Medicine by Alexandros G. Sfakianakis

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Δευτέρα 21 Ιανουαρίου 2019

Craniovertebral Junction and Spine

Malignant paraganglioma presenting as a mandibular metastasis

Abstract

Background

Metastatic paragangliomas are rare neuroendocrine tumors. Bony metastases most commonly occur in the ribs, vertebrae, and pelvis. Few cases of mandibular metastases have been reported.

Methods

A 75‐year‐old female presented with a 6‐month history of an enlarging mandibular mass. A biopsy was consistent with a paraganglioma.

Results

Staging workup with ¹⁸F‐fluorodeoxyglucose positron emission tomography demonstrated 2 hypermetabolic intra‐abdominal lesions adjacent to the inferior vena cava. These were confirmed as paraganglioma by biopsy and presumed as the primary lesions. The patient underwent left segmental mandibulectomy and neck dissection with osteocutaneous fibula free tissue reconstruction.

Conclusion

A rare case of malignant paraganglioma presenting as a mandibular metastasis is described. Nuclear medicine studies for paraganglioma are reviewed.

http://bit.ly/2Dp8dsl

Primary vs secondary zygomatic implant placement in patients with head and neck cancer—A 10‐year prospective study

Abstract

Background

Zygomatic implants can provide excellent remote anchorage to support the prosthetic rehabilitation of patients treated for maxillary and midfacial tumors.

Methods

Patients who underwent zygomatic implant placement by the author between 2006 and 2016 as part of their oncology treatment were followed prospectively.

Results

Forty‐nine consecutively treated patients received 131 zygomatic implants of which 9 failed and were removed from 4 patients; 24 patients (49%) received radiotherapy either before or after implant insertion. The overall 12‐month survival estimate was 94% and the 60‐month estimate was 92%.

Conclusions

The use of zygomatic implants in the management of maxillary and midfacial malignancy is a predictable prosthetic treatment modality to support complex oral and facial prostheses. Their use with or without free tissue transfer can provide effective prosthetic rehabilitation with high implant survival irrespective of the timing of placement or the need for adjuvant radiotherapy.

Clinical Significance

Zygomatic Implants provide an excellent platform for the restoration of the dentition and facial structures affected by maxillary and midfacial malignant disease.

http://bit.ly/2U8zi8H

Protocol driven outcomes in renal parathyroid surgery

Abstract

Background

Patients who require surgery for renal hyperparathyroidism represent a special population that is at high risk for postoperative complications. To optimize their treatment, we developed a multidisciplinary approach to the perioperative management of these patients undergoing parathyroidectomy.

Methods

The Augusta University endocrine surgery parathyroid database was interrogated to identify dialysis‐dependent patients undergoing parathyroidectomy from 2005 to 2015. Numerous clinical parameters were quantified. Patients were stratified into protocol patients and nonprotocol patients.

Results

A total of 42 patients undergoing renal parathyroidectomy who met the inclusion criteria were identified. Serious adverse events were nearly twice as common in the patients not treated on protocol. The length of stay was nearly 2 days shorter in the protocol group. Lowest calcium level and ionized calcium was higher in the protocol cohort despite a lower postoperative parathyroid hormone. The protocol group had fewer laboratory draws.

Conclusion

Implementation of a multidisciplinary renal hyperparathyroidism protocol has resulted in improved perioperative outcomes.

http://bit.ly/2Dq0BG2

A Study on Deep Neck Space Infections

Abstract

Deep neck space infections (DNSI) are serious diseases that involve several spaces in the neck. These are commonly seen in low socioeconomic group with poor oral hygiene, and nutritional disorders. These are bacterial infections originating from the upper aerodigestive tract. The incidence of this disease was relatively high before the advent of antibiotics. Treatment of DNSI includes antibiotic therapy, airway management and surgical intervention. Management of DNSI is traditionally based on prompt surgical drainage of the abscess followed by antibiotics or nonsurgical treatment using appropriate antibiotics in the case of cellulitis. This study was conducted to investigate the age and gender, clinical symptoms, site involved, etiology, co-morbidities, bacteriology, complications and outcomes in the patients of DNSI. A prospective study of deep neck space infections was conducted during the period July 2017 to July 2018 on the patients who attended the outpatient department and were admitted as inpatient in Safdarjung hospital, New Delhi. 40 Cases with DNSI all ages and both genders were included in the study. Patients who didn't require surgical intervention to drain pus were excluded. All parameters including age, gender, co-morbidities, presentation, site, bacteriology, complications, and investigations were studied. Due to advent of antibiotics, deep neck space infections are in decreasing trend. The common age group found to be affected is in 2nd and 3rd decade in our study. Out of all deep neck space infections, submandibular space infections were common (37.5%) followed by peritonsillar infections (12.5%). Infection of deep neck space remains fairly common and challenging disease for clinicians. Prompt recognition and treatment of DNSI are essential for an improved prognosis. Odontogenic and tonsillopharyngitis are the commonest cause. Key elements for improved results are the prompt recognition and early intervention. Special attention is required to high-risk groups such as diabetics, the elderly and patients with underlying systemic diseases as the condition may progress to life-threatening complications.

http://bit.ly/2FFiwLh

Suitable Alternative for Human Cadaver Temporal Bone Dissection: Comparative Micro Ear Anatomy of Cattle, Pig and Sheep with Human

Abstract

The study was undertaken to compare the micro ear anatomy of three commonly available animal models which are expected to have similar anatomy to human and to find out suitable model among them as an alternative for human cadaver temporal bone dissection. This is an observational study of comparison of micro ear anatomy of the three animal models with human. Decapitated heads of cattle, pig and sheep were collected from slaughter houses, soft tissues along with brain were removed and preserved in commercially available formalin preservative. CT scan was taken for the three specimens and 3D reconstructions were done. Each specimen was subjected to micro dissection and the anatomical features were studied and compared with human. Among the three animal models sheep is found to be an ideal model for a beginner because of ease of exposure of bone, very thin cortical bone, and no cellularity, good exposure of all the middle ear structures and similar interrelations of middle ear structures with human. Pig may not be an ideal model because of abundant fatty soft tissues, thick periosteum very narrow space occupied by the middle ear, difficulty in accessing cellularity small fragile ossicular chain and overhanging facial nerve.

http://bit.ly/2FMC6ES

Outcomes of salvage surgery for the oropharynx and larynx: a contemporary experience in a UK Cancer Centre

Abstract

Introduction

The purpose of this study was to review our recent experience of salvage surgery, comparing larynx and oropharynx recurrence patterns.

