OtoRhinoLaryngology by Alexandros G.Sfakianakis: Νοεμβρίου 2016

Τετάρτη 30 Νοεμβρίου 2016

Contamination of ground red pepper with fungi and mycotoxin

http://orl-medicine.blogspot.com/2016/11/mycobiota-of-ground-red-pepper-and.html

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Paediatric spinal cord infarction : A previously healthy 14-year-old female who began having difficulty breathing at school immediately after experiencing a burning sensation down her neck and back.

http://orl-medicine.blogspot.gr/2016/11/paediatric-spinal-cord-infarction.html

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Prognostic impact of adjuvant chemotherapy in high-risk nasopharyngeal carcinoma patients

Nasopharyngeal carcinoma (NPC) is distinct from other cancers of the head and neck by its epidemiology, histopathology, clinical characteristics, methods of treatment, and patterns of failure. Because of the inherent anatomic constraints and a high degree of radiosensitivity, radiotherapy (RT) has been the primary treatment for NPC patients without distant metastasis. NPC is also a chemosensitive tumor. More and more evidences have supported that RT combined with neoadjuvant chemotherapy (NeoCT) and/or concurrent chemotherapy (ConCT) is the best initial treatment modality for patients with locoregionally advanced diseases [1–12].

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An mTORC1/AKT1/Cathepsin H axis controls filaggrin expression and processing in skin, a novel mechanism for skin barrier disruption in Atopic Dermatitis

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Aishath S. Naeem, Cristina Tommasi, Christian Cole, Stuart J. Brown, Yanan Zhu, Benjamin Way, Saffron AG. Willis Owen, Miriam Moffatt, William O. Cookson, John I. Harper, Di WL, Sara J. Brown, Thomas Reinheckel, Ryan F.L. O'Shaughnessy
BackgroundFilaggrin, encoded by the FLG gene, is an important component of the skin's barrier to the external environment and genetic defects in FLG strongly associate with Atopic Dermatitis (AD). However, not all AD patients have FLG mutations.ObjectiveWe hypothesised that these patients may possess other defects in filaggrin expression and processing, contributing to barrier disruption and AD, and therefore present novel therapeutic targets for this disease.ResultsWe describe the relationship between the mTORC1 protein subunit RAPTOR, the serine/threonine kinase AKT1 and the protease cathepsin H, for which we establish a role in filaggrin expression and processing. Increased RAPTOR levels correlated with decreased filaggrin expression in AD. In keratinocyte cell culture, RAPTOR up-regulation or AKT1 shRNA knockdown reduced the expression of the protease cathepsin H. Skin of cathepsin H-deficient mice and CTSH shRNA knockdown keratinocytes showed reduced filaggrin processing and the mouse showed both impaired skin barrier function and a mild proinflammatory phenotype.ConclusionOur findings highlight a novel, potentially treatable, signalling axis controlling filaggrin expression and processing which is defective in AD.

Graphical abstract

Teaser

Capsule:FLG mutations strongly associate with Atopic Dermatitis (AD). However, not all AD patients have FLG mutations. An mTORC/AKT1 signalling axis controls both filaggrin expression and processing by controlling expression of the protease Cathepsin H.

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Oral Immunotherapy–Induced Gastrointestinal Symptoms and Peripheral Blood Eosinophil Responses

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Michael R. Goldberg, Arnon Elizur, Liat Nachshon, Michael Y. Appel, Michael B. Levy, Keren Golobov, Robert Goldberg, Miguel Stein, Marc E. Rothenberg, Yitzhak Katz

Teaser

Capsule Summary: Oral immunotherapy-induced gastrointestinal and eosinophilic responses (OITIGER) is an adverse response to OIT in ∼8% of patients and is typically reversible by decreasing dosage administration. The peripheral blood eosinophil count serves as a biomarker marker for susceptibility and the medical course.

