demographics such as occupation and presenting symptoms that do not readily fit into diagnostic criteria.

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Cutaneous infection with paucibacillary Mycobacterium tuberculosis treated successfully with a modified antituberculous drug regimen

Tuberculosis is a serious infection that is increasing in prevalence, affecting many people worldwide. The diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with often inconclusive diagnostic testing. Extrapulmonary tuberculosis comprises approximately 10% of all cases of tuberculosis, and cutaneous tuberculosis makes up only a small proportion of these cases. Discussed here is the case of a 61-year-old immunocompetent female with a large cutaneous lesion on her index finger secondary to Mycobacterium tuberculosis. Tissue cultures taken at biopsy were negative; however, empiric antimycobacterial therapy was initiated. The initial regimen was not tolerated, and antituberculous therapy was substituted for moxifloxacin and clarithromycin. The lesion improved significantly with a concurrent improvement in function.

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Short-course high-dose ibuprofen causing both early and delayed jejunal perforations in a non-smoking man

Description

A 48-year-old non-smoking man underwent laparotomy for peritonitis immediately after taking ibuprofen 800 mg 6 hourly for 14 days for back pain. His only other medication was long-term omeprazole 20 mg per day. At operation he had three separate perforations in his proximal jejunum. Fifteen centimetres of jejunum were resected with primary anastomosis. Histology showed focal mucosal ischaemic changes with normal mucosa between. There was no vasculitis. The perforations were attributed to ibuprofen intake. He made an uneventful recovery and was instructed to refrain from non-steroidal anti-inflammatory drug (NSAID) intake.

He was readmitted 5 months later with abdominal pain. He had continued omeprazole but had taken no further NSAID. CT showed extensive free intra-abdominal fluid with free gas adjacent to his proximal jejunum (figure 1), indicating a further perforation. This was confirmed at laparotomy when a 5 mm perforated ulcer was found in his proximal jejunum (figure...

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Oyster-related tenosynovitis: a rare case of Mycobacterium szulgai in the immunocompromised

A 66-year-old man with a history of renal transplant on chronic immunosuppression presented to his primary care physician with a swollen right index finger. On examination, mild swelling was present. Conservative management failed and initial plain films were negative. Corticosteroid injection was performed by orthopaedics, but symptoms recurred several months later and an MRI showed flexor digitorum tenosynovitis and abscesses of the superficialis and profundus tendons. A flexor tenolysis was performed with cultures positive for Mycobacterium szulgai, a rare, non-tuberculous mycobacterial infection. Treatment was initiated with moxifloxacin, ethambutol and azithromycin daily for nearly 4 months. Repeat MRI 3 months after completion of antibiotics showed near resolution of the tenosynovitis.

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HHV-8-associated haemophagocytic lymphohistiocytosis in a patient with advanced AIDS

We present a patient with advanced AIDS admitted with recurrent shock of unclear aetiology, fevers, altered mental status and refractory cytopenias. His case posed a diagnostic challenge because evaluation of septic shock in the setting of advanced AIDS requires a time-consuming work-up for broad infectious aetiologies that can delay consideration of other diagnoses, including primary or secondary haemophagocytic lymphohistiocytosis (HLH). After this patient did not improve with supportive care and empiric antimicrobials, there was concern for HLH given that he met ≥5 of the HLH consortium criteria. He underwent bone marrow biopsy, which was non-diagnostic. Empiric therapy for HLH was initiated, but unfortunately, the patient died. Autopsy revealed extensive haemophagocytosis in the spleen, bone marrow and liver, confirming the diagnosis of HLH. Postmortem, his soluble CD-25 returned 18 890 pg/mL (<1033 pg/mL), and his serum HHV-8 PCR resulted positive. The diagnosis was HLH secondary to Human Herpes Virus 8 (HHV-8) in a patient with advanced AIDS.

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Chickenpox: an ageless disease

A 97-year-old woman presented with 4-day history of vesicular rash, initially at the feet but then spread up to the thighs bilaterally, abdomen and trunk. The initial differentials included bullous pemphigus and cellulitis by the emergency department. She was then managed as bullous pemphigus by the acute medical team and started on high-dose steroids, with no other differentials considered. When her care was taken over by the general medical team, varicella zoster virus (VZV) infection was suspected. After confirmation by the dermatology team regarding the clinical diagnosis and the positive VZV DNA swabs, she was started on acyclovir.

