Abstract
Meta-analyses have reported a 2–3 fold increased risk of venous thrombosis (VT) in individuals with hyperhomocysteinemia, however, confounding factors were generally not considered. In contrast, randomized trials of homocysteine-lowering therapy and VT risk were negative. We investigated if hyperhomocysteinemia is associated with VT in the MEGA case-control study (1999–2004) from the Netherlands (1,689 cases and 1,726 controls), taking into account measured and unmeasured confounders. We compared patients with population controls to estimate odds ratios (OR) by unconditional logistic regression and adjusted for various potential confounders. We matched patients to their partners to additionally adjust for unmeasured confounders (e.g., lifestyle factors) using conditional logistic regression. We found that elevated homocysteine concentrations were not associated with an increased risk for VT when comparing patients to population controls, neither as a continuous variable (OR = 1.00, 95% CI:0.99, 1.01), or in terms of 0.7 mg/L increase (OR = 0.99, 95% CI: 0.93, 1.05), or within different homocysteine categories. We obtained similar results when patients were compared with their partners. Stratification by sex, deep vein thrombosis, pulmonary embolism, provoked and unprovoked VT also provided no evidence of an association. In conclusion, after extensive adjustments for confounding, hyperhomocysteinemia was not associated with an increased risk of venous thrombosis in this study.Πέμπτη 11 Ιανουαρίου 2018
The Great Recession and the Health of Young Children: A Fixed Effects Analysis in Ireland
Abstract
Economic recessions have been linked to adult health, but few studies have examined how recessions influence the health of young children. This study examines the impact of life transitions linked to the financial crisis in Ireland on the health of young children. Data came from the Growing Up in Ireland Infant Cohort Study (n = 11,134), which assessed children before (2008), during (2011), and after (2013) the recession and incorporated questions on the impacts of the financial crisis on families. Using fixed effects models to control for confounding, we found that a reduction in welfare benefits during the recession was associated with a significant increase in the risk of asthma (β = 0.0136, 95% confidence interval (95% CI): 0.0062, 0.0328) and atopy (β = 0.0161, 95% CI: 0.0026, 0.0297). While parental job loss was not associated with child health, a reduction in working hours was associated with increased reports of fair or poor child health (β = 0.0235, 95% CI: 0.0041, 0.0429), as were difficulties affording basics (β = 0.0193, 95% CI: 0.0005, 0.0381). Results suggest that failing to protect vulnerable families and children during economic recessions may have long-lasting implications for child health.Deployment and Preterm Birth Among United States Army Soldiers
Abstract
With increasing integration of women into combat roles in the United States military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined if deployment increases the risk of preterm birth; no studies have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all United States Army soldiers with deliveries between 2011–2014 to estimate the associations between prior deployment, recency of deployment, posttraumatic stress disorder and spontaneous preterm birth, adjusting for socio-demographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were spontaneous preterm births. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with spontaneous preterm birth (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder were significantly associated with spontaneous preterm birth. Within this cohort, timing of pregnancy in relation to deployment is identified as a novel risk factor. Increased focus on servicewomen's pregnancy timing and pre-deployment access to reproductive counseling and effective contraception is warranted.Supplementing dietary rosemary ( Rosmarinus officinalis L.) powder and vitamin E in broiler chickens: evaluation of humoral immune response, lymphoid organs, and blood proteins
Abstract
The aim of the present study was to evaluate the effect rosemary (Rosmarinus officinalis L.) powder (RP) and vitamin E (VE) at different levels on humoral immunity of broilers during a 42-day production cycle. A total of 270 1-day-old male chicks were assigned to nine groups with three replicates of ten birds each, and diets were supplemented with 0, 0.5, or 1.0% RP and 0, 100, or 200 mg/kg VE, respectively. Commercial-inactivated vaccines against avian influenza (AI) and Newcastle disease (ND) viruses, and living infectious bronchitis virus (IBV) vaccine were administered by spray method. Sheep red blood cells (SRBC) were administered subcutaneously. Blood samples were collected from birds 1 week after each vaccination to determine antibody titers. At the 42nd day, blood samples were also assessed for globulin level, and lymphoid tissues (thymus, spleen, and bursa) were weighed. Neither antibody titers against viruses nor lymphoid tissues weight were affected by RP and/or VE (P > 0.05) treatments. However, broilers supplemented with 0 mg/kg of VE had lower antibody titers against SRBC than those fed 100 mg/kg of VE (P < 0.05) at the 24th day. A significant RP × VE interaction effect (P < 0.05) on plasma globulin level was observed. The findings of our study suggest that dietary RP and VE additives can interact and modulate the humoral immunity of broilers, but not sufficiently to improve antibody titers against specific virus during a 42-day production cycle.
Testing the role of external debt in environmental degradation: empirical evidence from Turkey
Abstract
This study investigates the role of external debt stock in Turkey, which has suffered from heavy (external and domestic) debt stock for many years. Annual data from 1960 to 2013 was analyzed using time series analysis in order to study this. The results confirm the validity of the conventional environmental Kuznets curve (EKC) in the case of Turkey. However, this study also found that Turkey's external debt stock did not influence the Turkish economy's long-term EKC behavior. Fortunately, the results suggest that there are important interactions among external debt stock, CO2 emissions, energy consumption, and real income; that is, changes in external debt volume precede changes in these aggregates' volumes.
Contrasting effects of alkaline amendments on the bioavailability and uptake of Cd in rice plants in a Cd-contaminated acid paddy soil
Abstract
Reducing cadmium (Cd) concentrations in rice grains is important for food safety, particularly in acid paddy fields in South China where the soils have been previously contaminated with Cd. A field experiment was conducted to evaluate the effects of four alkaline amendments, i.e., lime, compost, biochar, and carbide slag on soil bioavailability and uptake of Cd in plants of two rice cultivars (Oryza sativa L.) in a Cd-contaminated acid paddy soil. The addition of these amendments significantly decreased the concentrations of CaCl2-extractable Cd by 13–41%. Cd in the acid-soluble fraction was decreased in these amended soils while it increased in the residual fraction. The amendments also decreased the uptake of Cd in the plants at the tillering and mature growth stages. The concentrations of Cd in plant tissues at maturity were in the order: root > shoot > bran > polished rice > husk. The amendment of carbide slag decreased Cd concentration in rice grains the most, followed by lime, biochar, and compost. The increases in soil pH and the decreases in the acid-soluble fraction of Cd (F1-Cd) indicated that these amendments can directly transform the highly availability fraction of Cd to a more stable fraction (residual Cd fraction) in soils. Furthermore, the Cd concentrations in polished rice grains of the two rice cultivars used were reduced by 66–67% by treatment with carbide slag. Our study suggests that carbide slag has a great potential to reduce the bioavailability and uptake of Cd in rice plants in Cd-contaminated acid paddy field soils.
Antimicrobial resistant Klebsiella pneumoniae carriage and infection in specialized geriatric care wards linked to acquisition in the referring hospital
Abstract
Background
Klebsiella pneumoniae is a leading cause of extended-spectrum beta-lactamase (ESBL) producing hospital-associated infections, for which elderly patients are at increased risk. Methods
We conducted a 1-year prospective cohort study, in which a third of patients admitted to two geriatric wards in a specialized hospital were recruited and screened for carriage of K. pneumoniae by microbiological culture. Clinical isolates were monitored via the hospital laboratory. Colonizing and clinical isolates were subjected to whole genome sequencing and antimicrobial susceptibility testing. Results
K. pneumoniae throat carriage prevalence was 4.1%, rectal carriage 10.8% and ESBL carriage 1.7%. K. pneumoniae infection incidence was 1.2%. The isolates were diverse, and most patients were colonized or infected with a unique phylogenetic lineage, with no evidence of transmission in the wards. ESBL strains carried blaCTX-M-15 and belonged to clones associated with hospital-acquired ESBL infections in other countries (ST29, ST323, ST340). One also carried the carbapenemase blaIMP-26. Genomic and epidemiological data provided evidence that ESBL strains were acquired in the referring hospital. Nanopore sequencing also identified strain-to-strain transmission of a blaCTX-M-15 FIBK/FIIK plasmid in the referring hospital. Conclusions
The data suggest the major source of K. pneumoniae was the patient's own gut microbiome, but ESBL strains were acquired in the referring hospital. This highlights the importance of the wider hospital network to understanding K. pneumoniae risk and infection control. Rectal screening for ESBL organisms upon admission to geriatric wards could help inform patient management and infection control in such facilities.Spinal tuberculosis: Clinicoradiological findings in 274 patients
Abstract
Background
Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in high TB/HIV prevalent settings. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance imaging (MRI) findings of spinal tuberculosis in these populations. Methods
A retrospective study of adults with spinal tuberculosis conducted at a referral center for patients with spinal disease without bony involvement on plain film radiography in South Africa. We report their clinical, laboratory and spinal MRI findings, compare HIV-infected and -uninfected patients and correlate clinical and cerebrospinal fluid (CSF) findings with that of MRI. Results
Of 274 patients, 209 (76%) were HIV-infected and 49 (18%) were HIV-uninfected. Radiculomyelitis occurred in 76% (n=210), whilst 39% (n=106) had spondylitis. Subdural abscess (n=42) and intramedullary tuberculoma (n=33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients spinal disease manifested as a paradoxical TB reaction, frequently following tuberculous meningitis (TBM). The triad of neurological deficit, fever and back pain was similar between patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%) and isolated myelitis (17%). Higher CSF neutrophil concentrations were observed in subdural abscess (median[IQR]= 38[4-202] cells x106/L) compared to epidural collection and isolated myelitis (0[0-0] cells x 106/L, both groups) and meningoradiculitis (2[0-16] cells x106/L); p=0.0026 –<0.0001. Conclusions
Radiculomyelitis is a common manifestation of spinal tuberculosis in high TB/HIV prevalence settings, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting these are more common than what the literature implies.The Clinical Utility of Methicillin Resistant Staphylococcus aureus (MRSA) Nasal Screening to Rule Out MRSA Pneumonia: A Diagnostic Meta-analysis with Antimicrobial Stewardship Implications
Abstract
Background
Recent literature has highlighted MRSA nasal screening as a possible antimicrobial stewardship program (ASP) tool for avoiding unnecessary empiric MRSA therapy for pneumonia, yet current guidelines recommend MRSA therapy based on risk factors. The objective of this meta-analysis was to evaluate the diagnostic value of MRSA nasal screening in MRSA pneumonia. Methods
Pubmed and EMBASE were searched from inception to November 2016 for English studies evaluating MRSA nasal screening and development of MRSA pneumonia. Data analysis was performed using a bivariate random-effects model to estimate pooled sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values. Results
Twenty-two studies, comprising of 5,163 patients met our inclusion criteria. Pooled sensitivity and specificity of MRSA nares screen for all MRSA pneumonia types was 70.9% and 90.3%, respectively. With a 10% prevalence of potential MRSA pneumonia, the calculated PPV was 44.8% while the NPV was 96.5%. The pooled sensitivity and specificity for MRSA community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) were at 85% and 92.1%, respectively. For CAP and HCAP both the PPV and NPV increased to 56.8% and 98.1%, respectively. In comparison, for MRSA ventilated-associated pneumonia (VAP), the sensitivity, specificity, PPV, NPV was 40.3%, 93.7%, 35.7%, and 94.8%, respectively. Conclusion
Nares screening for MRSA had a high specificity and NPV for ruling out MRSA pneumonia, particularly in cases of CAP/HCAP. Based on the NPV, utilization of MRSA nares screening is a valuable tool for AMS to streamline empiric antibiotic therapy, especially among patients with pneuLong-term variations of the riverine input of potentially toxic dissolved elements and the impacts on their distribution in Jiaozhou Bay, China
Abstract
The concentrations of the potentially toxic dissolved elements (PTEs) As, Hg, Cr, Pb, Cd, and Cu in the main rivers into Jiaozhou Bay (JZB) during 1981–2006 were measured, and the impact of the fluvial PTE fluxes on their distributions in the bay was investigated. The overall average concentration in the rivers into JZB ranged from 8.8 to 39.6 μg L−1 for As, 10.1 to 632.6 ng L−1 for Hg, 4.1 to 3003.6 μg L−1 for Cr, 8.5 to 141.9 μg L−1 for Pb, 1.1 to 34.2 μg L−1 for Cd, and 13.2 to 1042.8 μg L−1 for Cu. The interannual average concentration variations of the PTEs in these rivers were enormous, with maximum differences of 41–21,680 times, while their relative seasonal changes were far smaller with maximum differences of 3–12 times. The total annual fluvial fluxes for As, Hg, and Cr into JZB exhibited the inverse "U" pattern, while those for Pb and Cd showed the "N" pattern. As a whole, the total annual Cu flux presented a growing tendency from 1998 to 2006. In general, the changing trends of the PTE concentrations in JZB were similar to those of their annual fluxes from the rivers, indicating a great impact of their fluvial fluxes on their distributions in JZB. The annual concentration of Cd in the bay almost remained constant and differed from the fluvial flux of Cd. The diversified pattern of the environmental Kuznets curve (EKC) represented China's approach to industrialization as "improving while developing."