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Effects of nongenetic factors on immune cell dynamics in early childhood: The Generation R Study

Publication date: Available online 29 November 2016
Source:Journal of Allergy and Clinical Immunology
Author(s): Diana van den Heuvel, Michelle A.E. Jansen, Kazem Nasserinejad, Willem A. Dik, Ellen G. van Lochem, Liesbeth E. Bakker-Jonges, Halima Bouallouch-Charif, Vincent W.V. Jaddoe, Herbert Hooijkaas, Jacques J.M. van Dongen, Henriëtte A. Moll, Menno C. van Zelm
Background. Numbers of blood leukocyte subsets are highly dynamic in childhood and differ greatly between individuals. Inter-individual variation is only partly accounted for by genetic factors.ObjectiveDetermine which nongenetic factors affect the dynamics of innate leukocytes, and naive and memory lymphocyte subsets.Methods. We performed six-color flow cytometry and linear mixed effect modeling to define the dynamics of 62 leukocyte subsets from birth to 6 years of age in 1,182 children with one to five measurements per individual. Subsequently, we defined the impact of prenatal maternal lifestyle-related or immune-mediated determinants, birth characteristics and bacterial/viral exposure-related determinants on leukocyte subset dynamics.Results. Functionally similar leukocyte populations were grouped by unbiased hierarchical clustering of patterns of age-related leukocyte dynamics. Innate leukocyte numbers were high at birth and were predominantly affected by maternal low education level. Naive lymphocytes peaked around 1 year, while most memory lymphocyte subsets more gradually increased during the first 4 years of life. Dynamics of CD4⁺ T cells were predominantly associated with gender, birth characteristics, and persistent infections with cytomegalovirus (CMV) or Epstein Barr virus (EBV). CD8⁺ T cells were predominantly associated with CMV and EBV infections, and TCRγδ⁺ T cells with premature rupture of membranes and CMV infection. B-cell subsets were predominantly associated with gender, breastfeeding and Helicobacter pylori carriership.Conclusions. Our study identifies specific dynamic patterns of leukocyte subset numbers, as well as nongenetic determinants that affect these patterns, thereby providing new insights into the shaping of the childhood immune system.

Graphical abstract

Teaser

Capsule Summary: Human inter-individual immunological diversity can only partly be explained by genetic factors, indicating an important contribution of nongenetic factors. We here analyzed leukocyte dynamics in 1,182 children of the Generation R Study and determined the effect of 26 nongenetic factors on inter-individual immunological diversity.

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Predictive factors and treatment outcome of laryngeal carcinoma recurrence

Abstract

Background

Up to 30% of patients with laryngeal squamous cell carcinoma (SCC) present with recurrence after treatment. We analyzed factors associated with the risk of cancer recurrence and prognosis after recurrence.

Methods

A nationwide laryngeal SCC cohort from Finnish university hospitals during 2001 to 2005 with initial successful therapy (n = 316) was analyzed.

Results

Laryngeal SCC recurred in 22% of patients. The median time to recurrence was 9 months, with 90% occurring within 36 months after treatment. The World Health Organization (WHO) performance status >0, neck metastasis at presentation, and nonsurgical treatment were independent prognostic factors for recurrence. Patients with local recurrence had a 5-year overall survival (OS) of 53% compared with 5% in patients with regional/distant recurrences. OS for glottic and nonglottic laryngeal SCC recurrence was 45% and 0%, respectively.

Conclusion

The type of treatment affected the risk of recurrence in this retrospective series. Local recurrences carried a chance for successful salvage treatment. Routine follow-up beyond 36 months remains controversial. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Rhinosporidiosis: A Rare Cause of Proptosis and an Imaging Dilemma for Sinonasal Masses

Background. Rhinosporidiosis is a common disease entity in tropical countries; however, it can be encountered in other parts of the world as well due to increasing medical tourism. It may mimic other more malignant and vigorous pathologies of the involved part. Case Report. We present a case of a 36-year-old male presenting with proptosis due to involvement of nasolacrimal duct which is rare. We will discuss typical CT and MRI features of the disease which were present in the case. Conclusion. For a surgeon and a radiologist, this is a necessary differential to be kept in mind for sinonasal masses. CT and MRI are invaluable investigations. However, FNAC is confirmatory. Both clinical and radiological aspects are required to reach correct diagnosis.