Methods

A single centre, retrospective review of salvage surgery for recurrent head and neck cancer including patients between 2008 and 2016.

Results

61 patients were identified, 36 underwent salvage laryngectomy and 25 received oropharyngeal resections. The median overall survival of oropharyngeal recurrent tumors was 26 months (95% CI 15–118 months) and for laryngeal tumors was 23 months (95% CI 11–38 months), p = 0.1008. There was a significant overall survival benefit in patients with negative resection margin. The median survival in the negative margin group was 38 months (95% CI 25–108 months) compared to the positive margin group, 9 months (95% CI 5–15 months), p < 0.0001.

Conclusion

Survival results following surgical salvage in the larynx and oropharynx appear to be similarly poor. Those patients with clear margins appear to have a significantly better prognosis.

http://bit.ly/2U1qAsQ

Complications of Paediatric Cochlear Implantation in the Population of Uttarakhand

Abstract

Cochlear implants surgery is now routinely done at this center. Complications which have been experienced in cochlear implant surgery at our center are discussed, as a detailed knowledge about the complications and their early anticipation can save an expensive device and most importantly patients morbidity. To discuss the complications of the paediatric cochlear implantation in the population of Uttarakhand. The total of 60 patients were included in this study (age group 1–5 years) who had undergone the cochlear implantation surgery between Sept. 2015 and Sept. 2016. These patients were regularly monitored and followed up for 1 year. All the surgeries were performed by same team of surgeons. Rate of minor complications is 8.33% (reversible facial nerve paresis, injury to chorda tympani nerve, local skin reaction, perilymph gussher) and major complications is 5% (implant rejection and flap necrosis). The various complications should be closely monitored by the surgeon so that these can be avoided.

http://bit.ly/2RDtXd5

Correlation between the duration of locoregional control and survival in T1–T2 oropharyngeal cancer patients

Abstract

Purpose

To investigate the correlation between the time to locoregional recurrence and survival in T1–T2 oropharyngeal squamous-cell carcinoma (OPSCC) patients.

Methods

A retrospective, single-site study of patients with T1–T2 OPSCC treated with curative intent between 2000 and 2015 who had a locoregional recurrence without distant metastases. Patients without a disease-free interval (i.e., persistent macroscopic disease after the end of treatment and a time to locoregional recurrence of less than 3 months) were excluded. The endpoint considered was overall survival (OS).

Results

Out of 602 T1–T2 OPSCC patients, 121 patients had a locoregional recurrence and they were, hence, analyzed. All of the patients were heavy-smokers, with a consumption of more than 20 pack-years. The recurrence was local in 59.5%, regional in 27.3%, and both local and regional in 13.2% of the patients. The median time to locoregional recurrence and median OS was 15 months and 44 months, respectively. The time to locoregional recurrence was correlated with OS (p < 0.0001). In multivariate analyses, factors associated with survival were an initial N0–N2a versus N2b–N3 nodal staging and a 12-month threshold for the time to locoregional recurrence.

Conclusions

Locoregional control in T1–T2 OPSCC is not only a qualitative prognostic factor but also a quantitative prognostic factor of survival. A time to locoregional recurrence of less than 12 months was correlated with an unfavorable prognosis.

http://bit.ly/2S4LvOI

Fruits and vegetables (FVs)

Nature's bountiful gift to humankind: Vegetables & fruits & their role in cardiovascular disease & diabetes p. 569

Kamala Krishnaswamy, Rajagopal Gayathri

DOI:10.4103/ijmr.IJMR_1780_18

Fruits and vegetables (FVs) are recognized as healthy constituents of diet and a sustainable solution to the existing twin burden of micronutrient deficiencies and non-communicable diseases in developing and developed countries. In general, FVs are nutrient dense foods low in energy, containing varying amounts of vitamins and minerals including carotenoids, B vitamins, vitamin C, iron, zinc, potassium, calcium, magnesium and fibre. These are abundantly rich in phytochemicals that function as antioxidants, anti-atherosclerotic and anti-inflammatory agents. This review summarizes some epidemiological, prospective cohort and intervention studies on the health benefits of FVs in relation to cardiovascular disease, obesity and diabetes. The rich varieties of FVs available, their composition, production scenario in India, dietary intake and trends over time, barriers to sufficient intake mainly sociocultural, economic and horticulture environment, policies for promotion and prevention of diseases are considered.

Effects of treatment on anxiety levels among patients with benign paroxysmal positional vertigo

Abstract

Purpose

The association of vertigo with anxiety disorders is well known. Herein, we aimed to determine the relationship between pre-treatment and post-treatment anxiety levels, assessed with Beck anxiety inventory, with educational status among patients diagnosed with and treated for Benign paroxysmal positional vertigo (BPPV), and to evaluate the effect of treatment on the sub-parameters of the Beck anxiety inventory.

Methods

Our study included a total of 33 patients that presented to the otorhinolaryngology outpatient clinic with acute vertigo and were diagnosed to have posterior canal BPPV. Patients diagnosed with posterior BPPV were applied Beck anxiety inventory prior to the treatment as well as 1 week and 4 weeks after the treatment.