Biochar amendment with fertilizers increases peanut N uptake, alleviates soil N 2 O emissions without affecting NH 3 volatilization in field experiments
Abstract
Biochar application to soil is currently widely advocated for a variety of reasons related to sustainability. However, the synergistic effects of biochar combined with mineral or organic fertilizer on soil N2O emissions, NH3 volatilization, and plant N uptake are poorly documented. Field plot experiments planted with peanut were conducted under the application of biochar (derived from rice husk and cottonseed husk, 50 t ha−1) with organic or mineral fertilizer. It was found that biochar increased soil nutrient availability and decreased surface soil bulk density, demonstrating that biochar could improve the soil quality especially in the 0–20-cm profile. The total N content of the plant changed little with treatments, but the kernel N concentration increased significantly when biochar was applied with organic fertilizer. Peanut yield increased with biochar amendment while no significant difference was observed in plant biomass, suggesting biochar had a positive effect on belowground biomass. Peanut N uptake was also increased following biochar amendment with either organic or mineral fertilizers. While biochar amendment had no significant effect on soil NH3 volatilization, it did decrease the cumulative N2O emission by 36.3% on average with organic fertilizer, and by 32.6% with mineral fertilizer, respectively (p < 0.05). The copy numbers of 16S rDNA, nifH, nirK, and nirS were not influenced by the application of biochar; however, the copy number of nosZ was significantly increased under biochar plus mineral fertilizer treatment. The results imply that biochar application can suppress N2O emissions, as a result of abiotic factors and enhanced peanut N uptake rather than changes of denitrification genes.
Agro-industrial waste recycling by Trichosporon fermentans : conversion of waste sweetpotato vines alone into lipid
Abstract
Agro-industrial waste can be used to replace traditional carbohydrates, such as sucrose, starch, and glucose in many industrial fermentation processes. This study investigated the conversion of pre-treated waste sweetpotato vines (SV) into lipid by Trichosporon fermentans under the separate hydrolysis and fermentation (SHF) and the simultaneous saccharification and fermentation (SSF) processes. The results showed that SV autoclaving significantly increased the lipid accumulation of T. fermentans compared with acid or alkaline hydrolysis. The effects of different pre-treatments on SV were also studied by scanning electron microscopy and Fourier transform infrared spectroscopy, which showed the partial removal of the aliphatic fractions, hemicelluloses, and lignin during pre-treatment. Moreover, the lipid yield of T. fermentans in SSF was 6.98 g L−1, which was threefold higher than that (2.79 g L−1) in SHF, and the lipid contents of yeast in SSF and SHF were 36 and 25%, respectively. Overall, this study indicated that SSF using autoclaved SV could increase the growth and lipid production of T. fermentans and provided an efficient way to realize the resource utilization of waste SV.
A prospective cohort-study of 122 adult patients presenting to an otolaryngologist's office with globus pharyngeus
Abstract
Objectives
To investigate the epidemiology of globus pharyngeus in adult patients presenting to the otolaryngologist's office. Also the predictors of persisting symptoms, prevalence of anxiety and the effect of clinical assessment were analyzed.
Design
This was a prospective cohort study. Follow-up was done using a postal questionnaire.
Setting
One otolaryngologists' office comprising three medical doctors.
Participants
122 consecutive globus patients presenting to one otolaryngology office in a one-year period.
Main outcome measures
Globus incidence, gender- and age-distribution, predictors of persisting symptoms and the patient's health related concerns.
Results
3.8% of first-time visits were regarding globus. The mean age was 48 years [range 20-88 y] and a female predominance was found (ratio 1.49). 84% experienced anxiety, mainly due to fear of cancer. The most common pathological findings were reflux (15.6%) and post-infectious inflammation (10.6%). 21.4% of questionnaire-responders reported full remission of their symptoms. Three predictors regarding symptom persistence were identified: Male gender (OR 1.52), smoking (OR 3.4) and difficulties in breathing (OR 8.7). Patients with concomitant foreign body sensation were less likely to have persisting symptoms (OR 0.42). No cases of malignant disease were encountered. 94.7% was reassured by the office visit.
Conclusion
The incidence of globus is 3.8% in the otolaryngologist's office. Female gender and concomitant foreign body sensation were predictive for presenting to the clinic even if symptom remission had occurred. Male gender, smoking and self-perceived breathing difficulties were predictive for persisting symptoms. Globus is an anxiety causing symptom, but reassurance is provided by clinical examination by the otolaryngologist.
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A Differential Diagnosis of a Head and Neck Bony Lesion: Review of a Case Series with 18 Patients with Extra-Intestinal Features of Familial Adenomatous Polyposis
Abstract
We would like to draw to the attention of head and neck surgeons the following disease that can present first to head and neck specialists with either a head and neck lump or following an incidental finding on radiological imaging. Familial Adenomatous Polyposis (FAP) is a hereditary disease caused by a mutation in the APC gene on chromosome 5, which is inherited in an autosomal dominant fashion with complete penetrance but variable expression(1). However in approximately 25% of cases it arises from a de novo mutation of the APC gene(1).
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Five-year outcome of endoscopic laser cricopharyngeal myotomy: our experience in 10 patients
Abstract
Cricopharyngeal spasm is a failure of the cricopharyngeus muscle to relax and can be a cause of dysphagia.
Endoscopic laser cricopharyngeal myotomy with mucosal repair is associated with reduced operative times, inpatient stay and lower morbidity with favourable subjective short-term outcomes, although long-term outcomes are less well known.
In our cohort of patients, the majority had a subjectively improved swallow in the long-term although some did have regression of symptoms but remained better than pre-operatively.
Subjectively our cohort of patients appeared to favour less well in the long-term with regards to reflux symptoms, the majority fairing worse than pre-operatively at least 5 years previously.
This paper would suggest that as clinicians we can advise patients that in the long-term, laser cricopharyngeal myotomy will improve and maintain swallowing symptoms but that their reflux symptoms may be exacerbated over time.