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Osteoid bezoar: a rare case causing small bowel obstruction

Acute intestinal obstruction due to foreign bodies or bezoar is a rare occurrence in an adult. We report an unusual case of a 27-year-old male patient with no previous history of abdominal surgery or other medical disease, who presented with an acute episode of intestinal obstruction due to ingestion of a bone piece which was managed surgically by enterotomy, and the patient had an uneventful postoperative course. He was advised regular follow-up once in 2 weeks initially and once a month subsequently. He had no problems at the end of 6 months.

http://ift.tt/2BoTGcU

Syndrome of X linked intellectual disability, epilepsy, progressive brain atrophy and large head associated with SLC9A6 mutation

SLC9A6 gene encodes for a sodium/hydrogen exchanger-6 protein mainly involved in endosomal trafficking and maintaining intraluminal pH. Loss of function mutations in SLC9A6 gene in children has been associated with Christianson syndrome and autism spectrum disorder. We describe a 3-year-old boy with intellectual disability, infantile-onset drug-refractory epilepsy, progressive brain atrophy and large head with a novel missense hemizygous mutation in exon 16 of the SLC9A6 gene on chromosome X. Presence of large head, early developmental regression and progressive cerebral atrophy expand the phenotypic spectrum of SLC9A6 mutations. Our case also highlights the importance of genetic testing in children with unexplained intellectual disability, epilepsy and neurodevelopmental impairments.

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Idiopathic bilateral hypertrophic olivary degeneration

Description

A 55-year-old man presented with involuntary movements of the tongue and soft palate associated with unsteadiness in walking for a period of 3 months. The patient did not complain of ear clicking. Examination revealed palatal myoclonus, tongue fasciculation and ataxic gait. MRI of the brain showed increased T2 and Fluid Attenuation Inversion recovery (FLAIR) signal intensities in the bilateral inferior olivary complex without diffusion restriction (figure 1). Midbrain, pons, and cerebral and cerebellar parenchyma were normal (figure 2). Imaging features were consistent with bilateral hypertrophic olivary degeneration. Hypertrophic olivary degeneration is a unique type of trans-synaptic neuronal degeneration caused by damage to the dentatorubral pathway or the triangle of Guillain and Mollaret (figure 3). Focal lesions like infarction, haemorrhage, demyelination  and trauma involving this neuronal pathway lead to interruption, and following sequential pathological changes are described (table 1).1

Figure 1

Coronal T2 (A), axial T2 (B),...

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Contemporary non-surgical approach for faecal diversion in a case of Fourniers gangrene

Fournier's gangrene is a fatal necrotising fasciitis of the perineum, genitals and lower abdomen. Patients often need an aggressive surgical debridement, and in few cases, a diverting colostomy. We report the case of a 70-year-old man with multiple comorbidities diagnosed with Fournier's gangrene, who underwent debridement and had a wound complication due to faecal contamination. A novel, self-retaining rectal device was used to perform faecal diversion, which subsequently showed wound healing within a week, hence avoiding the need of a colostomy.

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Variant of Lemierres syndrome with internal jugular vein aneurysm

Internal jugular vein (IJV) aneurysm is a rare entity, and a thrombosed aneurysm poses diagnostic and management challenges. We came across a 53-year-old woman who presented with fever, vomiting and right neck swelling for a week. Laboratory investigations showed neutrophilic leucocytosis, raised acute phase reactant and blood culture yielded Klebsiella pneumoniae. Ultrasound and contrast-enhanced CT neck revealed a large fusiform aneurysm of the right IJV with filling defect extending from the aneurysm into the right transverse sinus. There was a cavity at the right lower third molar tooth. MRI confirmed the findings with additional enhancing focus at right lower periodontal region. The swelling reduced after 2 weeks of medical therapy, and follow-up imaging 4 months later showed complete resolution of the aneurysm with residual thrombosis. After extensive workup, dental infection remains the only identifiable primary source leading to thrombophlebitis of the right IJV and subsequent sequelae.