Results

Compared to the control group, statistically significant changes were observed in relation to pre-treatment and post-treatment inventory scores (p < 0.05). A comparison of the pre-treatment and post-treatment assessments revealed significant differences (p < 0.05). Improvements were observed in 48% (10/21) of the subparameters by the end of the first week at the earliest. Educational status had no significant effect on inventory scores (p > 0.05).

Conclusion

Anxiety-related subjective symptoms mostly started to improve 1 week after the treatment at the earliest, and symptoms showed persistence at a certain level even at the end of the first month. Inequalities between the patients' educational levels affect anxiety levels. It should be remembered that educational status should be considered when approaching patients.

http://bit.ly/2FLP31I

Pediatric skull base surgery: Encephaloceles and cerebrospinal fluid leaks

Publication date: Available online 21 January 2019

Source: Operative Techniques in Otolaryngology-Head and Neck Surgery

Author(s): Jacob G. Eide, Patrick Walz, Tord D. Alden, Jeffrey C. Rastatter

In recent years, endoscopic endonasal approaches to the pediatric skull base have become an increasingly popular method for treatment of a variety of malignant and benign lesions. These approaches have largely evolved from experience in adult patients and can be an excellent alternative to open procedures in carefully selected patients. Pediatric encephaloceles can be addressed via open craniotomy, transpalatal, and endoscopic endonasal methods. The surgical approach should be dictated by the anatomy of the patient as well as the size and location of the encephalocele in question. Pediatric cerebrospinal fluid leaks can occur due to iatrogenic causes during skull base resections or sinus surgery, as well as from traumatic injury. Multiple options for repair of cerebrospinal fluid leaks exist, but endoscopic nasoseptal flaps are among the most commonly utilized reconstruction options.

http://bit.ly/2S2vPLu

Locoregional flaps in pediatric anterior skull base surgery

Publication date: Available online 21 January 2019

Source: Operative Techniques in Otolaryngology-Head and Neck Surgery

Author(s): Christopher Pool, Neerav Goyal, Jessyka G. Lighthall

Management of skull base defects involves the separation of the cranial cavity from the nasal cavity in order to prevent cerebrospinal fluid leak, pneumocephalus, and intracranial infection. The size and location of the defect as well as donor tissue available will determine the type of reconstruction. Reconstruction options include free tissue grafts, locoregional flaps, and microvascular free flaps. In children, the size of potential flaps must be considered as well as the length of the pedicle, as often these differ in children. This article will discuss numerous reconstructive options, focusing on locoregional flaps in skull base reconstruction. In addition to outlining the surgical technique for each type, we will review considerations in pediatric patients for each reconstructive option.

http://bit.ly/2HqEp2E

Surgical management of clival chordomas in children

Publication date: Available online 21 January 2019

Source: Operative Techniques in Otolaryngology-Head and Neck Surgery

Author(s): Carl H. Snyderman, Paul A. Gardner, Elizabeth C. Tyler-Kabara

Objective: Describe the surgical management of clival chordomas in the pediatric population, with an emphasis on techniques of endoscopic endonasal surgery.

Finding: Endoscopic endonasal approaches to the clivus provide access from posterior clinoids to foramen magnum. The clivus is divided into thirds (superior, middle, and inferior), each with corresponding vascular and neural structures. The abducens nerve is at greatest risk for injury due to spread of tumor within the interdural space to Dorello's canal. Despite decreased pneumatization of the sinuses in pediatric patients, the same techniques can be applied to this population. The contralateral transmaxillary approach enhances the ability to achieve a gross total resection when tumor extends laterally into the petrous apex. A multi-layer reconstruction with vascularized tissue minimizes the risk of cerebrospinal fluid leak.

Conclusion: Endoscopic endonasal surgery can be safely applied to the pediatric population and provides the best opportunity for complete surgical excision for most tumors.

http://bit.ly/2RWXTjA

The Liverpool Peritonsillar abscess Score (LPS): Development of a predictive score through a prospective multi‐centre observational study

Abstract

Objectives

While uncommon in the population at large, peritonsillar abscess (PTA) is a common subject of ENT referrals. Missed or uncertain diagnosis is a source of concern for non‐specialist referrers. In line with the NHS England Second Sepsis Action Plan, we aimed to develop a predictive score for the presence of PTA. This would help to improve non‐specialist colleagues' diagnostic certainty as well as to support ENT surgeons' triage of these referrals.

Design

Prospective, multi‐centre observational study.

Setting

Primary and secondary care.

Participants

Patients >16 years with symptoms of sore throat.

Data

We prospectively collected comprehensive data on patient demographics, symptoms and clinical status. We documented whether the patient had aspiration‐proven PTA or not. We performed binary logistic regression analysis, iterative development of a predictive score which we validated internally.

Results

100 patients were included (46 PTA and 54 tonsillitis). Five variables added significantly to the logistic regression model: unilateral sore throat; trismus; male gender; pharyngeal voice change; uvular deviation. Using the odds ratio outputs, we developed the Liverpool Peritonsillar abscess Score (LPS) iteratively.

We validated the latest (third) iteration of the LPS internally (ie on the same sample), yielding sensitivity 96%; specificity 85%; positive predictive value 85% and negative predictive value 96%. Area under the receiver operating characteristics (AUROC) curve was 0.970.

Conclusions

We have developed the first predictive score for PTA based on symptoms and signs that do not require the user to have specialist experience. Its high negative predictive value may be particularly helpful to non‐specialist colleagues.

http://bit.ly/2FNMbBe

High‐density surface electromyography: A visualization method of laryngeal muscle activity

Objectives/Hypothesis

Laryngeal muscle activation is a complex and dynamic process. Current evaluation methods include needle and surface electromyography (sEMG). Limitations of needle electromyography include patient discomfort, interpretive complexity, and limited duration of recording. sEMG demonstrates interpretive challenges given loss of spatial selectivity. Application of high‐density sEMG (HD sEMG) arrays were evaluated for potential to compensate for spatial selectivity loss while retaining benefits of noninvasive monitoring.