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Clinical Considerations of the Role of Palbociclib in the Management of Advanced Breast Cancer Patients With and Without Visceral Metastases
Abstract
Background
This report assesses the efficacy and safety of palbociclib plus endocrine therapy (ET) in women with hormone receptor−positive, human epidermal growth factor receptor 2-negative advanced breast cancer (ABC) with or without visceral metastases. Patients and methods
Pre- and postmenopausal women with disease progression following prior ET (PALOMA-3; N=521) and postmenopausal women untreated for ABC (PALOMA-2; N=666) were randomized 2:1 to ET (fulvestrant or letrozole, respectively) plus palbociclib or placebo. Progression-free survival (PFS), safety, and patient-reported quality of life (QoL) were evaluated by prior treatment and visceral involvement. Results
Visceral metastases incidence was higher in patients with prior resistance to ET (58.3%, PALOMA-3) than in patients naive to endocrine therapy in the ABC setting (48.6%, PALOMA-2). In patients with prior resistance to ET and visceral metastases, median PFS (mPFS) was 9.2 months with palbociclib plus fulvestrant versus 3.4 months with placebo plus fulvestrant [hazard ratio (HR), 0.47; 95% confidence interval (CI), 0.35 − 0.61], and objective response rate (ORR) was 28.0% versus 6.7%, respectively. In patients with nonvisceral metastases, mPFS was 16.6 versus 7.3 months, HR, 0.53; 95% CI, 0.36 − 0.77. In patients naive to endocrine therapy in the advanced disease setting, mPFS was 19.3 months with palbociclib plus letrozole versus 12.9 months with placebo plus letrozole (HR, 0.63; 95% CI, 0.47 − 0.85); ORR was 55.1% versus 40.0%; in patients with nonvisceral disease, mPFS was not reached with palbociclib plus letrozole versus 16.8 months with placebo plus letrozole (HR, 0.50; 95% CI, 0.36 − 0.70). In patients with prior resistance to ET with visceral metastases, palbociclib plus fulvestrant significantly delayed deterioration of QoL versus placebo plus fulvestrant, whereas patient-reported QoL was maintained with palbociclib plus letrozole in patients naive to endocrine-based therapy for ABC. Conclusions
Palbociclib plus ET prolonged mPFS in patients with visceral metastases, increased ORRs, and in patients previously treated for ABC, delayed QoL deterioration, presenting a standard treatment option among patients with visceral metastases amenable to endocrine-based therapy. Clinical trial registration
NCT01942135, NCT01740427Watson for Oncology and breast cancer treatment recommendations: agreement with an expert multidisciplinary tumor board
Abstract
Background
Breast cancer oncologists are challenged to personalize care with rapidly changing scientific evidence, drug approvals, and treatment guidelines. Artificial intelligence (AI) clinical decision-support systems (CDSSs) have the potential to help address this challenge. We report here the results of examining the level of agreement (concordance) between treatment recommendations made by the AI CDSS Watson for Oncology (WFO) and a multidisciplinary tumor board for breast cancer. Patients and methods
Treatment recommendations were provided for 638 breast cancers between 2014 and 2016 at the Manipal Comprehensive Cancer Center, Bengaluru, India. WFO provided treatment recommendations for the identical cases in 2016. A blinded second review was carried out by the center's tumor board in 2016 for all cases in which there was not agreement, to account for treatments and guidelines not available before 2016. Treatment recommendations were considered concordant if the tumor board recommendations were designated 'recommended' or 'for consideration' by WFO. Results
Treatment concordance between WFO and the multidisciplinary tumor board occurred in 93% of breast cancer cases. Subgroup analysis found that patients with stage I or IV disease were less likely to be concordant than patients with stage II or III disease. Increasing age was found to have a major impact on concordance. Concordance declined significantly (P ≤ 0.02; P < 0.001) in all age groups compared with patients <45 years of age, except for the age group 55–64 years. Receptor status was not found to affect concordance. Conclusion
Treatment recommendations made by WFO and the tumor board were highly concordant for breast cancer cases examined. Breast cancer stage and patient age had significant influence on concordance, while receptor status alone did not. This study demonstrates that the AI clinical decision-support system WFO may be a helpful tool for breast cancer treatment decision making, especially at centers where expert breast cancer resources are limited.EQUAL Candida Score: An ECMM score derived from current guidelines to measure QUALity of Clinical Candidemia Management
Abstract
Candida species frequently cause blood stream infections and are reported to be the third to tenth most commonly isolated pathogens. Guidelines and standardized treatment algorithms provided by professional organisations aim to facilitate decision-making regarding diagnosis, management, and treatment of candidemia. In routine clinical practise, however, it may be challenging to comply with these guidelines. The reasons include lack of familiarity or feasibility to adherence, but also their length and complexity. There is no tool to measure guideline adherence currently. To provide such a tool, we reviewed the current guidelines provided by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and by the Infectious Diseases Society of America (IDSA), and selected the strongest recommendations for management quality as the bases for our scoring tool. Factors incorporated were diagnostic (blood cultures, echocardiography, ophthalmoscopy, species identification) and follow-up procedures (repeat blood cultures until negative result) as well as key treatment parameters (echinocandin treatment, step down to fluconazole depending on susceptibility result, CVC removal). The EQUAL Candida Score weighs and aggregates factors recommended for the ideal management of candidemia and provides a tool for antifungal stewardship as well as for measuring guideline adherence.
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Accuracy of FDG PET-CT response assessment following radiotherapy alone for head and neck squamous cell carcinoma: retrospective analysis of 45 patients
Abstract
FDG PET-CT is an established tool for response assessment following definitive concurrent chemoradiotherapy for head and neck squamous cell carcinoma with a high negative predictive value guiding treatment decisions.
Little data is available regarding the accuracy of FDG PET-CT for response assessment following definitive radiotherapy without chemotherapy.
We retrospectively analysed the accuracy of FDG PET-CT for response assessment following radiotherapy alone without planned neck dissection in 45 patients.
PET-CT had a high negative predictive value of 93% and positive predictive value of 88%.
Based upon the high negative predictive value, PET-CT can be used to avoid surgical intervention following radiotherapy alone
Overexpression of spoT gene in coccoid forms of clinical Helicobacter pylori isolates
Abstract
Helicobacter pylori (H. pylori) can convert to coccoid form in unfavorable conditions or as a result of antibiotic treatment. In order to adapt to harsh environments, H. pylori requires a stringent response which, encoded by the spoT gene, has a bifunctional enzyme possessing both (p)ppGpp synthetic and degrading activity. Our goal in this study was to compare spoT gene expression in spiral and induced coccoid forms of H. pylori with use of amoxicillin. First, clinical isolate coccoid forms were induced with amoxicillin; then, the viability test was analyzed by flow cytometer. After RNA extraction, cDNA synthesis and designing a specific primer for spoT gene, evaluation of the desired gene expression in both forms were studied. Bacterial isolates exposed to amoxicillin at MIC and 1/2 MIC induced morphological conversion better and faster than other MIC concentration. The expression of spoT gene was significantly downregulated in spiral forms of H. pylori, while the gene expression was upregulated and + 30.3-fold changes was seen in coccoid forms of bacterium. To summarize, spoT gene is one of the key factors for antibiotic resistance and its enhanced expression in coccoid form can be a valuable diagnostic marker for recognition of H. pylori during morphological conversion.
Increased levels of lipocalin 2 in palmoplantar pustular psoriasis
Palmoplantar pustular psoriasis (PPP) is a chronic immune-mediated skin disease that mainly affects women in the forth to seventh decade of life. The few available data on the prevalence rate of PPP vary between 0.01 to 0.05% for Western countries [1] and 0.1% for Japan [2]. The disease is characterized by erupting, sterile intraepidermal pustules on the palms and soles, with the pustules often located within psoriasis vulgaris (PV)-like erythematous and desquamating lesions [3]. In about 25% of PPP patients concomitant PV is present, and the family history for PV is positive in about 30% of cases [3,4].
Effect of vegetation type on treatment performance and bioelectric production of constructed wetland modules combined with microbial fuel cell (CW-MFC) treating synthetic wastewater
Abstract
An operation of microcosm-constructed wetland modules combined with microbial fuel cell device (CW-MFC) was assessed for wastewater treatment and bioelectric generation. One of the crucial aims of the present experiment is also to determine effect of vegetation on wastewater treatment process and bioelectric production in wetland matrix with microbial fuel cell. Accordingly, CW-MFC modules with vegetation had higher treatment efficiency compared to unplanted wetland module, and average COD, NH4+, and TP removal efficiency in vegetated wetland modules were ranged from 85 to 88%, 95 to 97%, and 95 to 97%, respectively. However, the highest NO3− removal (63%) was achieved by unplanted control module during the experiment period. The maximum average output voltage, power density, and Coulombic efficiency were obtained in wetland module vegetated with Typha angustifolia for 1.01 ± 0.14 V, 7.47 ± 13.7 mWatt/m2, and 8.28 ± 10.4%, respectively. The results suggest that the presence of Typha angustifolia vegetation in the CW-MFC matrix provides the benefits for treatment efficiency and bioelectric production; thus, it increases microbial activities which are responsible for biodegradation of organic compounds and catalyzed to electron flow from anode to cathode. Consequently, we suggest that engineers can use vegetated wetland matrix with Typha angustifolia in CW-MFC module in order to maximize treatment efficiency and bioelectric production.
Towards a better control of the wastewater treatment process: excitation-emission matrix fluorescence spectroscopy of dissolved organic matter as a predictive tool of soluble BOD 5 in influents of six Parisian wastewater treatment plants
Abstract
The online monitoring of dissolved organic matter (DOM) in raw sewage water is expected to better control wastewater treatment processes. Fluorescence spectroscopy offers one possibility for both the online and real-time monitoring of DOM, especially as regards the DOM biodegradability assessment. In this study, three-dimensional fluorescence spectroscopy combined with a parallel factor analysis (PARAFAC) has been investigated as a predictive tool of the soluble biological oxygen demand in 5 days (BOD5) for raw sewage water. Six PARAFAC components were highlighted in 69 raw sewage water samples: C2, C5, and C6 related to humic-like compounds, along with C1, C3, and C4 related to protein-like compounds. Since the PARAFAC methodology is not available for online monitoring, a peak-picking approach based on maximum excitation-emission (Ex-Em) localization of the PARAFAC components identified in this study has been used. A good predictive model of soluble BOD5 using fluorescence spectroscopy parameters was obtained (r2 = 0.846, adjusted r2 = 0.839, p < 0.0001). This model is quite straightforward, easy to automate, and applicable to the operational field of wastewater treatment for online monitoring purposes.
Autologous Flap Gluteal Augmentation
The ideal patient for purse-string gluteoplasty has buttock deflation and ptosis, and wishes to improve projection. Key elements of the procedure are buttock lifting combined with auto-augmentation, no undermining of auto-augmentation tissue, and use of a purse-string suture to enhance projection of auto-augmentation tissue. Purse-string gluteoplasty is a safe and effective technique to correct buttock ptosis and atrophy.
Persea americana Mill. crude extract exhibits antinociceptive effect on UVB radiation-induced skin injury in mice
Abstract
Persea americana, popularly known as avocado, has been empirically used as analgesic and anti-inflammatory including in the skin disorder treatment. Species of the genus Persea also show a photoprotective effect against UVB radiation. We investigated the antinociceptive and anti-inflammatory effects from a topical formulation containing the P. americana leaf extract in a UVB irradiation-induced burn model in mice and performed a gel-formulation stability study. The antinociceptive and anti-inflammatory effect was evaluated through mechanical allodynia, paw oedema, and inflammatory cell infiltration. Phenolic compounds were quantified by UHPLC–MS/MS. The gel-formulation stability study was performed analyzing organoleptic characteristics, pH, and viscosity. P. americana (3%) gel was able to prevent the UVB irradiation-induced mechanical allodynia on the 2nd and 3rd day after irradiation with maximum inhibition of 60 ± 12% at 2nd day. Such effect may be attributed, at least in part, due the presence of (+)-catechin (302.2 ± 4.9 μg/g) followed by chlorogenic acid (130 ± 5.1 μg/g) and rutin (102.4 ± 0.9 μg/g) found in the extract. The gel was not able to prevent the inflammatory parameters such as edema and leukocyte infiltration induced by UVB irradiation. No changes important were detected in the stability study, mainly in low temperature. Our results suggest that P. americana gel-formulation, which presented stability, ensuring its quality and the therapeutic effect, could be an interesting strategy for the treatment of the pain associated with sunburn; this effect could be attributed to its biological constituents, especially catechin, chlorogenic acid, and rutin.