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Laryngeal tumours and radiotherapy dose to the cricopharyngeus are predictive of death from aspiration pneumonia

Publication date: January 2017
Source:Oral Oncology, Volume 64
Author(s): Jolyne O'Hare, Julia Maclean, Michal Szczesniak, Rashmi Gupta, Peter Wu, Harry Quon, Ian Cook, Peter Graham
ObjectivesAspiration pneumonia is an under-reported treatment sequelae following radiotherapy for head and neck cancer (HNC) patients. This study aims to investigate its incidence and risk factors in this population.Materials and methodsA retrospective review of all HNC patients that had received radiotherapy or chemo radiotherapy with radical intent at a single institution was undertaken (n=206). Dose delivered to the pharyngeal constrictors, base of tongue and cricopharyngeus was calculated and compared between those patients who had died from aspiration pneumonia and those who are alive or had died from other causes.ResultsIn a cohort of 206 patients, the median time of follow up was 3.5years (IQR 1.8–4.9years). The cause of death was known in 80 and one of the leading causes of non-cancer related mortality was aspiration pneumonia (n=12) equating to an annual incidence of 0.016. Patients with a tumour located in the larynx had a higher risk of death compared to other sites (p=0.005). The mean cricopharyngeal dose was significantly higher in those patients who died of aspiration pneumonia (p=0.023) compared to those who were still alive or had died from other causes. In a multivariate regression analysis, maximum cricopharyngeal dose is a significant predictor of death from aspiration pneumonia.ConclusionDose to the cricopharyngeus and tumours located within the larynx is associated with an increased mortality due to aspiration pneumonia. Clinical awareness of high risk groups and more studies into causative nature are needed.

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Three cases of interstitial pneumonia with anti-signal recognition particle antibody

Publication date: Available online 29 November 2016
Source:Allergology International
Author(s): Ryuichi Togawa, Yoshinori Tanino, Takefumi Nikaido, Naoko Fukuhara, Manabu Uematsu, Kenichi Misa, Yuki Sato, Nozomu Matsuda, Yoshihiro Sugiura, Sachiko Namatame, Hiroko Kobayashi, Yasuhito Hamaguchi, Manabu Fujimoto, Masataka Kuwana, Mitsuru Munakata

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Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Christopher Schardt, Angela Schmid, Jens Bodem, Johannes Krisam, Jürgen Hoffmann, Christian Mertens
PurposeBone defects after resective tumor surgeries often require the use of microvascular reanastomized bone grafts for reconstruction. The decision as to which specific flap is most suitable for the particular patient is dependent on various factors. The aspects donor site morbidity and quality of life are rarely taken into account in this connection. The aim of this study was to analyze whether these factors, in the future, should influence the choice of donor site.Material and MethodsIn this study, the donor sites of 46 patients with respect to deep-circumflex iliac artery (DCIA) and fibula flaps were analyzed using subjective and objective parameters. The primary outcome was postoperative pain measured by VAS. Postoperative complication evaluations as well as 2 orthopedic scores were implemented (American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Harris Hip Score) and the patients' quality of life was assessed using the 36-Item Short Form (SF-36) questionnaire to quantify donor site impairment.ResultsPostoperative pain was rated with a mean value of 42.4 mm (SD 34.8) for the DCIA group and 36.9 mm (SD 37.1) for the fibula group (p=0.617). After a mean period of 13.72 months, pain was rated with a mean value of 15.3 mm (SD 21.7) for DCIA and 13.3 mm (SD 22.6mm) for the fibula (p=0.763). Persistent pain, however, was recorded only in 11.11% of DCIA patients and 5.26% of fibula patients. Furthermore pain intensity was higher in the DCIA group. A changed gait pattern was observed in 59.26% of DCIA patients and 21.05% of fibula patients. DCIA patients required walking aids for walking and stair climbing more often. Looking at the results of the 2 orthopedic scores, fibula patients showed slightly better results. Concerning quality of life, patients after reconstructive surgery with DCIA flaps showed slight better results than patients in the fibula group.ConclusionsTaking the results of this study into account, the outcome in terms of pain, morbidity and quality of life did not show a significant superiority of any donor site.