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Correction: Gangrenous digital infarcts in a severe case of cutaneous polyarteritis nodosa

The correct order of authors is as follows:

Hamzah Mahmood-Rao, Nirav Gandhi, Tina Ding

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Double hit! A unique case of resistant hypertension

A middle-aged woman with obesity, hyperlipidaemia and diet-controlled diabetes was referred for resistant hypertension. Her blood pressure (BP) was uncontrolled on five medications, including a diuretic. Physical exam revealed a systolic ejection murmur, and ECHO demonstrated moderate hypertrophy. Laboratory examination revealed elevated aldosterone level (20.7 ng/dL) and elevated aldosterone:renin ratio (41.4 (ng/dL)/(ng/mL/h)), meeting criteria for primary aldosteronism (PA), and confirmed by saline infusion testing. CT scan of the adrenals was non-localising. Adrenal venous sampling confirmed bilateral idiopathic adrenal hyperplasia. Concurrent primary hyperparathyroidism was demonstrated by elevated calcium and parathyroid hormone levels and localised by sestamibi scan. Idiopathic adrenal hyperplasia was treated medically with spironolactone. Her BP remained elevated until postparathyroidectomy. Evidence shows that a hyperfunctioning parathyroid gland may contribute to maintaining hyperaldosteronism in PA making this bidirectional link unique. The significance of this case is in the potential for further understanding of the pathophysiology of common causes of secondary hypertension.

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Epstein–Barr virus exanthem in an adult patient with myelodysplastic syndrome

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Ischaemic ulcers on the toes secondary to Raynaud phenomenon in a patient with systemic sclerosis successfully treated with botulinum toxin

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Folliculotropism in pigmented facial macules: Differential diagnosis with Reflectance confocal microscopy

Abstract

Pigmented facial macules are common on sun damage skin. The diagnosis of early stage lentigo maligna (LM) and lentigo maligna melanoma (LMM) is challenging. Reflectance confocal microscopy (RCM) has been proven to increase diagnostic accuracy of facial lesions.

A total 154 pigmented facial macules, retrospectively collected, were evaluate for the presence of already described RCM features and new parameters depicting aspects of the follicle .

Melanocytic nests, roundish pagetoid cells, follicular infiltration, bulgings from the follicles and many bright dendrites, and infiltration of the hair follicle (i.e. folliculotropism) were found to be indicative of LM/LMM compared to non-melanocytic skin neoplasms, with an overall sensitivity of 96% and specificity of 83%. Concerning non-melanocytic skin neoplasms, solar lentigo and lichen planus-like keratosis resulted better distinguishable from LM/LMM because usually lacking malignant features and presenting characteristic diagnostic parameters, such as cepidermal cobblestone pattern and polycyclic papillary contours. On the other hand, distinction of pigmented actinic keratosis (PAK) resulted more difficult, and needing evaluation of hair follicle infiltration and bulging structures, due to the frequent observation of few bright dendrites in the epidermis, but predominantly not infiltrating the hair follicle (estimated specificity for PAK 53%). .

A detailed evaluation of the components of the folliculotropism may help to improve the diagnostic accuracy. The classification of the type, distribution and amount of cells, and the presence of bulging around the follicles seem to represent important tools for the differentiation between PAK and LM/LMM at RCM analysis.

This article is protected by copyright. All rights reserved.

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Reply to: “An exploratory study using framework analysis to investigate health-seeking behaviour in patients with psoriasis”

Abstract

We recently read with interest "An exploratory study using framework analysis to investigate health-seeking behaviour in patients with psoriasis" by Simpson et al. This interview based-study added to the understanding of obstacles patients face when seeking psoriasis treatment. Given the recent advances in effective systemic treatment options for psoriasis, we were similarly interested in exploring the discordance between available therapies and patient satisfaction and outcomes using a survey in a larger series of patients.

This article is protected by copyright. All rights reserved.

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Novel POFUT1 mutation associated with hidradenitis suppurativa-Dowling Degos Disease firm up a role for Notch signalling in the pathogenesis of this disorder: reply from authors

Abstract

We thank González-Villanueva et al. for their comments and commend them for their intriguing results. They report on a single patient with clinical and histopathological evidence for Dowling-Degos disease. In addition, the patient developed hidradenitis suppurativa. The patient was found to carry a mutation in POFUT1, a gene previously known to be associated with Dowling-Degos disease.

This article is protected by copyright. All rights reserved.

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Illuminating the covert mission of mononuclear phagocytes in their regional niches

Shu Zhen Chong | Maximilien Evrard | Chi Ching Goh | Lai Guan Ng

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Evaluation of mapping biopsies for extramammary Paget’s disease: a retrospective study

Extramammary Paget's disease (EMPD) sometimes shows an ill-defined border and an unexpectedly extended tumor spread beyond the clinical borders. Mapping biopsy is one approach for complete surgical removal, but its efficacy has remained controversial.