Graphical abstract
Using a high-organic matter biowall to treat a trichloroethylene plume at the Beaver Dam Road landfill
Abstract
Trichloroethylene (TCE) is a highly effective industrial degreasing agent and known carcinogen. It was frequently buried improperly in landfills and has subsequently become one of the most common groundwater and soil contaminants in the USA. A common strategy to remediate TCE-contaminated sites and to prevent movement of the TCE plumes into waterways is to construct biowalls which consist of biomaterials and amendments to enhance biodegradation. This approach was chosen to contain a TCE plume emanating from a closed landfill in Maryland. However, predicting the effectiveness of biowalls is often site specific. Therefore, we conducted an extensive series of batch reactor studies at 12 °C as opposed to the typical room temperature to examine biowall fill-material combinations including the effects of zero-valent iron (ZVI) and glycerol amendments. No detectable TCE was observed after several months in the laboratory study when using the unamended 4:3 mulch-to-compost combination. In the constructed biowall, this mixture reduced the upstream TCE concentration by approximately 90% and generated ethylene downstream, an indication of successful reductive dechlorination. However, the more toxic degradation product vinyl chloride (VC) was also detected downstream at levels approximately ten times greater than the maximum contaminant level. This indicates that incomplete degradation also occurred. In the laboratory, ZVI reduced VC formation. A hazard quotient was calculated for the landfill site with and without the biowall. The addition of the biowall decreased the hazard quotient by 88%.
Iron-impregnated zeolite catalyst for efficient removal of micropollutants at very low concentration from Meurthe river
Abstract
In this paper, for the first time, faujasite Y zeolite impregnated with iron (III) was employed as a catalyst to remove a real cocktail of micropollutants inside real water samples from the Meurthe river by the means of the heterogeneous photo-Fenton process. The catalyst was prepared by the wet impregnation method using iron (III) nitrate nonahydrate as iron precursor. First, an optimization of the process parameters was conducted using phenol as model macro-pollutant. The hydrogen peroxide concentration, the light wavelength (UV and visible) and intensity, the iron loading immobilized, as well as the pH of the solution were investigated. Complete photo-Fenton degradation of the contaminant was achieved using faujasite containing 20 wt.% of iron, under UV light, and in the presence of 0.007 mol/L of H2O2 at pH 5.5. In a second step, the optimized process was used with real water samples from the Meurthe river. Twenty-one micropollutants (endocrine disruptors, pharmaceuticals, personal care products, and perfluorinated compounds) including 17 pharmaceutical compounds were specifically targeted, detected, and quantified. All the initial concentrations remained in the range of nanogram per liter (0.8–88 ng/L). The majority of the micropollutants had a large affinity for the surface of the iron-impregnated faujasite. Our results emphasized the very good efficiency of the photo-Fenton process with a cocktail of a minimum of 21 micropollutants. Except for sulfamethoxazole and PFOA, the concentrations of all the other microcontaminants (bisphenol A, carbamazepine, carbamazepine-10,11-epoxide, clarithromycin, diclofenac, estrone, ibuprofen, ketoprofen, lidocaine, naproxen, PFOS, triclosan, etc.) became lower than the limit of quantification of the LC-MS/MS after 30 min or 6 h of photo-Fenton treatment depending on their initial concentrations. The photo-Fenton degradation of PFOA can be neglected. The photo-Fenton degradation of sulfamethoxazole obeys first-order kinetics in the presence of the cocktail of the other micropollutants.
Temporal variation in bacterial and methanogenic communities of three full-scale anaerobic digesters treating swine wastewater
Abstract
To investigate the effects of temporal variations of process parameters on microbial community structures in the two types of full-scale anaerobic digester treating swine wastewater, three full-scale anaerobic digesters were monitored. An anaerobic filter (AF)-type digester located in Gong-Ju (GJ) showed the highest COD removal among three digesters and maintained stable efficiency. A digester in Hong-Seong (HS) was of the same type as it GJ and showed improved efficiency over the sampling period. A continuously stirred tank reactor (CSTR)-type digester in Soon-Cheon (SC) showed decreasing efficiency due to a high residual concentration of VFAs and NH4+. These process efficiencies were closely correlated to the Simpson indices of the methanogenic communities. Genera Bacillus, Methanosaeta, and Methanospirillum that have filamentous morphology were dominant in both AF-type digesters, but genera Acholeplasma, Methanosarcina, and Methanoculleus that have spherical or coccoid morphology were dominantly abundant in the CSTR-type digester. Correlation between populations suggests a possible syntrophic relationship between genera Desulfobulbus and Methanosaeta in digesters GJ and HS.
Chemical characterization and quantitativ e assessment of source-specific health risk of trace metals in PM 1.0 at a road site of Delhi, India
Abstract
This study presents the concentration of submicron aerosol (PM1.0) collected during November, 2009 to March, 2010 at two road sites near the Indian Institute of Technology Delhi campus. In winter, PM1.0 composed 83% of PM2.5 indicating the dominance of combustion activity-generated particles. Principal component analysis (PCA) proved secondary aerosol formation as a dominant process in enhancing aerosol concentration at a receptor site along with biomass burning, vehicle exhaust, road dust, engine and tire tear wear, and secondary ammonia. The non-carcinogenic and excess cancer risk for adults and children were estimated for trace element data set available for road site and at elevated site from another parallel work. The decrease in average hazard quotient (HQ) for children and adults was estimated in following order: Mn > Cr > Ni > Pb > Zn > Cu both at road and elevated site. For children, the mean HQs were observed in safe level for Cu, Ni, Zn, and Pb; however, values exceeded safe limit for Cr and Mn at road site. The average highest hazard index values for children and adults were estimated as 22 and 10, respectively, for road site and 7 and 3 for elevated site. The road site average excess cancer risk (ECR) risk of Cr and Ni was close to tolerable limit (10−4) for adults and it was 13–16 times higher than the safe limit (10−6) for children. The ECR of Ni for adults and children was 102 and 14 times higher at road site compared to elevated site. Overall, the observed ECR values far exceed the acceptable level.
Examining Exposure Assessment in Shift Work Research: A Study on Depression Among Nurses
Abstract
Introduction
Coarse exposure assessment and assignment is a common issue facing epidemiological studies of shift work. Such measures ignore a number of exposure characteristics that may impact on health, increasing the likelihood of biased effect estimates and masked exposure–response relationships. To demonstrate the impacts of exposure assessment precision in shift work research, this study investigated relationships between work schedule and depression in a large survey of Canadian nurses. Methods
The Canadian 2005 National Survey of the Work and Health of Nurses provided the analytic sample (n = 11450). Relationships between work schedule and depression were assessed using logistic regression models with high, moderate, and low-precision exposure groupings. The high-precision grouping described shift timing and rotation frequency, the moderate-precision grouping described shift timing, and the low-precision grouping described the presence/absence of shift work. Final model estimates were adjusted for the potential confounding effects of demographic and work variables, and bootstrap weights were used to generate sampling variances that accounted for the survey sample design. Results
The high-precision exposure grouping model showed the strongest relationships between work schedule and depression, with increased odds ratios [ORs] for rapidly rotating (OR = 1.51, 95% confidence interval [CI] = 0.91–2.51) and undefined rotating (OR = 1.67, 95% CI = 0.92–3.02) shift workers, and a decreased OR for depression in slow rotating (OR = 0.79, 95% CI = 0.57–1.08) shift workers. For the low- and moderate-precision exposure grouping models, weak relationships were observed for all work schedule categories (OR range 0.95 to 0.99). Conclusions
Findings from this study support the need to consider and collect the data required for precise and conceptually driven exposure assessment and assignment in future studies of shift work and health. Further research into the effects of shift rotation frequency on depression is also recommended.3-D Analysis of Fat-Processing Techniques for Facial Fat Grafting
This randomized clinical trial uses 3-dimensional volumetric analysis to assess which of 3 fat-processing techniques results in better volume retention in recipient sites in autologous fat grafting to correct facial asymmetry.
Surgical Procedure Grid for Increased Safety and Communication
This Viewpoint describes the Surgical Procedure Grid, a tool to help organization in the operating room during multisite surgery.
Expression Changes in Lactate and Glucose Metabolism and Associated Transporters in Basal Ganglia following Hypoxic-Ischemic Reperfusion Injury in Piglets [PEDIATRICS]
BACKGROUND AND PURPOSE:
The neonatal brain has active energy metabolism, and glucose oxidation is the major energy source of brain tissue. Lactate is produced by astrocytes and released to neurons. In the central nervous system, lactate is transported between neurons and astrocytes via the astrocyte-neuron lactate shuttle. The aim of this study was to investigate the regulatory mechanisms of energy metabolism in neurons and astrocytes in the basal ganglia of a neonatal hypoxic-ischemic brain injury piglet model.
MATERIALS AND METHODS:A total of 35 healthy piglets (3–5 days of age; 1.0–1.5 kg) were assigned to a control group (n = 5) or a hypoxic-ischemic model group (n = 30). The hypoxic-ischemic model group was further divided into 6 groups according to the 1H-MR spectroscopy and PET/CT scan times after hypoxia-ischemia (0–2, 2–6, 6–12, 12–24, 24–48, and 48–72 hours; n = 5/group). 1H-MR spectroscopy data were processed with LCModel software. Maximum standard uptake values refer to the maximum standard uptake values for glucose (or FDG). The maximum standard uptake values of the basal ganglia–to-occipital cortex ratio were analyzed. The expression levels of glucose transporters and monocarboxylate transporters were detected by immunohistochemical analysis.
RESULTS:Lactate levels decreased after an initial increase, with the maximal level occurring around 2–6 hours following hypoxia-ischemia. After hypoxia-ischemia, the maximum standard uptake values of the basal ganglia and basal ganglia/occipital cortex initially increased then decreased, with the maximum occurring at approximately 6–12 hours. The lactate and glucose uptake (basal ganglia/occipital cortex maximum standard uptake values) levels were positively correlated. The expression levels of glucose transporter-1 and glucose transporter-3 were positively correlated with the basal ganglia/occipital cortex. The expression levels of monocarboxylic acid transporter-2 and monocarboxylic acid transporter-4 were positively correlated with lactate content.
CONCLUSIONS:The results indicate that lactate and glucose transporters have a synergistic effect on the energy metabolism of neurons and astrocytes following hypoxic-ischemic reperfusion brain injury.
Carotid Artery Wall Imaging: Perspective and Guidelines from the ASNR Vessel Wall Imaging Study Group and Expert Consensus Recommendations of the American Society of Neuroradiology [WHITE PAPER]
SUMMARY:
Identification of carotid artery atherosclerosis is conventionally based on measurements of luminal stenosis and surface irregularities using in vivo imaging techniques including sonography, CT and MR angiography, and digital subtraction angiography. However, histopathologic studies demonstrate considerable differences between plaques with identical degrees of stenosis and indicate that certain plaque features are associated with increased risk for ischemic events. The ability to look beyond the lumen using highly developed vessel wall imaging methods to identify plaque vulnerable to disruption has prompted an active debate as to whether a paradigm shift is needed to move away from relying on measurements of luminal stenosis for gauging the risk of ischemic injury. Further evaluation in randomized clinical trials will help to better define the exact role of plaque imaging in clinical decision-making. However, current carotid vessel wall imaging techniques can be informative. The goal of this article is to present the perspective of the ASNR Vessel Wall Imaging Study Group as it relates to the current status of arterial wall imaging in carotid artery disease.