Study Design

Basic science.

Methods

Ten adults performed phonatory tasks while a 20‐channel array recorded spatiotemporal data of the anterior neck. Data were processed to provide average spectral power of each electrode. Comparison was made between rest, low‐, and high‐pitch phonation. Two‐dimensional (2D) spectral energy maps were created to evaluate use in gross identification of muscle location.

Results

Three phonatory tasks yielded spectral power measures across the HD sEMG array. Each electrode within the array demonstrated unique power values across all subjects (P < .001). Comparison of each electrode to itself across phonatory tasks yielded differences in all subjects during rest versus low versus high, rest versus low, and rest versus high and in 9/10 subjects (P < .001) for low versus high phonation. Symmetry of HD sEMG signal was noted. Review of 2D coronal energy maps allowed for gross identification of cricothyroid muscle amidst anterior strap musculature.

Conclusions

HD sEMG can be used to identify differences in anterior neck muscle activity between rest, low‐, and high‐pitch phonation. HD sEMG of the anterior neck holds potential to enhance diagnostic and therapeutic monitoring for pathologies of laryngeal function.

Level of Evidence

NA Laryngoscope, 2019

http://bit.ly/2W5rarA

Endoscopic Sinus Surgery for Type‐2 CRS wNP: An Endotype‐Based Retrospective Study

Objectives

Nasal polyps are often characterized by type 2 inflammation and disease recurrence. We developed a new surgical technique, referred to as reboot approach, which aims to maximally remove all sinus mucosa and allow healthy re‐epithelialization from the preserved nasal mucosa. We here review type 2 endotype chronic rhinosinusitis with nasal polyps (CRSwNP) patients who underwent classical mucosa‐sparing endoscopic sinus surgery (ESS) or the reboot approach.

Methods

Retrospective case‐control study of 50 consecutive CRSwNP patients who underwent endoscopic sinus surgery between 2015 and 2017, either as a classical non‐reboot ESS (n = 20); a partial reboot approach removing the mucosa of the ethmoidal, sphenoidal, and maxillary sinuses (n = 18); or a complete reboot approach including Draf III and removal of all frontal sinus mucosa (n = 12). Polyp recurrence over the follow‐up period of 2 years served as the primary outcome.

Results

All patients demonstrated a type 2 inflammation of the mucosal tissue harvested during surgery. In the classical approach group (n = 20), nine patients relapsed within 2 years (45%); in the partial reboot group, three out of 18 patients (17%) relapsed; and in the full reboot group one out of 12 patients (8%) relapsed. The relapse rates were significantly different between the non‐reboot and the reboot groups (P = 0.02) but also between all treatment groups (P = 0.038).

Conclusion

Complete removal of diseased mucosa from the paranasal sinuses (reboot approach) significantly reduces the recurrence of nasal polyps for 30 months postoperatively compared to the current mucosa‐sparing approach in type 2 inflammatory CRSwNP.

Level of Evidence

3b. Laryngoscope, 2019

http://bit.ly/2R26JrQ

Improving decision making in larynx cancer by developing a decision aid: A mixed methods approach

Objective

Patients diagnosed with advanced larynx cancer face a decisional process in which they can choose between radiotherapy, chemoradiotherapy, or a total laryngectomy with adjuvant radiotherapy. Clinicians do not always agree on the best clinical treatment, making the decisional process for patients a complex problem.

Methods

Guided by the International Patient Decision Aid (PDA) Standards, we followed three developmental phases for which we held semi‐structured in‐depth interviews with patients and physicians, thinking‐out‐loud sessions, and a study‐specific questionnaire. Audio‐recorded interviews were verbatim transcribed, thematically coded, and analyzed. Phase 1 consisted of an evaluation of the decisional needs and the regular counseling process; phase 2 tested the comprehensibility and usability of the PDA; and phase 3 beta tested the feasibility of the PDA.

Results

Patients and doctors agreed on the need for development of a PDA. Major revisions were conducted after phase 1 to improve the readability and replace the majority of text with video animations. Patients and physicians considered the PDA to be a major improvement to the current counseling process.

Conclusion

This study describes the development of a comprehensible and easy‐to‐use online patient decision aid for advanced larynx cancer, which was found satisfactory by patients and physicians (available on www.treatmentchoice.info). The outcome of the interviews underscores the need for better patient counseling. The feasibility and satisfaction among newly diagnosed patients as well as doctors will need to be proven. To this end, we started a multicenter trial evaluating the PDA in clinical practice (ClinicalTrials.gov Identifier: NCT03292341).

Level of Evidence

NA. Laryngoscope, 2019

http://bit.ly/2W7btQI

Preoperative low skeletal muscle mass as a risk factor for pharyngocutaneous fistula and decreased overall survival in patients undergoing total laryngectomy

Abstract

Background

Low skeletal muscle mass (SMM) is associated with postoperative complications, prolonged hospital stay, and short overall survival (OS) in surgical oncology. We aimed to investigate this association in patients undergoing total laryngectomy (TL).

Methods

A retrospective study was performed of patients undergoing TL. SMM was measured using CT or MRI scans at the level of the third cervical vertebra (C3).

Results

In all, 235 patients were included. Low SMM was observed in 109 patients (46.4%). Patients with low SMM had more pharyngocutaneous fistulas (PCFs) than patients with normal SMM (34.9% vs 20.6%; P = .02) and prolonged hospital stay (median, 17 vs 14 days; P < .001). In multivariate analysis, low SMM (hazards ratio, 1.849; 95% confidence interval, 1.202‐2.843) and high N stage were significant prognosticators of decreased OS.