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Fractional ablative carbon-dioxide laser treatment improves histological and clinical aspects of striae gravidarum: a prospective open label paired study

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A real-world, community-based cohort study comparing the effectiveness of topical fluoruracil vs. topical imiquimod for the treatment of actinic keratosis

The most widely used topical agents for the field-based treatment of multiple actinic keratoses (AKs) are 5-fluorouracil and imiquimod, but their comparative effectiveness has not been assessed in a real-world setting.

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Effects of curettage after shave biopsy of unexpected melanoma: A retrospective review

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A simple method to facilitate fat removal from full-thickness skin grafts

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Three-dimensional growth pattern of the rat mandible revealed by periodic live micro-computed tomography

Publication date: March 2018
Source:Archives of Oral Biology, Volume 87
Author(s): Hak-Jin Kim, Kyeong-Mee Park, Hye-Jin Tak, Ji Wook Choi, Sang-Hoon Kang, Wonse Park, Sang-Hwy Lee
ObjectiveWe wanted to evaluate the three-dimensional (3D) mandibular growth of Sprague-Dawley rats from 4th to 16th postnatal weeks with periodic and live micro-computed tomographic scanning.DesignTwenty Sprague-Dawley rats were used for micro-CT scanning from 4th to 16th postnatal weeks. After 3D reconstruction of rat mandible, we performed the linear and angular measurements and the superimposition of the 3D models to evaluate the mandibular growth of rat.ResultsThe results showed that the growth direction of the condylar and coronoid regions was superior primarily and posterior secondarily, while the condyle had minimal lateral growth. Moreover, the angular region was growing mainly toward the posterior and lateral direction, while the body and symphysis maintained small, incremental anterior-posterior growth.ConclusionsWe could evaluate the amount, rate, and direction of growth using the mandibular skeletal unit. Some reference points and measurements were more relevant in properly characterizing 3D growth of the mandible. Their growth rates were the greatest between 4th and 8th postnatal weeks, a period which seems most appropriate for studies of rat mandible growth.



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Mechanical stiffness of TMJ condylar cartilage increases after artificial aging by ribose

Publication date: March 2018
Source:Archives of Oral Biology, Volume 87
Author(s): Fereshteh Mirahmadi, Jan Harm Koolstra, Frank Lobbezoo, G.Harry van Lenthe, Samaneh Ghazanfari, Jessica Snabel, Reinout Stoop, Vincent Everts
ObjectiveAging is accompanied by a series of changes in mature tissues that influence their properties and functions. Collagen, as one of the main extracellular components of cartilage, becomes highly crosslinked during aging. In this study, the aim was to examine whether a correlation exists between collagen crosslinking induced by artificial aging and mechanical properties of the temporomandibular joint (TMJ) condyle. To evaluate this hypothesis, collagen crosslinks were induced using ribose incubation.MethodsPorcine TMJ condyles were incubated for 7 days with different concentrations of ribose. The compressive modulus and stiffness ratio (incubated versus control) was determined after loading. Glycosaminoglycan and collagen content, and the number of crosslinks were analyzed. Tissue structure was visualized by microscopy using different staining methods.ResultsConcomitant with an increasing concentration of ribose, an increase of collagen crosslinks was found. The number of crosslinks increased almost 50 fold after incubation with the highest concentration of ribose. Simultaneously, the stiffness ratio of the samples showed a significant increase after incubation with the ribose. Pearson correlation analyses showed a significant positive correlation between the overall stiffness ratio and the crosslink level; the higher the number of crosslinks the higher the stiffness.ConclusionThe present model, in which ribose was used to mimic certain aspects of age-related changes, can be employed as an in vitro model to study age-related mechanical changes in the TMJ condyle.



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Diagnostic X-Ray Exposure and Thyroid Cancer Risk: Systematic Review and Meta-Analysis

Thyroid , Vol. 0, No. 0.


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Clinical Thyroidology for the Public – Highlighted Article

From Clinical Thyroidology for the Public: Prematurity is one of the most important causes of death in newborns and babies. Research has shown that both hyperthyroidism and hypothyroidism are associated with poor outcomes for the mother and the developing newborn, including premature delivery. Read More….