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Patient-specific Biodegradable Implant in Pediatric Craniofacial Surgery

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): H. Essig, D. Lindhorst, T. Gander, P. Schumann, D. Könü, S. Altermatt, M. Rücker
Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver. 3.0.5; Brainlab, Feldkirchen, Germany) to generate a 3D reconstruction. Virtual osteotomies and simulation of the ideal outer contour with reassembled bony segments were performed. Digital planning was transferred with a cutting guide, and an individually manufactured resorbable implant was used for rigid fixation. A resorbable patient-specific implant (Resorb X-PSI) allows precise surgery for FOA in craniosynostosis using a complete digital workflow and should be considered superior to manually bent resorbable plates.

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Patient-specific polymethylmethacrylate prostheses for secondary reconstruction of large calvarial defects: A retrospective feasibility study of a new intraoperative moulding device for cranioplasty

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Manuel Moser, Raphael Schmid, Ralf Schindel, Gerhard Hildebrandt
PurposeThe aim of this study was to review a new template-based technique for intraoperative patient-specific cranioplasty manufacturing (PSCM) with polymethylmethacrylate (PMMA) to cover large calvarial defects.Material and MethodsA polypropylene foil thermoformed on a three-dimensional reprint of the calvarial defect was used as an intraoperative moulding device for PMMA between August 2012 and December 2015. Surgical and radiological data were retrospectively reviewed, and a patient questionnaire was used to assess functional and cosmetic outcome (numeric rating scale, Odom´s criteria).ResultsSeventeen patients (mean age 42.2±14.5 years) received PSCM. Operating time averaged 130±34 min, and the approximate blood loss was 293±185ml. Volumetric analysis revealed a lower implant volume compared to index bone (mean 66.5 vs. 72 cm³, p=0.513), the mean difference in thickness being the lowest in the posterior parietal and pterional (0.4-0.7 mm) and the highest in the anterior-superior frontal area (1.8 mm). Cosmetic satisfaction averaged 9±1.5, with 70.6% of patients judging the overall result as excellent or good and 29.4% as satisfactory. Mean follow-up was 19.5±13.3 months, with an overall complication rate of 17.6%, including 11.8% surgical site infections (SSIs) and one implant removal.ConclusionsIntraoperative PSCM using PMMA moulded on a thermoformed polypropylene foil leads to satisfactory outcomes. It is a safe technique with complication rates comparable but not superior to those of other alloplastic techniques, but the device has considerable production costs.

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Influence of Bone Invasion on Outcomes after Marginal Mandibulectomy in Squamous Cell Carcinoma of the Oral Cavity

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Ivana Petrovic, Pablo H. Montero, Jocelyn C. Migliacci, Frank L. Palmer, Ian Ganly, Snehal G. Patel, Jatin P. Shah
IntroductionMarginal mandibulectomy (MM) is indicated for oral cavity squamous cell carcinomas (OCSCC) that abut or minimally erode the mandible without gross invasion. Successful implementation of MM is predicated on accurate patient selection and appropriate adjuvant treatment based on well-known host and tumor characteristics. The incidence of microscopically diagnosed bone involvement in MM specimens and its implications on outcomes have however not been reported in large contemporary series.PurposeTo report the incidence of bone involvement and analyze its influence on oncologic outcomes in selected patients who underwent MM in treatment of OCSCC.MethodA retrospective cohort study was performed on a consecutive series of previously untreated patients requiring MM, at a tertiary care cancer center between 1985 and 2012 (n=326). The median age was 64 years and 59% were male. The majority of patients (67%) had a primary tumor of the floor of the mouth or lower alveolus, 80% were clinically staged T1-2, and 31% were clinically N+. Postoperative radiation (PORT) was used in 27% and chemoradiation (POCTRT) in 8% of patients who had microscopic bone invasion. The median follow up period was 55 months and endpoints of interest were local and regional recurrence free (LRFS and RRFS) and disease specific (DSS) survival.ResultsMicroscopic bone invasion was present in 15% of patients. (n=49). . Among these cortical invasion was present in 32, medullary in 13 and it was not specified in 4. Eight patients had microscopic positive bone margins. Positive bone margins were associated with medullary bone involvement (p<0.001), floor of mouth and buccal mucosa primary site (p=0.0), and positive soft tissue margins (p=0.05). LRFS and DSS were similar in patients without versus with bone invasion (62.8% vs 79.7% and 76.2% vs 66% respectively, p=NS). LRFS were similar in patients with microscopic positive versus negative bone margins, as long as postoperative adjuvant treatment was administered.ConclusionMicroscopic bone involvement does not adversely influence outcomes but medullary bone involvement does confer a higher risk of positive bone margins. MM and appropriate adjuvant treatment is an effective strategy for treatment of OCSCC in selected patients with primary tumors adherent to or in proximity to the mandible.