Conclusion

Low SMM is associated with PCF and prolonged hospital stay in patients undergoing TL. Low SMM is an independent prognostic factor for shorter OS.

http://bit.ly/2HltjvX

Leiomyosarcoma of Mandible: A Diagnostic Dilemma; Case Report and Review of Literature

Abstract

Leiomyosarcoma and its pleomorphic variant are rare entities in the head and neck region. Since they usually present as slow growing, discrete firm, and non-ulcerated painless mass, they seem to be deceptively benign and are thus misdiagnosed. Histopathological and immunohistochemical studies are the ways of getting a definitive diagnosis. Till date surgery has been the primary treatment but effectiveness of radiotherapy/chemotherapy is still questionable. Here, we describe a case of leiomyosarcoma in mandible along with discussion about the ways of diagnosis, its differentiation with its pleomorphic variant and their managements.

http://bit.ly/2CxPUQ7

Κυριακή 20 Ιανουαρίου 2019

Oxytocin facilitates the proliferation, migration and osteogenic differentiation of human periodontal stem cells in vitro

Publication date: Available online 19 January 2019

Source: Archives of Oral Biology

Author(s): Bin Ge, Hongrui Liu, Qianyu Liang, Lingling Shang, Ting Wang, Shaohua Ge

Abstract

Objective

To explore the effect of oxytocin (OT) on the proliferation, migration, and osteogenic differentiation of periodontal ligament stem cells (PDLSCs) in vitro.

Design

PDLSCs were obtained by limiting dilution method. Immunofluorescence (IF), cell-counting kit-8 (CCK8), cell migration assay, Alizarin Red S staining, cetylpyridinium chloride (CPC) colorimetry, quantitative real-time polymerase chain reaction (qRT-PCR), and western blot analysis were used to examine the effect of OT on oxytocin receptor (OTR) expression, cell proliferation, migration and osteogenic differentiation of PDLSCs.

Results

Our study showed that PDLSCs expressed OTR. One hundred nanomolar OT exhibited the maximal effect on migration, while only 50 nM OT significantly promoted proliferation of PDLSCs, as well as mineralized nodule formation and calcium deposition (p < 0.05). Furthermore, 50 nM OT significantly up-regulated expression of osteogenesis-related genes—alkaline phosphatase (ALP), Collagen I (Col I), runt related transcription factor 2 (Runx 2), osteopontin (OPN) and osteocalcin (OCN)—at specific time points compared with osteogenic inductive medium (p < 0.05). In addition, western blot analysis demonstrated that 50 nM OT enhanced protein levels of ALP, Col I, and Runx 2 at day 7 and day 14 (p < 0.01), as well as activating the phosphorylation of extracellular-signal-regulated kinase (ERK) and protein kinase B (AKT) pathway; notably, 50 nM OT inhibited phosphorylation of the phosphatidylinositol 3-kinase (PI3K) pathway (p < 0.05).

Conclusions

OT promoted proliferation, migration, and osteogenic differentiation of PDLSCsin vitro. Furthermore, the effect of OT on osteogenic differentiation was mediated through ERK and AKT pathway. Thus, OT may have potential for use in periodontal regeneration.

http://bit.ly/2Mpcuze

Jagged1 promotes mineralization in human bone-derived cells

Publication date: Available online 18 January 2019

Source: Archives of Oral Biology

Author(s): Thanaphum Osathanon, Jeeranan Manokawinchoke, Noppadol Sa-Ard-Iam, Rangsini Mahanonda, Prasit Pavasant, Jaijam Suwanwela

Abstract

Objectives

The present study aimed to investigate the expression of Notch signaling components during osteogenic differentiation in vitro and bone healing in vivo. In addition, the influence of Notch signaling on osteogenic differentiation of human bone-derived cells was examined.

Methods

Gene expression profiling of osteogenic differentiation of human bone marrow-derived mesenchymal stromal cells in vitro (GSE80614) and bone healing period of murine tibial fracture in vivo (GSE99388) was downloaded from Gene Expression Omnibus database. The expression of Notch signaling components was obtained from bioinformatic tools. Human bone-derived cells were isolated from alveolar and iliac bone. Cells were seeded on Jagged1 immobilized surface. Osteogenic marker gene expression and mineralization were examined using real-time polymerase chain reaction and alizarin red s staining, respectively.

Results

From bioinformatic analysis of gene expression profiling, various Notch signaling components were differentially expressed during osteogenic differentiation of human bone marrow-derived mesenchymal stromal cells in vitro and bone healing period of murine tibial fracture in vivo. The common genes differentially regulated of these two datasets were Hes1, Aph1a, Nsctn, Furin, Adam17, Hey1, Pcsk5, Nedd4, Jag1, Heyl, Notch3, Dlk1, and Hey2. For an in vitro analysis, the mineral deposition markedly increased after seeding human bone-derived cells on Jagged1 immobilized surface, correspondingly with the increase of ALP mRNA expression. Jagged1 treatment downregulated TWIST2 mRNA expression in both human alveolar and iliac bone-derived cells.

Conclusion

Notch signaling is regulated during osteogenic differentiation and bone healing. In addition, the activation of Notch signaling promotes osteogenic differentiation in human alveolar and iliac bone-derived cells. Therefore, Notch signaling manipulation could be a useful approach for enhancing bone regeneration.

http://bit.ly/2sFjqyN

The effects of different packing materials on healing and hearing after trauma to middle ear mucosa, an experimental study in rats

Publication date: Available online 20 January 2019

Source: American Journal of Otolaryngology

Author(s): Baklaci Deniz, Kum Rauf Oguzhan, Ozdemir Erdem, Sahin Hasan, Yilmaz Yavuz Fuat, Ozcan Muge

http://bit.ly/2R42P1L

EDITORIALS

	From "only decompression" to "only fixation:" A century-long journey of surgical treatment for spinal spondylosis	*p. 219*
	Atul Goel DOI:10.4103/jcvjs.JCVJS_118_18
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	Suboccipital pain in Chiari formation: Its cause and significance	*p. 221*
	Atul Goel DOI:10.4103/jcvjs.JCVJS_117_18
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ORIGINAL ARTICLES