We welcome your feedback and suggestions. Let us know what you want to see in this publication.

Feedback & Suggestions

The post Clinical Thyroidology for the Public – Highlighted Article appeared first on American Thyroid Association.

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Breast metastasis from squamous cell carcinoma of the oropharynx: a case report

Breast metastases from extramammary tumors are extremely rare, the most common primary tumors being contralateral breast carcinoma, followed by lung, gynecological, gastrointestinal, melanoma, and hematologica...

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Pharmacological management of delusional infestation

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Rare presentation of heterotopic ossification along a fibula free flap pedicle in a high-volume microvascular reconstruction practice

Abstract

Background

Heterotopic ossification along free flap pedicles has been reported. Reports suggest that subperiosteal dissection of the pedicle from the bone during the harvest of the fibula free flap may predispose the pedicle to heterotopic ossification.

Methods

A 56-year-old man with history of a T2N1M0 squamous cell cancer of the left tonsil who was treated with chemoradiation developed osteoradionecrosis of the mandible requiring fibula free flap reconstruction. The patient presented with a firm submandibular mass 1 year after reconstruction.

Results

Imaging revealed bone along the mandible projecting to the floor of the mouth. Surgery revealed heterotopic bone along the submandibular triangle and vascular pedicle. The bone was removed and the periosteum fulgurated to prevent further proliferation.

Conclusion

Our practice includes a high-volume head and neck extirpative and reconstruction practice. To the best of our knowledge, this represents the first documented case of heterotopic ossification along a free flap pedicle despite routine subperiosteal elevation to free the peroneal artery from the proximal fibula.

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Carbon dioxide embolism during transoral robotic thyroidectomy: A case report

Abstract

Background

Carbon dioxide (CO₂) embolism is a serious, although rare, complication of remote access thyroidectomy using CO₂ insufflation. Recently, we encountered a case of CO₂ embolism during transoral thyroidectomy, and present it here with a review of the literature.

Methods and Results

A 59-year-old female patient with papillary thyroid carcinoma underwent transoral robotic thyroidectomy with CO₂ insufflation. During skin flap elevation, the anterior jugular vein was lacerated. Simultaneously, an electrocardiogram (ECG) showed bradycardia with premature atrial complexes, followed by asystole. After 2 cycles of cardiopulmonary resuscitation with an injection of 1-mg epinephrine, spontaneous circulation returned, and sinus tachycardia with ST segment elevation was noted in ECGs. The patient's vital signs returned to normal within 30 minutes, and normal sinus rhythm was observed. She was discharged on postoperative day 7, without neurologic and cardiac deficit.

Conclusion

The possibility of CO₂ embolism during transoral thyroidectomy with CO₂ insufflation should not be overlooked.

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Androgen deprivation therapy for androgen receptor-positive advanced salivary duct carcinoma: A nationwide case series of 35 patients in The Netherlands

Abstract

Background

Salivary duct carcinoma, an aggressive subtype of salivary gland cancer, is mostly androgen receptor-positive. Only limited data are available on androgen deprivation therapy (ADT).

Methods

Patients with advanced androgen receptor-positive salivary duct carcinoma treated with first-line ADT were retrospectively evaluated for clinical benefit (ie, partial response [PR] and stable disease, progression-free survival [PFS] and overall survival [OS]). The OS was compared with patients with advanced salivary duct carcinoma who received best supportive care.

Results

Thirty-four of 35 patients who were ADT-treated were evaluable: 6 patients had a PR (18%) and 11 had stable disease (32%) leading to a clinical benefit ratio of 50%. The median PFS for the ADT-treated patients was 4 months and the median duration of clinical benefit was 11 months. The median OS was 17 months versus 5 months in 43 patients receiving best supportive care (P = .02).

Conclusion

We recommend ADT in advanced androgen receptor-positive salivary duct carcinoma given its response and clinical benefit. © 2017 Wiley Periodicals, Inc. Head Neck, 2017

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Prognostic value of tumor volume in patients with head and neck squamous cell carcinoma treated with primary surgery

Abstract

Background

Tumor volume in head and neck squamous cell carcinoma (HNSCC) was mainly measured in nonsurgically treated patients. We analyzed the influence of tumor volume on complete response (CR), overall survival (OS), and clear surgical margins also in primarily surgically treated patients.

Methods

In contrast-enhanced CTs, the tumor volumes of patients with incident HNSCC were measured.