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Delay Techniques for Nipple-Sparing Mastectomy: A Systematic Review

Publication date: Available online 29 November 2016
Source:Journal of Plastic, Reconstructive & Aesthetic Surgery
Author(s): Laurel S. Karian, Paul J. Therattil, Philip D. Wey, Kevin T. Nini
BackgroundRare but serious complications of nipple-sparing mastectomy (NSM) include necrosis of the nipple-areolar complex (NAC) or mastectomy skin flaps. NAC and mastectomy flap delay procedures are novel techniques designed to avoid these complications, and may be combined with retroareolar biopsy as a first-stage procedure. We performed a systematic review of the literature to evaluate various techniques for NAC and mastectomy flap delay.MethodsPubMed and Cochrane databases were searched from January 1975 through April 15, 2016. The following search terms were used for both subjects and key words: 'nipple sparing mastectomy' AND ('delay' OR 'stage' OR 'staged'). Two independent reviewers determined study eligibility, accepting only studies involving patients who underwent a delay procedure prior to NSM, and studies with objective results including specific outcomes of NAC and mastectomy flap necrosis.ResultsThe literature search yielded 242 studies, of which five studies met inclusion criteria, with a total of 101 patients. Various techniques for NSM delay have been described, all of which involve undermining the nipple and surrounding mastectomy skin to some degree. Partial NAC necrosis was reported in a total of 9 patients (8.9%). Mastectomy flap necrosis was reported in a total of 8 patients (7.9%). Three of five studies reported positive retroareolar biopsy findings in a total of 7 patients (6.9%).ConclusionsDelay procedures for NSM have a good safety profile and may be considered in patients at risk for NAC or mastectomy flap necrosis, such as patients with pre-existing breast scars, active smoking, prior radiation, or ptosis. These procedures have the added benefit of allowing a retroareolar biopsy to be sent for permanent sections prior to mastectomy, allowing the surgical team to plan for removal of the NAC at the time of mastectomy if indicated, and eliminating the risk of a false-negative result on frozen section analysis.

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Abnormal cell-clearance and accumulation of autophagic vesicles in lymphocytes from patients affected with Ataxia-Teleangiectasia

Publication date: Available online 30 November 2016
Source:Clinical Immunology
Author(s): Roberta D'Assante, Anna Fusco, Loredana Palamaro, Elena Polishchuk, Roman Polishchuk, Gabriella Bianchino, Vitina Grieco, Maria Rosaria Prencipe, Andrea Ballabio, Claudio Pignata

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Long-term Symptom-specific Outcomes for Patients With Petrous Apex Cholesterol Granulomas: Surgery Versus Observation.

Objective: Review long-term symptom-specific outcomes for petrous apex cholesterol granulomas (PACG). Study Design: Retrospective review. Setting: Tertiary center. Patients: Adults with PACG were assessed from 1998 to 2015. Intervention(s): Symptomatic patients were stratified into surgical and observation subgroups. Main Outcome Measure(s): Resolution rates of individual symptoms and chief complaints were assessed as was the impact of surgical approach and stent usage on symptom-specific outcomes. Symptom recurrence rates were tabulated. Results: Twenty-seven patients were included whose mean age was 44.8 +/- 3.3 years. Fourteen and 13 patients stratified into the surgical and observation subgroups respectively. The surgical subgroup trended toward a longer follow-up period (mean 68.5 vs. 33.8 mo; p = 0.06). Overall, the most frequent symptoms encountered were headache (52%), aural fullness, tinnitus, and vestibular complaints (41% each). Visual complaints, retro-orbital pain, and cranial neuropathies were less common (18%, 15%, 11%). The overall symptom resolution rate was significantly higher in the surgical subgroup (48% vs. 26%, p = 0.03). In both subgroups, headache, retro-orbital pain, and visual complaints had the highest resolution rates. Vestibular complaints and tinnitus were very unlikely to resolve. Significantly more patients in the surgical group resolved their chief complaints (70% vs. 25%, p = 0.02). While approach type and stent usage did not significantly influence symptom outcomes, all patients with symptom recurrence (11%) were initially managed without stents. Conclusion: Symptom-specific outcomes were better in patients managed surgically for PACG. Individual symptom resolution rates were highly variable. Some symptoms were refractory regardless of management strategy. Surgical approach and stent usage did not significantly influence symptom outcomes. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Initial Results of a Safety and Feasibility Study of Auditory Brainstem Implantation in Congenitally Deaf Children.