Using Correlative Properties of Neighboring Pixels to Improve Gray-White Differentiation in Pediatric Head CT Images [PEDIATRICS]
BACKGROUND AND PURPOSE:
A lower radiation dose can have a detrimental effect on the quality of head CT images. The aim of this study performed in a pediatric population was to test whether an image-processing algorithm (Correlative Image Enhancement) based on the correlation among intensities of neighboring pixels can improve gray-white differentiation in head CTs.
MATERIALS AND METHODS:Sixty baseline head CT images with normal findings obtained from scans of 30 children were processed using Correlative Image Enhancement to produce corresponding enhanced images. Gray-white differentiation in baseline and enhanced images was assessed quantitatively by calculating the contrast-to-noise ratio and conspicuity in equivalent ROIs in gray and white matter. Two masked readers rated the images for visibility of gray-white differentiation on a 5-point Likert scale. Differences in both quantitative and qualitative measures of gray-white differentiation between baseline and enhanced images were tested for statistical significance. P values < .05 were considered significant.
RESULTS:Image processing resulted in improvement in the contrast-to-noise ratio (from 1.86 ± 0.94 to 2.26 ± 1.00, P = .02) as well as conspicuity (from 37.28 ± 11.56 to 46.4 ± 11.5, P < .001). This was accompanied by improved subjective visibility of gray-white differentiation as reported by both readers (P < .01).
CONCLUSIONS:Image processing using Correlative Image Enhancement had a beneficial effect on quantitative measures of gray-white differentiation. This translated into improved perception of gray-white differentiation by readers. Further studies are needed to assess the effect of such image processing on the detection of disease processes using head CTs.
Cerebellar Hypoperfusion in Migraine Attack: Incidence and Significance [ADULT BRAIN]
BACKGROUND AND PURPOSE:
Patients diagnosed with migraine with aura have an increased lifetime risk of ischemic stroke. It is not yet clear whether prolonged cortical hypoperfusion during an aura increases the immediate risk of cerebellar infarction because it may induce crossed cerebellar diaschisis and subsequent tissue damage. To address this question, we retrospectively analyzed potential relationships between cortical oligemia and cerebellar hypoperfusion in patients with migraine with aura and their potential relation to small infarct-like cerebellar lesions.
MATERIALS AND METHODS:One hundred six migraineurs who underwent MR imaging, including DSC perfusion, were included in the study. In patients with apparent perfusion asymmetry, we used ROI analysis encompassing 18 infra- and supratentorial ROIs to account for differences in regional cerebral blood flow and volume. The presence of cerebellar hypoperfusion was calculated using an asymmetry index, with values of >10% being considered significant.
RESULTS:We observed perfusion asymmetries in 23/106 patients, 22 in patients with migraine with aura (20.8%). Cerebellar hypoperfusion was observed in 12/23 patients (52.2%), and crossed cerebellar diaschisis, in 9/23 patients (39.1%) with abnormal perfusion. In none of the 106 patients were DWI restrictions observed during migraine with aura.
CONCLUSIONS:Cerebellar hypoperfusion and crossed cerebellar diaschisis are common in patients with migraine with aura and cortical perfusion abnormalities. Crossed cerebellar diaschisis in migraine with aura may be considered a benign phenomenon because we observed no association with DWI restriction or manifest cerebellar infarctions, even in patients with prolonged symptom-related perfusion abnormalities persisting for up to 24 hours.
Patterns of Sonographically Detectable Echogenic Foci in Pediatric Thyroid Carcinoma with Corresponding Histopathology: An Observational Study [HEAD & NECK]
BACKGROUND AND PURPOSE:
Small echogenic foci within pediatric thyroid nodules are commonly seen by ultrasound and are one of the features used to determine the level of suspicion for malignancy. These are sometimes termed "microcalcifications," but their relation with malignancy is controversial due to the lack of standard terminology. Our aim was to evaluate sonographic patterns of echogenic foci in malignant pediatric thyroid nodules and describe the distribution of corresponding psammoma bodies and other histopathologic findings in thyroidectomy specimens.
MATERIALS AND METHODS:Ultrasounds of 15 pathologically proved malignant thyroid nodules in children were retrospectively reviewed by 2 radiologists who separately classified echogenic foci into the 4 morphologic patterns described in the American College of Radiology Thyroid Imaging, Reporting and Data System and noted their presence and distribution. Interobserver agreement was assessed, and consensus was reached for nodules for which there was disagreement. Surgical pathology findings from thyroidectomy specimens were retrospectively reviewed for the presence and distribution of psammomatous and dystrophic/stromal calcifications and eosinophilic/sticky colloid. Ultrasound and histopathologic ratings were compared, and frequencies and percentages corresponding to observed agreement levels were calculated.
RESULTS:Interobserver agreement between radiologists' sonographic assessments for the presence and distribution of echogenic foci ranged from 53% to 100% for all categories. Punctate echogenic foci were present in all nodules, and macrocalcifications, in 27%. Histopathology of the 15 nodules revealed that only 4 (27%) had psammomatous calcifications, while 9 (60%) had stromal calcifications and 8 (53%) had sticky colloid.
CONCLUSIONS:Sonographically detectable echogenic foci in malignant pediatric thyroid nodules can be reliably classified on the basis of American College of Radiology Thyroid Imaging, Reporting and Data System, with punctate echogenic foci composing the most common subtype. These echogenic foci do not represent psammomatous calcifications most of the time; instead, more than half of the malignant thyroid nodules with echogenic foci contained stromal calcifications or sticky colloid.
Posttreatment Infarct Volumes when Compared with 24-Hour and 90-Day Clinical Outcomes: Insights from the REVASCAT Randomized Controlled Trial [INTERVENTIONAL]
BACKGROUND AND PURPOSE:
Endovascular therapy has become the standard of care for patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi. Our aim was to determine whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in posttreatment infarct volume in the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) trial.
MATERIALS AND METHODS:The REVASCAT trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 206 enrolled subjects (endovascular treatment, n = 103; control, n = 103), posttreatment infarct volume was measured in 204 subjects. Posttreatment infarct volumes were compared with treatment assignment and recanalization status. Appropriate statistical models were used to assess the relationship among baseline clinical and imaging variables, posttreatment infarct volume, the 24-hour NIHSS score, and functional status with the 90-day modified Rankin Scale score.
RESULTS:The median posttreatment infarct volume in all subjects was 23.7 mL (interquartile range = 68.9 mL) and 16.3 mL (interquartile range = 50.2 mL) in the endovascular treatment arm and 38.6 mL (interquartile range = 74.9 mL) in the control arm (P = .02 for endovascular treatment versus control subjects). Baseline NIHSS (P < .01), site of occlusion (P < .03), baseline NCCT ASPECTS (P < .01), and recanalization status (P = .02) were independently associated with posttreatment infarct volume. Baseline NIHSS (P < .01), time from symptom onset to randomization (P = .02), treatment type (P = .04), and recanalization status (P < .01) were independently associated with the 24-hour NIHSS scores. The 24-hour NIHSS score strongly mediated the relationship between treatment type and 90-day mRS (P < .01 for indirect effect when adjusted for age), while posttreatment infarct volume did not (P = .26).
CONCLUSIONS:Endovascular treatment saves brain and improves 90-day clinical outcomes primarily through a beneficial effect on the 24-hour stroke severity.
Health Care Economics: A Study Guide for Neuroradiology Fellows, Part 1 [review-article]
SUMMARY:
Few resources are available in the medical literature for a comprehensive review of current health care economics as it relates to radiologists, specifically framed by topics defined by the Accreditation Council for Graduate Medical Education in the evaluation of neuroradiology fellows. Therefore, we present a comprehensive review article as a study guide for fellows to learn from and gain competence in the Accreditation Council for Graduate Medical Education neuroradiology milestones on health care economics.
CT Attenuation Analysis of Carotid Intraplaque Hemorrhage [EXTRACRANIAL VASCULAR]
BACKGROUND AND PURPOSE:
Intraplaque hemorrhage is considered a leading parameter of carotid plaque vulnerability. Our purpose was to assess the CT characteristics of intraplaque hemorrhage with histopathologic correlation to identify features that allow for confirming or ruling out the intraplaque hemorrhage.
MATERIALS AND METHODS:This retrospective study included 91 patients (67 men; median age, 65 ± 7 years; age range, 41–83 years) who underwent CT angiography and carotid endarterectomy from March 2010 to May 2013. Histopathologic analysis was performed for the tissue characterization and identification of intraplaque hemorrhage. Two observers assessed the plaque's attenuation values by using an ROI (≥ 1 and ≤2 mm2). Receiver operating characteristic curve, Mann-Whitney, and Wilcoxon analyses were performed.
RESULTS:A total of 169 slices were assessed (59 intraplaque hemorrhage, 63 lipid-rich necrotic core, and 47 fibrous); the average values of the intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue were 17.475 Hounsfield units (HU) and 18.407 HU, 39.476 HU and 48.048 HU, and 91.66 HU and 93.128 HU, respectively, before and after the administration of contrast medium. The Mann-Whitney test showed a statistically significant difference of HU values both in basal and after the administration of contrast material phase. Receiver operating characteristic analysis showed a statistical association between intraplaque hemorrhage and low HU values, and a threshold of 25 HU demonstrated the presence of intraplaque hemorrhage with a sensitivity and specificity of 93.22% and 92.73%, respectively. The Wilcoxon test showed that the attenuation of the plaque before and after administration of contrast material is different (intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue had P values of .006, .0001, and .018, respectively).
CONCLUSIONS:The results of this preliminary study suggest that CT can be used to identify the presence of intraplaque hemorrhage according to the attenuation. A threshold of 25 HU in the volume acquired after the administration of contrast medium is associated with an optimal sensitivity and specificity. Special care should be given to the correct identification of the ROI.
Spinal Cord Gray Matter Atrophy in Amyotrophic Lateral Sclerosis [SPINE]
BACKGROUND AND PURPOSE:
There is an emerging need for biomarkers to better categorize clinical phenotypes and predict progression in amyotrophic lateral sclerosis. This study aimed to quantify cervical spinal gray matter atrophy in amyotrophic lateral sclerosis and investigate its association with clinical disability at baseline and after 1 year.
MATERIALS AND METHODS:Twenty-nine patients with amyotrophic lateral sclerosis and 22 healthy controls were scanned with 3T MR imaging. Standard functional scale was recorded at the time of MR imaging and after 1 year. MR imaging data were processed automatically to measure the spinal cord, gray matter, and white matter cross-sectional areas. A statistical analysis assessed the difference in cross-sectional areas between patients with amyotrophic lateral sclerosis and controls, correlations between spinal cord and gray matter atrophy to clinical disability at baseline and at 1 year, and prediction of clinical disability at 1 year.