Results

The tumor volumes of 259 patients were measured, of which 125 patients (48%) underwent primary surgery and 102 patients (84%) had clear margins. The tumor volume was not an independent factor for CR at the primary tumor site. Risk of death increased by 1.4% per mL of tumor volume (95% confidence interval [CI] 0.8%-2.0%; P < .001). The OS was better in patients treated with primary surgery, if the tumor volume was ≤12 mL (P < .001). Risk of involved margins increased by 4.5% per mL of tumor volume (95% CI 0.9%-8.3%; P = .003). The predicted probability of clear margins was ≥80% in tumor volumes ≤ 16 mL.

Conclusion

The tumor volume had an impact on CR, OS, and clear margins. The tumor volume may also aid in selecting HNSCC treatment.

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Different Radiation Dose of Neoadjuvant Chemoradiation for Resectable Thoracic Esophageal Squamous Carcinoma

Conditions:   Esophageal Carcinoma;   Neoadjuvant Chemoradiation;   Surgery
Interventions:   Radiation: Higher dose (50.4Gy/28F) of neoadjuvant chemoradiation;   Radiation: Lower dose (41.4Gy/23F) of neoadjuvant chemoradiation
Sponsor:   Zhejiang Cancer Hospital
Not yet recruiting

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Identical COL71A1 heterozygous mutations resulting in different dystrophic epidermolysis bullosa phenotypes

Abstract

Dystrophic epidermolysis bullosa is a rare blistering condition caused by mutations in the COL7A1 gene. Different clinical variants have been described, with dominant and recessive inheritance, but no consistent findings have been elucidated to establish a genotype–phenotype correlation. We present three unrelated patients with two identical pathogenic compound heterozygous mutations in the COL7A1 gene that developed different clinical forms of dystrophic epidermolysis bullosa—epidermolysis bullosa pruriginosa and mild recessive non-Hallopeau–Siemens—raising the possibility of other genetic or environmental modifying factors responsible for the phenotype of the disease.

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Ethnic rhinoplasty

Abstract

Rhinoplasty is one of the main facial plastic procedures performed worldwide. Ethnic patients today are mainly mixed-race patients. Diagnosis is based on anatomical findings and surgery should be planned based on patients' needs and what they define as beautiful. Different surgical techniques are presented where a structural approach to rhinoplasty is explained. Very little tissue is resected and support structures of the nose are strengthened with sutures and grafts. A gradual approach to the nasal tip is also presented progressing from simple predictable techniques to more complex unpredictable ones. The final result should be noses with greater definition and refinement that are harmonious and blend in with patients' faces.

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The Crosscourt Draf IIb Procedure for Advanced, Refractory Frontal Sinus, and Nasal Septum Pathology

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Dermoscopic features of pseudoxanthoma elasticum

Summary

Pseudoxanthoma elasticum (PXE) is a disease characterized by aberrant mineralization of soft tissue and fragmentation of elastic fibres. It is often difficult to distinguish PXE clinically from pseudoxanthoma elasticum-like papillary dermal elastolysis (PXE-like PDE). However, we have identified that the dermoscopic findings in PXE include coalescing and reticulated yellow-white clods on a light purple-red background, whereas the dermoscopic findings in PXE-like PDE lack such a coloured background. To our knowledge, this is the first detailed description of dermoscopic differences between PXE and PXE-like PDE.

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Mucinous adenocarcinoma in association with hidradenitis suppurativa: a new example of isoscartopic response

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Unilateral improvement of nail psoriasis with denervation injury

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A large force of health system- the medical students: have they been utilized adequately?

BMJ Elective: A new experience leading a newer perspective….The Patient-centered learning.

By Vivek Podder

Currently, undergraduate medical education is largely limited to the lectures or textbooks based teaching-learning approach rather than a patient-centered learning in various parts of the world. Lack of formal training for students in medical school as well as lack of future incentives and motivation are not enabling a graduate doctor with necessary basic skills for critical appraisal of available evidence to make best clinical decision in their practice. [1] We may need to revisit the aspects of traditional medical education system that need to be optimized in order to build different mechanisms that can help student critically think, provide a patient-centered learning experience, equip with a platform where medical student can improve knowledge through conversational learning- a process keeps one involved, the facts learned to stay longer than those learned directly from the book, basic mandatory skills for critical appraisal of new evidence and by closely working with patients one can learn to build better doctor-patient relationship and thus build confidence in clinical decision through proper clinical reasoning and better clinical problem solving. I am sharing my experience of a BMJ Elective program wherein I have experienced medical education in a different way.