	Preliminary results of anterior cervical arthroplasty by porous alumina ceramic cage for cervical disc herniation surgery	*p. 223*
	Keyvan Mostofi, Babak Gharaei Moghaddam, Morad Peyravi, Reza Karimi Khouzani DOI:10.4103/jcvjs.JCVJS_95_18 Objective: Anterior cervical arthroplasty (ACA) is the gold standard surgery in severe or unresponsive cases of cervical disc herniation, uncarthrosis, and foraminal stenosis. The aim of this study is to establish the impact and outcome evaluations of managing the patients operated for cervical arthroplasty by the intersomatic porous alumina ceramic cervical cages (PACC). The authors describe their experience in the area to allow the comparison of effectiveness of ceramic cages versus other interbody fusion cages. Materials and Methods:Between April 2015 and September 2018, we operated 118 for ACA by using PACC. Among them, 52 were female and 66 were male, with an average age of 46.78 years. Results: The mean symptoms duration was 14.1 months. The most frequent level of the disorder was C5–C6 followed by C6–C7 level. Mean follow-up was 3.3 years. The Neck Disability Index (NDI) and the visual analog scale (VAS) were used to evaluate the patients status. No significant differences were observed between our results and literature data regarding operative time, duration of hospitalization, and NDI; however, we observed a shorter period and higher rate of bony fusion. Conclusion: The results from the present study corroborate that implementing of PACC is a good alternative treatment for the patient operated by ACA for cervical disc herniation or foraminal cervical stenosis.
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	Timing for surgical intervention in DISHphagia	*p. 227*
	Waeel Ossama Hamouda DOI:10.4103/jcvjs.JCVJS_83_18 Introduction: Dysphagia in old patients secondary to diffuse idiopathic skeletal hyperostosis (DISH) syndrome is underdiagnosed. Surgical resection of the offending osteophytes is the definitive treatment. However, the timing of surgery in the course of the disease is still controversial. The study tries to find a correlation if any, between the timing of osteophytectomy surgery aimed to relieve DISH syndrome-induced dysphagia and the surgical outcome.Methods: During the period from 2010 to 2015, clinical and radiological data of patients who presented with dysphagia attributed to DISH syndrome were retrospectively reviewed along with their management and outcome.Results: One female and seven male patients were included in the study. Mean age was 71 years. Mean duration of dysphagia was 3 years and 10 months. Surgical resection was attempted through anterolateral cervical approach in five cases who were fit for surgery, in which four showed complete resolution of dysphagia (one experienced transient hoarseness of voice for 4 weeks postoperatively), and the fifth showed minimal improvement after limited resection due to intraoperative finding of marked esophageal adherence to osteophytes. The two unfavorable outcomes (subtotal resection and transient hoarseness of voice) occurred in relatively older patients (average: 75.5 years) with longer standing dysphagia (average: 7 years). Conclusion: DISH syndrome as a cause of dysphagia is commonly underlooked. Surgical resection of the offending osteophytes through an anterolateral approach is a safe and effective procedure. For patients who are fit for surgery, older age or longer duration of dysphagia might be associated with less favorable surgical outcome.
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	Who benefits more in osteoporotic fractures: Pedicle screw instrumentation or kyphoplasty for American Society of Anesthesiologists II/III patients?	*p. 232*
	Tjark Tassemeier, Marcel Haversath, Moritz Schutzbach, Marcus Jäger DOI:10.4103/jcvjs.JCVJS_55_18 Purpose: Osteoporotc fractures with posterior wall injury are commonly treated with a pedicle srcrew instrumentation (PSI) or a ballonkyphoplasty (BKP). A predictor for complications for these patients is the American Society of Anesthesiologists (ASA) class. Clinical results in ASA II/III patients who underwent BKP and PSI due to OF were evaluated to find the optimal treatment regimen. Materials and Methods: In a retrospective study design, ASA Class II and III patients with OF type OF 2 and OF 3 according to the German Society of Orthopedics and Trauma Surgery classification who underwent surgery between 2011 and 2016 were enrolled. Perioperative data such as time of surgery, cement leakage, adjacent level fractures, screw loosening, wound infections, and segmental kyphosis correction were measured and a statistical analysis was conducted. Results:Ninety-nine patients met the inclusion criteria, 17 were classified as ASA II and 82 patients were classified as ASA III. Twenty-eight individuals were treated by PSI, whereas 71 underwent BKP. Not only a longer average operation (120 min) and hospital stay (21 days) were documented in the PSI group but also a better kyphosis correction (7.5°). In comparison, the BKP group required an average operation time of 35.5 min with a mean kyphosis correction of 2.1°. A statistical analysis revealed the surgical procedure and not the ASA class to be a relevant factor for complication and revision surgery. Conclusions: BKP is a safe and effective therapy including also fractures with posterior wall defects while PSI showed advantages in restoring the sagittal realignment but higher complication and revision risk.
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	Lumbar disk herniation: How far should efforts go to minimally invasive procedure?	*p. 238*
	Keyvan Mostofi, Babak Gharaei Moghadam, Morad Peyravi, Reza Karimi Khouzani DOI:10.4103/jcvjs.JCVJS_70_18 Background: Minimally invasive surgery (MIS) of lumbar disk herniation allows avoiding less of a mess in crossing structures, reducing muscular and cutaneous scarring, postoperative pain, lengthy recovery times, and the rate of infection. The aim of this study is to explain our experience in MIS of disc herniation. We compare the outcome of three different surgical techniques used for the treatment of lumbar disc herniation. Materials and Methods: A total of 1147 patients have been operated from July 2008 to December 2015 for lumbar disk herniation by posterior endoscopic approach. Three hundred and seventy-nine patients underwent discectomy and herniectomy (DH), 557 patients have been operated by herniectomy (H), and 211 patients underwent only bone decompression (BD). Results: The results show 80.10%, 82.06%, and 84.02% excellent outcome, respectively, in BD, DH, and BD techniques. Conclusion: Analysis of the data demonstrates that the results obtained are equivalent and comparable in different used techniques for the treatment of disc herniation, we do not need to perform discectomy in all cases in a systematic way.