Objective: To determine the safety and feasibility of the auditory brainstem implant (ABI) in congenitally deaf children with cochlear aplasia and/or cochlear nerve deficiency. Study Design: Phase I feasibility clinical trial of surgery in 10 children, ages 2 to 5 years, over a 3-year period. Setting: Tertiary children's hospital and university-based pediatric speech/language/hearing center. Intervention(s): ABI implantation and postsurgical programming. Main Outcome Measure(s): The primary outcome measure is the number and type of adverse events during ABI surgery and postsurgical follow-up, including behavioral mapping of the device. The secondary outcome measure is access to and early integration of sound. Results: To date, nine children are enrolled. Five children have successfully undergone ABI surgery and postoperative behavioral programming. Three children were screen failures, and one child is currently undergoing candidacy evaluation. Expected adverse events have been documented in three of the five children who received the ABI. One child experienced a cerebral spinal fluid leak, which resolved with lumbar drainage. One child demonstrated vestibular side effects during device programming, which resolved by deactivating one electrode. One child experienced postoperative vomiting resulting in an abdominal radiograph. Four children have completed their 1-year follow-up and have speech detection thresholds of 30 to 35 dB HL. Scores on the IT-MAIS/MAIS range from 8 to 31 (out of a total of 40), and the children are demonstrating some ability to discriminate between closed-sets words that differ by number of syllables (pattern perception). Conclusion: ABI surgery and device activation seem to be safe and feasible in this preliminary cohort. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Facial Nerve Meningioma: A Cause of Pediatric Facial Weakness.

Objective: To present an unusual case of a temporal bone meningioma with intrafascicular spread throughout the temporal facial nerve from cerebellopontine angle (CPA) to stylomastoid foramen. Patient: Four-year-old female with progressive facial weakness and normal hearing. Main Outcome Measure: Clinical, radiological, and histopathological findings of temporal bone meningiomas. Results: A patient presented with progressive facial weakness and normal hearing. Imaging demonstrated a mass within the left internal auditory canal radiologically consistent with a schwannoma. Asymmetric enlargement with enhancement of the left facial nerve from CPA to the stylomastoid foramen suggested facial schwannoma. At surgery, gross tumor was noted in the internal auditory canal, the fallopian canal seemed expanded and the facial nerve was enlarged and had an irregular contour. Resection of the facial nerve from the CPA to just proximal to its exit at the stylomastoid foramen was necessary to achieve negative margins. Cable grafting was performed. The histopathologic diagnosis was transitional meningioma with intraneural growth throughout the length of the resected facial nerve segment. Conclusion: Meningiomas involving the temporal bone are exceedingly rare. We report a rare case of a child presenting with progressive facial weakness due to a presumed facial schwannoma spreading along the facial nerve throughout its intratemporal course that at surgery was found to be an intrafascicular CN VII meningioma. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Effects of Intratympanic Dexamethasone on High-Dose Radiation Ototoxicity In Vivo.