RESULTS:Gray matter atrophy was more sensitive to discriminate patients with amyotrophic lateral sclerosis from controls (P = .004) compared with spinal cord atrophy (P = .02). Gray matter and spinal cord cross-sectional areas showed good correlations with clinical scores at baseline (R = 0.56 for gray matter and R = 0.55 for spinal cord; P < .01). Prediction at 1 year with clinical scores (R2 = 0.54) was improved when including a combination of gray matter and white matter cross-sectional areas (R2 = 0.74).
CONCLUSIONS:Although improvements over spinal cord cross-sectional areas were modest, this study suggests the potential use of gray matter cross-sectional areas as an MR imaging structural biomarker to monitor the evolution of amyotrophic lateral sclerosis.
Association of Developmental Venous Anomalies with Demyelinating Lesions in Patients with Multiple Sclerosis [ADULT BRAIN]
SUMMARY:
We present 5 cases of demyelination in patients diagnosed with multiple sclerosis that are closely associated with a developmental venous anomaly. Although the presence of a central vein is a known phenomenon with multiple sclerosis plaques, demyelination occurring around developmental venous anomalies is an underreported phenomenon. Tumefactive demyelination can cause a diagnostic dilemma because of its overlapping imaging findings with central nervous system neoplasm. The relationship of a tumefactive plaque with a central vein can be diagnostically useful, and we suggest that if such a lesion is closely associated with a developmental venous anomaly, an inflammatory or demyelinating etiology should be a leading consideration.
Hemodynamic Changes Caused by Multiple Stenting in Vertebral Artery Fusiform Aneurysms: A Patient-Specific Computational Fluid Dynamics Study [INTERVENTIONAL]
BACKGROUND AND PURPOSE:
The multiple stent placement technique has largely improved the long-term outcomes of intracranial fusiform aneurysms, but the hemodynamic mechanisms remain unclear. In this study, we analyzed the hemodynamic changes caused by different stent-placement strategies in patient-specific models using the computational fluid dynamics technique, aiming to provide evidence for clinical decision-making.
MATERIALS AND METHODS:Ten vertebral artery fusiform aneurysms were included, and their patient-specific computational fluid dynamics models were reconstructed. A fast virtual stent placement technique was used to simulate sequential multiple stent placements (from a single stent to triple stents) in the vertebral artery fusiform aneurysm models. Hemodynamic parameters, including wall shear stress, pressure, oscillatory shear index, relative residence time, and flow pattern, were calculated and compared among groups with different numbers of stents.
RESULTS:Virtual stents were deployed in all 10 cases successfully, consistent with the real stent configuration. Wall shear stress decreased progressively by 7.2%, 20.6%, and 25.8% as the number of stents increased. Meanwhile, relative residence time and pressure increased on average by 11.3%, 15.4%, and 45.0% and by 15.7%, 21.5%, and 28.2%. The oscillatory shear index showed no stable variation trend. Flow patterns improved by weakening the intensity of the vortices and displacing the vortex center from the aneurysmal wall.
CONCLUSIONS:Stent placement modifies hemodynamic patterns in vertebral artery fusiform aneurysms, which might favor thrombosis formation in the aneurysmal sac. This effect is amplified with the number of stents deployed. However, a potential risk of rupture or recanalization exists and should be considered when planning to use the multiple stent placement technique in vertebral artery fusiform aneurysms.
Diffusion-Weighted Imaging of the Head and Neck: Influence of Fat-Suppression Technique and Multishot 2D Navigated Interleaved Acquisitions [HEAD & NECK]
BACKGROUND AND PURPOSE:
DWI of the head and neck can reveal valuable information, but the effects of fat suppression and multishot acquisition on image quality have not been thoroughly investigated. We aimed to comprehensively compare the quality of head and neck DWI at 3T using 2 fat-suppression techniques, STIR, and spectral presaturation with inversion recovery, which were used with both single- and multishot EPI.
MATERIALS AND METHODS:Sixty-five study participants underwent 3 DWI sequences of single-shot EPI–STIR, single-shot EPI–spectral presaturation with inversion recovery, and multishot EPI–spectral presaturation with inversion recovery of the head and neck. In multiple anatomic regions, 2 independent readers assessed 5-point visual scores for fat-suppression uniformity and image distortion, and 1 reader measured the contrast-to-noise ratio and ADC.
RESULTS:The mean visual score for fat-suppression uniformity was higher in single-shot EPI–STIR than in other sequences (all regions except for the orbital region, P < .05). The mean visual score for image distortion was higher in multishot EPI–spectral presaturation with inversion recovery than in single-shot EPI sequences (all regions, P < .001). Contrast-to-noise ratio was mostly lower in single-shot EPI–STIR than in other sequences (P < .001), and ADC was significantly higher in multishot EPI–spectral presaturation with inversion recovery than in single-shot EPI sequences (P ≤ .001).
CONCLUSIONS:Overall, multishot EPI–spectral presaturation with inversion recovery provided the best image quality, with relatively homogeneous fat suppression, less image distortion than single-shot EPI sequences, and higher contrast-to-noise ratio than single-shot EPI–STIR. The measured ADC values can be higher in multishot EPI–spectral presaturation with inversion recovery, which necessitates cautious application of the previously reported ADC values to clinical settings.
Health Care Economics: A Study Guide for Neuroradiology Fellows, Part 2 [review-article]
SUMMARY:
In this second article, we continue the review of current health care economics as it relates to radiologists, specifically framed by topics defined by the Accreditation Council for Graduate Medical Education in the evaluation of neuroradiology fellows. The discussion in this article is focused on topics pertaining to levels 4 and 5, which are the more advanced levels of competency defined by the Accreditation Council for Graduate Medical Education Neuroradiology Milestones on Health Care Economics and System Based Practice.
MR Imaging of the Superior Cervical Ganglion and Inferior Ganglion of the Vagus Nerve: Structures That Can Mimic Pathologic Retropharyngeal Lymph Nodes [PERIPHERAL NERVOUS SYSTEM]
BACKGROUND AND PURPOSE:
The superior cervical ganglion and inferior ganglion of the vagus nerve can mimic pathologic retropharyngeal lymph nodes. We studied the cross-sectional anatomy of the superior cervical ganglion and inferior ganglion of the vagus nerve to evaluate how they can be differentiated from the retropharyngeal lymph nodes.
MATERIALS AND METHODS:This retrospective study consists of 2 parts. Cohort 1 concerned the signal intensity of routine neck MR imaging with 2D sequences, apparent diffusion coefficient, and contrast enhancement of the superior cervical ganglion compared with lymph nodes with or without metastasis in 30 patients. Cohort 2 used 3D neurography to assess the morphology and spatial relationships of the superior cervical ganglion, inferior ganglion of the vagus nerve, and the retropharyngeal lymph nodes in 50 other patients.
RESULTS:All superior cervical ganglions had homogeneously greater enhancement and lower signal on diffusion-weighted imaging than lymph nodes. Apparent diffusion coefficient values of the superior cervical ganglion (1.80 ± 0.28 x 10–3mm2/s) were significantly higher than normal and metastatic lymph nodes (0.86 ± 0.10 x 10–3mm2/s, P < .001, and 0.73 ± 0.10 x 10–3mm2/s, P < .001). Ten and 13 of 60 superior cervical ganglions were hypointense on T2-weighted images and had hyperintense spots on both T1- and T2-weighted images, respectively. The latter was considered fat tissue. The largest was the superior cervical ganglion, followed in order by the retropharyngeal lymph node and the inferior ganglion of the vagus nerve (P < .001 to P = .004). The highest at vertebral level was the retropharyngeal lymph nodes, followed, in order, by the inferior ganglion of the vagus nerve and the superior cervical ganglion (P < .001 to P = .001). The retropharyngeal lymph node, superior cervical ganglion, and inferior ganglion of the vagus nerve formed a line from anteromedial to posterolateral.
CONCLUSIONS:The superior cervical ganglion and the inferior ganglion of the vagus nerve can be almost always differentiated from retropharyngeal lymph nodes on MR imaging by evaluating the signal, size, and position.
Urticaria: an update on diagnostics, therapy, and differential diagnosis
Abstract
Urticaria is a common skin disorder that can occur at any age; middle-aged women are most commonly affected. The diagnosis of urticaria is straightforward: the clinical picture includes wheals and/or angioedema accompanied by extreme itch. As a general rule, a wheal lasts for up to 1 day, whilst mast cell-mediated angioedema can remain symptomatic for up to 2 days. A distinction is made between acute and chronic forms (≥6 weeks), whereby symptoms may be present every day. Relapsing disease courses have also been described. This paper presents a current overview.
Urticaria requires a detailed patient history and appropriate diagnostic methods in order to establish the diagnosis accurately. There are more than 10 subtypes of this disorder, which can also occur as a combined form. A distinction is made between two main groups: spontaneous and inducible forms of urticaria. Acute urticaria is the most common form. A search for the cause is only necessary in the case of long-term and severe disease. The symptomatic treatment of urticaria should be performed parallel to the search for its cause. Any possible causes/trigger factors that are identified can be treated/remedied or eliminated. Urticaria then resolves or regresses after only a few weeks. Spontaneous remissions are possible. Only one extremely rare subgroup of cold urticaria shows a familial aggregation. No other forms of urticaria are inherited.