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	Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries	*p. 241*
	Adam R Dyas, Thomas E Niemeier, Gerald Mcgwin, Steven M Theiss DOI:10.4103/jcvjs.JCVJS_81_18 Objective: The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD). Materials and Methods: Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa. Results: Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62). Conclusion: The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.
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	On the linear sizes of vertebrae and intervertebral discs of children in the beginning of puberty	*p. 246*
	Mikhail Dudin, Yuri Baloshin, Igor Popov, Nikita Lisitsa, Stepan Bober DOI:10.4103/jcvjs.JCVJS_91_18 Study Design: We collected experimental data concerning vertebrae sizes and performed an investigation of these data for different patient ages by methods of mathematical statistics. Purpose: The standard dimensions of vertebrae and intervertebral discs are of major importance for obtaining a comprehensive understanding of spine diseases and their successful treatment. The purpose is to study these sizes for children at the age of 9–14 years.Overview of Literature: Unfortunately, this issue is poorly presented in the corresponding literature. There are no systematic results. Only particular cases are presented. Materials and Methods: Experimental is based on the: results of X-ray investigations of children spines. Theoretical background is given by methods of mathematical statistics. Results: Systematic description of vertebrae sizes for children of age 9–14 is given. This specific age interval is the most common period of initiation of various pathological deformations of human spine.Conclusions: The acquired data both reflect the process of spine growth and can serve for building correct mathematical models of a healthful or diseased spine.
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	A novel technique for the subfascial insertion of magnetically controlled growing rods – The Alder Hey technique	*p. 250*
	Sudarshan Munigangaiah, Phil Brown, Mohamed Mohamed, Colin E Bruce, Jayesh M Trivedi, Neil T Davidson DOI:10.4103/jcvjs.JCVJS_105_18 Purpose: In this study, we would like to describe a novel technique for subfascial insertion of magnetically controlled growing rods using chest drain during surgery for early-onset scoliosis. Materials and Methods:Posterior approach, surgical dissection to the spine is performed exposing the relevant anatomy to allow placement of pedicle screws always in the distal construct and pedicle screws or hooks in the proximal construct. To allow easy passage of the Magnetic Expansion Control (MAGEC) rod, as well as easy maneuvering of the rod in either the cranial to caudal direction, we use a chest drain of size 24 French diameter as a tunnel. This allows surgeons to fit the nonflexible part of MAGEC rod in the middle of the deformity and cut to length passed through the chest drain from a cranial to caudal position and then chest drain is removed. Results: A total of 40 children with early-onset scoliosis had insertion of MAGEC rods using this technique. There were 21 female and 19 male patients. Early-onset scoliosis etiology is idiopathic in 20 patients, neuromuscular in 16 patients, and others in 4 patients. Median age across all groups was 7 years (range 4–13) at the time of surgery. Follow-up ranged from 11 to 56 months with a median of 24 months. Conclusion: The use of a chest drain during subfascial passage of magnetically controlled growing rod is a safe, reliable, reproducible novel technique. This shortens overall time of surgery in our experience.
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	Clinical and radiological union rate evaluation of type 2 odontoid fractures: A comparison between anterior screw fixation and halo vest in elderly patients	*p. 254*
	Massimo Girardo, Alessandro Rava, Giosuè Gargiulo, Angela Coniglio, Stefano Artiaco, Alessandro Massè, Federico Fusini DOI:10.4103/jcvjs.JCVJS_93_18 Purpose: Odontoid fracture is a very common cervical injury, especially in elderly patients. Despite the high frequency, the appropriate management is still debated. The aim of this study is to evaluate clinical and radiological outcomes after anterior screw fixation or halo vest (HV) in type II odontoid fracture in elderly patients.Materials and Methods: Between January 2013 and December 2015, 135 consecutive patients affected by odontoid process were found. According to inclusion and exclusion criteria, 57 patients were included in the study. Patients were evaluated with visual analog scale (VAS), Smiley–Webster Scale (SWS), Italian Version of the Neck Disability Index (NDI), and patient satisfaction during follow-up. Furthermore, radiological data were evaluated for bone healing. Student's t-test or Fisher's exact test was used between groups, analyzing radiological and clinical results, and level of statistical significance was set at P < 0.05. Results: Seventeen patients were female and 40 were male. Twenty-seven patients were included in surgical group (SG) while 30 were included in HV group with a mean follow-up of 37.74 ± 10.52 months. A significant difference (P < 0.05) between groups was found for pseudoarthrosis, with a lower rate for SG. No significant differences in term of VAS, NDI, and SWS were found between groups (P > 0.05); SG reached higher satisfaction than HV group (P = 0.0271). Conclusions: Both treatments are equivalent in terms of clinical outcomes, and they are a valuable choice in the management of type II odontoid fracture. However, it must be considered that patients could slightly tolerate HV and may need a change of treatment.
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	Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis	*p. 260*
	Alessandro Landi, Giovanni Grasso, Cristina Mancarella, Demo Eugenio Dugoni, Fabrizio Gregori, Giorgia Iacopino, Harrison Xiao Bai, Nicola Marotta, Andrea Iaquinandi, Roberto Delfini DOI:10.4103/jcvjs.JCVJS_94_18 Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as "other" was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ² < 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence.
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CASE REPORTS