Background: Stereotactic radiosurgery for lateral skull base tumors can cause hearing loss when the cochleae are exposed to high doses of single-fraction radiation. Currently, there are no known nondosimetric preventative treatments for radiation-induced ototoxicity. Hypothesis: Intratympanic (IT) dexamethasone (DXM), a synthetic steroid, protects against radiation-induced auditory hair cell (HC) and hearing losses in rats in vivo. Methods: Seven rats received radiation (12 Gy) to both cochleae. In irradiated rats and six nonirradiated rats, IT DXM was randomized to one ear, while tympanic puncture without DXM was performed on the contralateral ear. Baseline and 4-week postradiation auditory-evoked potential tests were performed. The cochleae were processed for HC viability. Results: Cochleae exposed to radiation demonstrated more outer HC (OHC) loss in all turns than nonirradiated ears (p

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Effect of Spatial Orientation of the Horizontal Semicircular Canal on the Vestibulo-ocular Reflex.

Objective: To determine if an alignment of the horizontal semi-circular canal (hSCC) with the plane of rotation would enhance the vestibular-ocular reflex (VOR) gain result as it has been previously suggested. Study Design: Comparative study of a physiological vestibular function test in healthy subjects. Setting: Tertiary referral center for otology and neurotology. Patients: Twenty two healthy volunteers were recruited for this study. Their mean age was 25.6 years and the sex distribution was 14:8 (M:F). None of the subjects had a history of audiovestibular disorders. Intervention: The video Head Impulse Test (v-HIT) was performed with the hSCC in the conventional position (head upright, horizontal gaze) and also with the hSCC in-line with the earth horizontal. Main Outcome Measures: 1. the VOR gain at 60 ms, 2. the regression slope VOR gain, depending on the alignment of the hSCC with the plane of head rotation. Results: There was no significant difference between the results, either for the VOR gain at 60 ms, or the regression slope gain, when the two alternative head positions were compared. Conclusions: The data acquired in this study show that the VOR as measured by the v-HIT is not enhanced by aligning the plane of the hSCC with the plane of rotation during the testing procedure. Hence, we recommend that the positioning of the patient, with the head upright and a horizontal gaze direction should be routinely used in the clinical evaluation of the angular VOR by v-HIT. Copyright (C) 2016 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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The Effect of Scala Tympani Morphology on Basilar Membrane Contact With a Straight Electrode Array: A Human Temporal Bone Study: Erratum.

No abstract available

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Long-term Symptom-specific Outcomes for Patients With Petrous Apex Cholesterol Granulomas: Surgery Versus Observation.

Initial Results of a Safety and Feasibility Study of Auditory Brainstem Implantation in Congenitally Deaf Children.

Facial Nerve Meningioma: A Cause of Pediatric Facial Weakness.

Effects of Intratympanic Dexamethasone on High-Dose Radiation Ototoxicity In Vivo.

Effect of Spatial Orientation of the Horizontal Semicircular Canal on the Vestibulo-ocular Reflex.

Level of Evidence

NA Laryngoscope, 2016

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A novel thyroid cancer nodal map classification system to facilitate nodal localization and surgical management: The A to D map

Objectives/Hypothesis

To evaluate the effectiveness, reproducibility, and usability of our proposed nodal nomenclature and classification system employed for several years in our high-volume thyroid cancer unit, for the adequate localization and mapping of lymph nodes in thyroid cancer patients with extensive nodal disease.

Study Design

Retrospective review.

Methods

Thirty-three thyroid cancer patients with extensive nodal disease treated from January 2004 to May 2013 were included in our study. Preoperative ultrasound and computed tomography scans of these patients were reanalyzed by blinded radiologists to investigate the feasibility for the assignment of abnormal lymph nodes to compartments defined in our proposed nodal classification system and to identify areas of difficulty in the assignment.

Results

Analysis of nodal localization revealed a discrepancy in compartment agreement between the two radiologists in the assignment of abnormal nodes in nine patients (9/33, 27%). In six patients (6/33, 18%), discrepancy existed in labeling paratracheal and pretracheal nodes. In three patients (3/33, 9%), disagreement arose in the classification of retrocarotid nodes into lateral versus central compartment. A further refinement of the definition of key borderline regions of the pretracheal versus paratracheal and retrocarotid regions of our classification improved the agreement and demonstrated a complete concordance (100%) amongst the reviewing radiologists.

Conclusions

The proposed nodal classification system, derived specifically for differentiated thyroid carcinoma, with readily identifiable anatomic boundaries on imaging and at surgery, facilitates communication among multidisciplinary physicians and aids in creating a uniform and reproducible radiographic nodal map to guide surgical therapy.