BMJ Elective Experience: (Pros and Cons)

 Pros:

BMJ elective was one of the best experience I went through which transformed my thinking from traditional medical learning system to a new blended offline-online learning system offered through BMJ Case reports under the supervision of Professor Rakesh Biswas (editorial board member, BMJ Case reports).

It was a patient-centered learning experience where through face-face interactions with the patients in the ward, ICU, SICU, HDU and outpatient department, I was collecting data (bedside clinical evaluation as well as imaging and labs) followed by sharing the de-identified raw data to web-based medical record (blog after taking consent), processing the clinical data through an online discussion in various web-based network of medical professionals providing clinical output (patients management) to our primary beneficiaries of medical education-the patients, chiefly by the supervising doctor to tailor them to match available resources where I can experience and reflect upon the consequences and causation of health disadvantage and share them with our team in the form of written text in our online forum. We were using three online platforms- WhatsApp, Tabula rasa (Facebook) and Email wherein doctors from various disciplines like internal medicine, cardiology, endocrinology, pulmonology, critical care medicine, orthopedics, oncology, hematology, radiology, pathology, microbiology, pharmacology, epidemiology etc. were involved in the discussion providing their collective patient-centered feedback through asynchronous communication. Often I needed to visit microbiology, pathology labs, radiology departments and cath labs to discuss patients' laboratory findings with faculty doctors. I also used to make home visit for the patients previously admitted or came to our OPD and was evaluating their history and clinical progress while guiding them in various home procedures they were advised to e.g. medicine compliance, blood glucose monitoring, diet plan, temperature record in graphs (which would tell the pattern of fever) etc., and educating them about their diseases and updating their case records so that any further management plan can be applied after further discussion.

I was formatively assessed as well as supervised through our online community where all our cases are discussed regularly (and an online learning-portfolio for the student can be made from the learning interactions). I was encouraged to critically appraise the literatures using CASP check-list from PubMed [2], share searches on the recent evidences from UpToDate as well as reflections, and thoughts on each case with a larger community so that my inputs can actually benefit the patient in terms of generating interest and quality care from all those involved with the patient (offline and online). During this elective, I had involved 50-60 medical students from the same institution to go through the same experience and with involvement of all the stakeholders the patient was getting integrated evidence-based management and much better care even at a low resource setting which also allowed students to develop confidence in clinical decision-making process especially with the joy of knowing that their management strategy can be used effectively in an actual setting. The primary objective for which I had started this elective was initially to make case reports for BMJ and through this excellent learning experience I did make one case report which is under review and three case reports are in the pipeline for submission to BMJ Case Reports. Another global case report which I am working on to raise an issue of unnecessary coronary interventions across the globe.

Cons:

In spite of many learning opportunities it gives, lack of like-minded academic peer groups during the rotation, lack of academic credit (that makes it difficult to get medical school permission), overwhelming tasks (partly due to lack of more elective students), can be improved for optimization of this elective experience.

While the shortage of doctors is of prime concern in a health system, a large force of health system, the medical students have not been utilized better in patient care in a more patient-centered way. If the way I have been involved in the patient-centered learning can also be done by all the medical students then how greatly patient care could be improved and during the process medical student could become much more confident and skillful in critical appraisal of literature, clinical problem solving, and a better empathetic doctor.

A system I expect where the mental presence will be given priority over the physical presence. 

 

1. Kaustav Bera, Bhavna Seth, Rakesh Biswas. Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Ann Neurosci. 2013; 20(2): 37–38.

2. http://casp-uk.net/

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A squamous odontogenic tumor following an orthodontic micro-screw: A rare case report and review of the literature

Publication date: February 2018
Source:Oral Oncology, Volume 77
Author(s): Jingqiu Tu, Ping Yin, Yunyi Yuan, Jie Chen, Yongxiang Yuan, Yonghua Lei
We reported a very rare case of squamous odontogenic tumor(SOT) in a 23-year-old female. The tumor arose after an implanting operation of an orthodontic micro-screw, and was definitely diagnosed by the histopathological examination. Based on the case report and a review of the literature, we discussed about the general features, differential diagnosis and pathogenesis of SOT.



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