	The repair using a fibular graft of cervical vertebral collapse due to renal cell carcinoma: Late results with a case report	*p. 267*
	Vaner Koksal, Hüseyin Eren, Hasan Güçer DOI:10.4103/jcvjs.JCVJS_32_18 The most common cause of spinal tumors is metastases, but the cervical vertebra is the least common region of spinal metastasis, and relatively, little is published about surgery in metastasis to the cervical vertebra. While spinal metastasis is most often caused by neoplasms originating from the lung, breast, and prostate, renal cell carcinoma (RCC) metastasis is very rare. A 47-year-old patient introduced here presented with severe pain spontaneously on his neck and in his arm. In the radiology of the patient without neurological deficit, a pathologic vertebral collapse was detected in the C6 vertebral corpus. The patient underwent anterior cervical corpectomy. The fibula graft taken from his right leg was implanted in the emptied area and supported by an anterior plaque, and restoration of physiological cervical lordosis was established. From the pathological tissue that was taken, it was determined that the cause of the lysis was an RCC metastasis. After surgical repair of the cervical spine, a primary pathology with a diameter of 10 cm was detected in the patient's kidney, and a radical nephrectomy was performed. After 6 years of follow-up, there was no recurrence, and the patient continued his normal daily life. Radiologically between the autologous fibula graft and its own vertebral body was observed to achieve very good fusion. In this study, we emphasized the importance of resection of metastasis together with a primary tumor in a metastatic RCC case to cure the patient and provide the desired quality of life.
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	Transthoracic approach for ventrally situated paraspinal extradural hydatid cyst of the dorsal spine	*p. 271*
	Mohnish P Dighe, Srikant Balasubramaniam, Trimurti D Nadkarni DOI:10.4103/jcvjs.JCVJS_71_18 A 40-year-old female presented with back pain without any neurological deficits. Radiological investigations revealed a ventrally situated paraspinal lesion causing widening of the right D4 neural foramen. She underwent a right posterolateral thoracotomy and excision of the lesion in toto, which was reported as a hydatid cyst on histology. Ventrally situated paraspinal extradural hydatid cysts are rare. A Transthoracic surgical exposure offers a direct approach for complete excision of the lesion, minimizing the chances of rupture and spillage.
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	Autostabilization of neglected high-grade fracture–dislocation in the cervical spine	*p. 274*
	Kunal Shah, Akshay Gadiya, Abhay Nene DOI:10.4103/jcvjs.JCVJS_92_18 Neglected cervical spine trauma is rare with very few case series reported in literature. There are no clear guidelines for its treatment. If operative treatment is sought, the role of skull traction, type of approach (anterior only, posterior only, or combined), sequence of surgery, type of instrumentation, etc., have to be considered. Hence, the treatment is challenging. Autostabilization has been described in the natural history of degenerative lumbar spondylolisthesis. As a result, many patients are treated nonoperatively, obviating need of surgery. We report two cases of neglected/untreated fracture–dislocation at subaxial cervical spine. They presented with exertional neck pain. Computed tomography scan showed bony fusion at involved level. The patient was treated nonsurgically with favorable outcome at long-term follow-up. Our cases depict autostabilization in a case of neglected traumatic cervical spine injury, which is never been reported. Such patients do well with nonsurgical treatment, thus obviating need for extensive deformity correction.
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	Performing the screw fixation from C3 to odontoid process in a patient with Klippel-Feil syndrome and type II odontoid fracture	*p. 277*
	Mustafa Ogden, Ulas Yuksel, Ibrahim Akkurt, Bulent Bakar DOI:10.4103/jcvjs.JCVJS_54_18 A 56-year-old female patient was admitted with a history of pain during neck movements after cervical injury. Computerized tomography scan revealed type II odontoid fracture and fusion anomaly between C2 and C3 vertebrae. At surgery, the anteroinferior part of C2 vertebra corpus could not be reached; therefore, transodontoid screw was advanced from C3 vertebra toward odontoid process. At follow-up examination, the complaints of the patient had recovered, and fracture line was completely fused. Advancing screw from C3 to odontoid process via anterior cervical approach could be thought an alternative treatment option in the patient with short neck caused from vertebra fusion anomaly and/or obesity.
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	Unprecedented complication of odontoid regeneration after transoral odontoidectomy	*p. 280*
	Manish Garg, MS Sridhar, Saurabh Verma, Jitendra Bhadoria DOI:10.4103/jcvjs.JCVJS_98_18 Transoral odontoidectomy followed by occipitocervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction. Despite the large amount of literature on this approach and its complications, odontoid process regeneration and causing the worsening of symptoms of brainstem dysfunction and upper cervical cord were not found in the English literature. We report the case of odontoid regeneration in a 12-year-old girl. She presented with torticollis and symptoms of brainstem dysfunction and upper cervical cord compression with syringohydromyelia and underwent transoral resection of dens and posterior occipitocervical fusion at the age of 7 years. Post surgery, clinically and radiologically, the resolution was evident till the age of 11 years when the child started to have relapse and worsening of the previous symptoms. The computed tomography/magnetic resonance imaging shows regeneration of the odontoid process compressing the brain stem with an increase in syringohydromyelia. We suggest that there is a need for the removal of the complete odontoid process with periosteum and also beyond the dentocentral synchondrosis to prevent late recurrences of odontoid regeneration.
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	Isolated enchondroma of the atlas	*p. 283*
	Necati Ucler DOI:10.4103/jcvjs.JCVJS_101_18 Periosteal enchondromas located in the spine are rare. We reported an even more infrequent occurrence of a periosteal enchondroma in the cervical spine of a 19-year-old girl. During the operation, a giant (>8 cm × 5.5 cm × 5 cm) ossified periosteal enchondroma with involvement of posterior structures and muscles of the axis was resected. The pathological examination revealed that the tumor consisted of enchondroid tissue with typical chondrocytes, confirming the diagnosis of periosteal enchondroma. Early identification of the initial lesion should be coupled with total surgical resection, as a definitive treatment, to prevent malignant transformation. Enchondromas grow in an expanding manner which makes easy total resection.
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LETTER TO EDITOR


	Giant cell glioblastoma with spinal and spinal leptomeningeal metastasis in a child: A rare presentation of a rare tumor	*p. 286*
	Mahmood Dhahir Al-Mendalawi DOI:10.4103/jcvjs.JCVJS_97_18
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