A Simple Flap Design for the Salvage of Immediate Implant-Based Breast Reconstruction
Background Breast reconstruction with implants is a real challenge in patients with large breast volume. Skin-reducing inverted-T mastectomy is the best solution for these patients. Delayed wound healing or necrosis at the T-junction area can be seen in this procedure, although it may also lead to severe conditions such as the exposure and loss of implant. In this article, the use of local pedicled flap for the management of these situations was discussed. Methods Between April 2010 and July 2015, 54 patients underwent breast reconstruction by inverted-T skin-reducing mastectomy and immediate implant-based breast reconstruction at our clinic. During the postoperative follow-up period, necrosis at the T-junction area was observed in 8 patients. All the patients received proper wound care, and the necrosis was surgically debrided. The defect was closed with Limberg-like rectangular flap. Results The mean age was 45.2 (range, 33–54) years. The mean body mass index was 25.57 ± 6.53 (range, 21.2–35.2) kg/m2. The mean follow-up was 10.9 (range, 4–19) months. Two patients had implant exposure at the defect site after the debridement. There was no implant loss in any of the patients. Conclusions The Limberg-like rectangular flap can be used as a salvage option in complicated skin-reducing mastectomies and can be considered as a safe and effective method because of its easy-to-use nature, low cost, and no need for microsurgery experience.Long-term Outcomes After Flap Reconstruction in Pediatric Pressure Ulcers
Background Pressure ulcers refractory to nonoperative management may undergo flap reconstruction. This study aims to evaluate the long-term outcomes and recurrence rates of flap reconstruction for pediatric pressure ulcers. Methods We reviewed the records of patients who underwent flap reconstruction for pressure ulcer(s) from 1995 to 2013. Results Twenty-four patients with 30 pressure ulcers, requiring 52 flaps were included. Ulcers were stages III and IV and mostly involved either the ischia (15/30) or sacrum (8/30). Flaps were followed for a median of 4.9 years. Twenty-three patients were wheelchair dependent, and 20 had sensory impairment at their ulcer site(s). Ten patients had a history of noncompliance with preoperative management, 8 of whom experienced ulcer recurrence. Twenty-one ulcers had underlying osteomyelitis, associated with increased admissions (P = 0.019) and cumulative length of stay (P = 0.031). Overall, there was a 42% recurrence rate in ulceration after flap reconstruction. Recurrence was associated with a preoperative history of noncompliance with nonoperative therapy (P = 0.030), but not with flap type or location, age, sex, body mass index, osteomyelitis, or urinary/fecal incontinence (P > 0.05, all). Conclusions Flap reconstruction can be beneficial in the management of pediatric pressure ulcers. Although high rates of long-term success with this intervention have been reported in children, we found rates of ulcer recurrence similar to that seen in adults. Poor compliance with nonoperative care and failure to modify the biopsychosocial perpetuators of pressure ulcers will likely eventuate in postoperative recurrence. Despite the many comorbidities observed in our patient sample, compliance was the best indicator of long-term skin integrity and flap success.Course Review: The First International Oldenburg–Groningen Fresh Cadaver Flap Course
The first international fresh cadaver flap course held in Groningen, the Netherlands, was a 2-day course where participants could learn and practice a wide variety of flap dissections on fresh cadavers under close supervision from international specialists in reconstructive surgery. Despite its high cost and long days, this was justified in excellent content, proficient teachers. and a one-to-one teacher-student ratio.
Human and Autologous Adipose-derived Stromal Cells Increase Flap Survival in Rats Independently of Host Immune Response
Introduction There is a rising interest in adipose-derived stromal cells for clinical use; however, it is unknown whether freshly isolated stromal cells (SVF) or culture-expanded cells (ASCs) are more efficacious. We therefore aimed to compare the 2 cellular therapies in an in vivo model of angiogenesis, the ischemic flap in rats, which induces acute ischemia. We also aimed to determine the importance of cell presence and the host immune response. Methods A total of 96 rats (n = 12 in each group) were used, and in each rat, a caudally based random flap measuring 2 × 7 cm was made. The study was conducted in 3 phases. First, each rat was treated with human SVF cells, human ASCs, or vehicle. Second, each rat was treated with human SVF, human SVF lysate, or vehicle. Finally, each rat was treated with rat (autologous) SVF cells or vehicle. Flap survival, vessel density, and stromal cell retention were evaluated after 7 days. Results The mean survival rates for SVF treatment regardless of human or autologous origin were significantly increased as compared with the control group. Adipose stem/stromal cell and SVF lysate injection did not increase flap survival. Vessel density was increased for human and rat SVF and human ASC but not for SVF lysate. Human cells were not detected in the flaps after 7 days. Conclusions Flap survival increased with SVF treatment regardless of human or autologous origin, suggesting that increased flap survival is independent of the host immune response. All cell injections lead to increased vessel density, but it did not necessarily lead to increased flap survival. Further research should elaborate which molecular events make SVF treatment more efficacious than ASC.Safety and Utility of the Drainless Abdominoplasty in the Post–Bariatric Surgery Patient
Introduction Surgical drains are used in abdominoplasty patients to combat wound closure disruption by hematoma or seroma formation. Several recent publications have described techniques that allow abdominoplasty to be performed safely without the need for surgical drains. This has not, however, been described in the case of the bariatric patient, who is often considered to be of higher postoperative complication risk. Here, we describe our experience of the drainless abdominoplasty in patients who have undergone massive weight loss (MWL) after a bariatric procedure. Methods A retrospective review was conducted of 172 patients who had undergone drainless abdominoplasty using the progressive tension suture technique from 2011 to 2014. Thirty-five patients who had undergone MWL after bariatric surgery were assigned to group A. One hundred thirty-seven patients who had not undergone MWL with no history of bariatric surgery were assigned to group B. Demographics, intraoperative outcomes, and postoperative outcomes were compared. Results Patients in group A were older (mean age, 48.7 vs 42.7 years; P = 0.003) and had a higher body mass index (26.6 vs 24.6 kg/m2, P = 0.01), a significantly larger tissue resection (2379 vs 1228 g, P = 0.0001), and a higher estimated blood loss (100 vs 120 mL, P = 0.049). There was also a significant group-to-group difference in the American Society of Anesthesiologists Physical Status Classification distribution, with a higher percentage of MWL patients having higher scores. Despite these differences, group A did not have a statistically higher incidence of complications. There was no statistically significant difference in the rate of seroma formation (11% vs 2%, P = 0.055), wound infection (2.9% vs 4.4%, P = 0.68), wound dehiscence (8.6% vs 8.0%, P = 0.91), meralgia paresthetica (2.8% vs 1.5%, P = 0.51), or rate of reoperation (11.4% vs 13.9%, P = 0.7) between the 2 groups. Conclusion Despite post–bariatric surgery patients being considered higher risk for postoperative complications, drainless abdominoplasty can be safely offered to this population by using a progressive tension suture technique.Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience
Background Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. Methods Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. Results A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. Conclusions This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.Endoscopic Delayed Breast Reconstruction With Expanders and Implants via the Axillary Incision Made for Sentinel Lymph Node Biopsy or Lymphadenectomy
Background Classic techniques of delayed prosthetic breast reconstruction use the mastectomy scar as an access route. As a result, the filling of the expander must be postponed until the wounds have healed. This creates an asymmetry between the breasts with the volume changes caused by the filling of the expander, which may occur over several weeks and cause considerable discomfort. Methods Delayed breast reconstruction was performed via the axillary incision made for sentinel lymph node biopsy or lymphadenectomy with endoscopic assistance and detachment of the pectoralis major muscle. The filling of the expander and symmetrization with the contralateral breast was performed in the first stage. The expander was replaced with the definitive prosthesis 3 months later, after endoscopic capsulotomy. Fat grafting was performed to create a lipobed around the implant and to improve tissue quality. Results Sixty-two patients underwent surgery. Mean follow-up was 19 months. There were no major complications in the reconstructed breast. One case of hematoma in a contralateral breast reduction and an oil cystic mass secondary to fat grafting were recorded. In all cases, the filling of the expander with the definitive volume was possible during the first stage. Conclusions Endoscopic delayed breast reconstruction with insertion of implants through the axillary incision for sentinel node biopsy or lymphadenectomy is safe and feasible. It achieves complete intraoperative expansion, symmetry between the volumes of the breasts during the first stage, and avoids problems with the scar and the risk of extrusion, as the scar is placed remotely in the axilla.Prevention of Peritendinous Adhesion Formation After the Flexor Tendon Surgery in Rabbits: A Comparative Study Between Use of Local Interferon-α, Interferon-β, and 5-Fluorouracil
Background Peritendinous adhesion is the most common complication after tendon surgery, particularly in zone II of the hand. Prevention of inflammation around the tendon, which develops after trauma and surgery, can decrease the tendon adhesion formation. This study compares the effect of some anti-inflammatory cytokines with 5-fluorouracil (5-FU) on the tensile strength and in prevention of peritendinous adhesion formation. Methods Sixteen rabbits were allocated equally into 4 groups. Tendons of the index and ring fingers in zone II of the right hind paw were cut in all animals and then repaired. Interferon (IFN)-α in group 1, 5-FU in group 2, normal saline in group 3, and IFN-β in group 4 were locally applied to the repaired sites. Three weeks later, tensometric and histopathologic evaluations were performed. Results The force required for removing the tendon from the sheath was not different between the groups (P = 0.130), but the time required for removal was significantly shorter in 5-FU group (P = 0.049). The strength of repair was not different between the groups in terms of force and time needed for rupture (P = 0.11 and 0.67, respectively). In histopathologic examination, normal architecture of the tendon and peritendon environment was less disturbed in the IFN groups, especially in IFN-β specimens. Conclusions Local application of 5-FU significantly reduced peritendinous adhesion. Local IFN-α and IFN-β had no significant effect on the prevention of peritendinous adhesion formation. The strength of the repair was not affected by these cytokines and 5-FU.Tuberous Breast: Past, Present, and Future Personal Classification, Treatment, and Surgical Outcomes
Background Tuberous breast (TB) is a rare congenital deformity, which may appear in different clinical forms representing various degrees of a single pathological entity. The worst cases are characterized by severe hypoplasia. Following a detailed analysis of the available relevant literature and a significant number of treated cases, in this article, the authors propose a new classification, with the aim of summarizing and simplifying a more intuitive categorization of the malformation, considering all the clinical aspects and including all types of TBs, even the minor ones, thus allowing a more immediate diagnosis and surgical planning. Methods Between September 2006 and December 2015, 78 patients with TBs underwent surgical procedures to correct the deformity. The patients' mean age was 18.6 years, ranging between 17 and 26 years. There being 11 monolateral deformities, the treated TBs amounted to 145. A periareolar approach, adipo-glandular flaps, and dual plane breast implant placements were performed. Postoperative follow-up include photos collected 12 months after operation. The authors present a personal classification including all the forms of the deformity, plus the minor forms based on the following 2 principal categories: hypoplastic and normoplastic TBs, taking into account all the clinical aspects of the malformation including the morphology and the consistency of the breast. Conclusions Preoperative identification of the type of the deformity is essential to obtain satisfactory results and a complete and intuitive classification including all the possible variants of the deformity, even the minor forms, and fundamental in diagnosing and resolving the problem. In this article, the authors propose a personal classification and surgical procedure to resolve the malformation.Selective Scalp Nerve Block: A Useful Technique With Tissue Expansion in Postburn Pediatric Alopecia
Background Scalp defects can be reconstructed either with skin graft, local flaps, free flaps, or tissue expansion. Tissue expanders have been proved to be fruitful in the pediatric population. Scalp expansion has proved to be useful in the reconstruction of posttraumatic and postburn alopecic defects. Selective nerve block can be added for attenuation of sympathetic stimulation and decrease surgical stress in cranial surgeries. In this study, a comparison was done between using selective nerve block and without selective nerve block in both stages of tissue expansion procedure. Patients and Methods This study included 32 different children who underwent tissue expansions in the management of postburn alopecia. Pediatric patients presented with postburn alopecia of the scalp with mature scar were included in this work. Results Postoperative analgesics were less in children who had received scalp block, whereas it was shorter in patients who did not receive any scalp block. Meperidine consumption was much more less in patients who received selective scalp nerve block. Pain score was markedly decreased in children who had received selective scalp nerve block in the immediate postoperative period. Children who received scalp block showed marked attenuation in the surgical stress responses with minimal changes in heart rate and mean arterial blood pressure after skin incision. Conclusions Scalp nerve block is considered an excellent choice for postoperative pain control with less need for opioid analgesia.Immediate Perineal Reconstruction After Extralevatory Abdominoperineal Excision: Buried Desepidermised Fasciocutaneous V-Y Advancement Flap
Background According to National Cancer Institute, there are approximately 39,800 rectal cancer cases per year, 25% of which will need an abdominoperineal resection (APR). The key to avoid most of the complications related to pelvic defect that occurs after APR is choosing an appropriate reconstruction option for perineum. This study aims to introduce an easily applicable flap option for closure to address postoperative pelvic defect in low rectal cancer. Methods This is a retrospective evaluation of 9 patients who have undergone perineal reconstruction for pelvic defects after extralevatory abdominoperineal excision with rectal cancer between 2014 and 2016. Reconstruction consists of a novel technique defined by our clinic, which is buried desepidermised fasciocutaneous V-Y advancement flap. Results All defects are closed successfully. Patients are followed postoperatively for complications such as perineal infection, wound dehiscence, seroma, perineal sinus, or fistula formation. Flaps are evaluated with magnetic resonance imaging postoperatively, for viability and effectiveness on defect closure. Mean follow-up time is 20 (±9) months. Mean average hospital stay is 8 (±2) days. We did not experience any total or partial flap loss or encounter any local complication related to the wound. Conclusions Buried desepidermised fasciocutaneous V-Y advancement flap is a reasonably easy and time-saving operation. It is effective in filling the pelvic dead space while closing the sacral defect after APR and therefore decreases late term complications related to large perineal excision.Isolated Dorsoradial Capsular Tear of the Thumb Metacarpophalangeal Joint: Missed Diagnosis and the Management of Delayed Presentation
Isolated dorsoradial capsule injuries of the thumb metacarpophalangeal joint are different from those associated with collateral ligament disruption. Early suspicion of this rare injury is important because, if overlooked, ulnarward subluxation of extensor pollicis longus tendon can develop. Functionally, active thumb extension becomes impaired, and over the long term, a thumb Boutonniere's deformity becomes established. Joint hypermobility/instability may predispose to this injury. The 2 cases presented illustrate this through anatomic differences. At the time of acute injury, 3 presenting clinical features should raise suspicion of dorsoradial capsular rupture: a history of isolated hyperflexion injury to the thumb, stable collateral ligaments on examination, and x-ray evidence of palmar subluxation of the proximal phalanx on the metacarpal. Ulnarward subluxation of the extensor pollicis longus is a delayed sign. Diagnostic imaging, beyond x-ray studies, may not be helpful in defining the injury. Early exploration and repair of this injury give the best long-term outcome. Postrepair, metacarpophalangeal joint range of motion may not be fully restored, but stability and a preinjury level of hand function can usually be reestablished.Integrated Plastic Surgery Residency Applicant Trends and Comparison With Other Surgical Specialties
Background There has been a relatively rapid increase in the number and size of "integrated" residency programs in plastic surgery (PS) over the past decade. The objective of this study is to evaluate trends of US senior applicants of PS compared with other surgical specialties from 2007 to 2016. Methods Data were obtained from "NRMP: Main Residency Match" and from "NRMP: Charting Outcomes in the Match." Frequencies, percentages, and proportions were calculated for categorical variables. Odds ratios with 95% confidence interval were calculated to evaluate the relationship of Alpha Omega Alpha membership and match success. Results The overall National Resident Matching Program match rate ranged from 93.1% to 95.1%, but rates were lower for surgical specialties, ranging from 74.7% to 86.6% in 2016. From 2008 to 2016, PS had a relatively high growth rate in the number of positions (65.2%) from 2008 to 2016. Matched PS and Otolaryngology applicants routinely had the highest mean United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge scores. Alpha Omega Alpha membership has a significant impact on successfully matching into a surgical specialty (PThe Effectiveness of Sternocleidomastoid Flap Versus Superficial Musculoaponeurotic System Flap for the Prevention of Frey Syndrome and Facial Depressed Deformity in Parotid Surgery for Pleomorphic Adenoma
The purpose of this study was to compare 2 types of reconstruction techniques: sternocleidomastoid (SCM) flap and superficial musculoaponeurotic system (SMAS) flap after partial parotidectomy (PP) for preventing Frey syndrome (FS) and concave facial depressed deformity. A total of 99 patients underwent PP for pleomorphic adenoma of the parotid gland. The patients were divided in 2 groups according to the dimension of the tumor: tumors less than 3 cm (group A, 47 patients) and tumors greater than or equal to 3 cm (group B, 52 patients). The patients in the 2 groups were assigned to 3 subgroups: PP without reconstruction (subgroup 1), PP and reconstruction with SMAS flap (subgroup 2), PP, and reconstruction with SCM flap (subgroup 3). In group A, the results of FS subjective symptoms, positivity of Minor starch test, and the median score of cosmetic results assessed with Visual Analogue Scale were as follows: in subgroup 1: 20%, 35%, 6; in subgroup 2: 13.3%, 13,3%, 8; in subgroup 3: 0%, 8.3%, 9. In patients of group B, the results were as follows: 60%, 73.3%, 3 in subgroup 1; 28.5%, 35.7%, 5 in subgroup 2; and 8.6%, 8.6%, 8 in subgroup 3. The study demonstrates a statistical difference (PRadioprotection With Amifostine Enhances Bone Strength and Regeneration and Bony Union in a Rat Model of Mandibular Distraction Osteogenesis
Background Using distraction osteogenesis (DO) to regenerate robust endogenous bone could greatly enhance postoncologic reconstruction of head and neck cancer. However, radiation (XRT) corrosive effects still preclude DO's immense potential. We posit that adjunctive pretreatment with the radioprotectant amifostine (AMF) can optimize wound healing and allow for successful DO with quantifiable enhancements in bony union and strength despite previous surgical bed irradiation. Methods Two groups of murine left hemimandibles were exposed to a human equivalent radiation dosage fractionated over 5 daily doses of 7 Gy. AMF-XRT-DO (n = 30) received AMF before radiation, whereas XRT-DO (n = 22) was untreated. All animals underwent left hemimandibular osteotomy and external fixator placement, followed by distraction to a 5.1-mm gap. Left hemimandibles were harvested and mechanically tested for parameters of strength, yield, and breaking load. Results Radiation-related complications such as severe alopecia were significantly increased in XRT-DO compared with the AMF-treated group (P = 0.001), whereas infection and death were comparable (P = 0.318). Upon dissection, bony defects were grossly visible in XRT-DO distraction gap compared with AMF-XRT-DO, which exhibited significantly more complete unions (P = 0.004). Those results were significantly increased in the specimens prophylactically treated with AMF (yield: 39.41 N vs 21.78 N, P = 0.023; breaking load: 61.74 N vs 34.77 N, P = 0.044; respectively). Conclusions Our study revealed that AMF enhances biomechanical strength, regeneration, and bony union after radiation in a murine model of DO. The use of prophylactic AMF in combination with DO offers the promise of an alternative reconstructive option for patients afflicted with head and neck cancer.A Comparative Study of Lateral Extension Versus Conventional Deltopectoral Flap in Head and Neck Reconstruction After Surgical Extirpation of Tumor
Background We investigated outcomes for nondelayed conventional deltopectoral (CDP) flaps and lateral extension deltopectoral (LEDP) flaps. Material and Methods Fifteen CDP flaps and 17 LEDP flaps were raised in 32 patients. All flaps were nondelayed. The flaps were folded only in the LEDP flap group. Six of 17 LEDP flaps were folded to become bilayered flaps to repair full thickness defects. Flap success rates and complication rates were compared between the CDP flap and LEDP flap groups. Results Success rates were 93.33% in the CDP flap group and 94.12% in the LEDP flap group. Overall complication rates of the transferred flaps were 6.67% and 11.76% for CDP and LEDP flaps, respectively. Flap failure rates were 6.67% and 5.88% with CDP flaps and LEDP flaps, respectively. Conclusions Although the CDP flap is the "aged workhorse" in contemporary head and neck reconstructions, it was shown to be a beneficial regional flap with a dependable pedicle and easy technique. The LEDP flap is of value particularly when used to treat full thickness defects of the head and neck or in cases when higher reach is required.Venous Thromboembolism After Surgical Treatment of Breast Cancer
Background Venous thromboembolism (VTE) remains a serious complication after the surgical treatment of breast cancer. Contemporary guidelines limit VTE chemoprophylaxis to the period of hospitalization. We conducted this study to evaluate the frequency of postdischarge VTE among surgically treated breast cancer patients and identify patient level factors associated with postdischarge VTE. Methods Using Arkansas, Florida, Nebraska, and New York state inpatient databases, we conducted a retrospective cohort study of adult women who underwent surgical treatment for breast cancer between October 1, 2008, and September 30, 2013. The primary outcome was a VTE event within 90 days of discharge. Multivariable logistic regression modeling was used to identify patient factors associated with VTE development. Results The final sample included 52,547 women with most undergoing mastectomy without reconstruction (n = 25,665), followed by mastectomy with implant based reconstruction (n = 16,851), lumpectomy (n = 5319), and mastectomy with autologous reconstruction (n = 4622). There were 395 patients (0.8%) who developed at least 1 VTE. Of the 395 VTEs, 32.9% (n = 130) were identified before discharge, whereas 67.1% were identified within 90 days after discharge. Patients with respiratory disease (adjusted odds ratio [AOR] = 1.56 [1.22–1.98]), hypothyroidism (AOR = 1.31 [1.01–1.70]), a hospital stay of more than 5 days (AOR = 8.07 [5.99–10.89]), previous VTE (AOR = 6.26 [3.95–9.91]), or mastectomy with autologous reconstruction (AOR = 1.50 [1.03–2.19]) more frequently developed postdischarge VTEs. Conclusions Nearly two thirds of all 90-day VTE events after breast cancer surgery occur after discharge. Further research should determine whether a longer course of VTE prophylaxis is warranted among specific populations including those with prolonged hospitalizations, previous VTE, and those undergoing autologous reconstruction.
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Publication date: Available online 25 July 2018 Source: Journal of Photochemistry and Photobiology B: Biology Author(s): Marco Ballestr...
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Editorial AJR Reviewers: Heartfelt Thanks From the Editors and Staff Thomas H. Berquist 1 Share + Affiliation: Citation: American Journal...
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Publication date: Available online 28 September 2017 Source: Actas Dermo-Sifiliográficas Author(s): F.J. Navarro-Triviño