Level of Evidence

4 Laryngoscope, 2016

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Variable Cold-Induced Brown Adipose Tissue Response to Thyroid Hormone Status

Thyroid , Vol. 0, No. 0.

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Response by Parikh and Kamel to Letter Regarding Article, “Stroke Risk and Mortality in Patients With Ventricular Assist Devices” [Letters to the Editor]

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Letter by Jennings Regarding Article, “Stroke Risk and Mortality in Patients With Ventricular Assist Devices” [Letters to the Editor]

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Drip and Ship Versus Direct to Comprehensive Stroke Center [Comments and Opinions]

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Rehabilitation Augments Hematoma Clearance and Attenuates Oxidative Injury and Ion Dyshomeostasis After Brain Hemorrhage [Original Contributions]

Background and Purpose—We assessed the elemental and biochemical effects of rehabilitation after intracerebral hemorrhage, with emphasis on iron-mediated oxidative stress, using a novel multimodal biospectroscopic imaging approach.Methods—Collagenase-induced striatal hemorrhage was produced in rats that were randomized to enriched rehabilitation or control intervention starting on day 7. Animals were euthanized on day 14 or 21, a period of ongoing cell death. We used biospectroscopic imaging techniques to precisely determine elemental and molecular changes on day 14. Hemoglobin content was assessed with resonance Raman spectroscopy. X-ray fluorescence imaging mapped iron, chlorine, potassium, calcium, and zinc. Protein aggregation, a marker of oxidative stress, and the distribution of other macromolecules were assessed with Fourier transform infrared imaging. A second study estimated hematoma volume with a spectrophotometric assay at 21 days.Results—In the first experiment, rehabilitation reduced hematoma hemoglobin content (P=0.004) and the amount of peri-hematoma iron (P<0.001). Oxidative damage was highly localized at the hematoma/peri-hematoma border and was decreased by rehabilitation (P=0.004). Lipid content in the peri-hematoma zone was increased by rehabilitation (P=0.016). Rehabilitation reduced the size of calcium deposits (P=0.040) and attenuated persistent dyshomeostasis of Cl− (P<0.001) but not K+ (P=0.060). The second study confirmed that rehabilitation decreased hematoma volume (P=0.024).Conclusions—Rehabilitation accelerated clearance of toxic blood components and decreased chronic oxidative stress. As well, rehabilitation attenuated persistent ion dyshomeostasis. These novel effects may underlie rehabilitation-induced neuroprotection and improved recovery of function. Pharmacotherapies targeting these mechanisms may further improve outcome.

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Perioperative Antihypertensive Treatment in Patients With Spontaneous Intracerebral Hemorrhage [Brief Reports]

Background—Studies on antihypertensive treatment for surgical patients with spontaneous intracerebral hemorrhage are insufficient. This pilot study was conducted to investigate the safety of the perioperative intensive blood pressure lowering in surgical patients with spontaneous intracerebral hemorrhage.Methods—This study was a prospective, parallel, randomized, assessor-blinded trial. Patients allocated to the intensive group received perioperative intensive antihypertensive treatment aiming to achieve a target systolic blood pressure between 120 and 140 mm Hg, whereas the patients in the conservative group received conservative treatment aiming to achieve a target systolic blood pressure between 140 and 180 mm Hg for 7 days. The primary outcome was the rate of rehemorrhage at 7 days after surgery.Results—Rehemorrhage was noted in 11 patients (11%) in the intensive group and 14 (14%) in the conservative group (P=0.689). There was no significant difference in mortality at 7 days (4.0% versus 10.0%; P=0.164), 30 days (10.4% versus 17.2%; P=0.247), and 90 days (13.5% versus 18.2%; P=0.490) between the 2 groups.Conclusions—Perioperative intensive blood pressure lowering was not associated with a reduced incidence of rehemorrhage, death, or other serious adverse events.Clinical Trial Registration—URL: http://ift.tt/1hvxAeO. Unique identifier: ChiCTR-TRC-13004304.

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Estimating the Risks of Adverse Radiation Effects After Gamma Knife Radiosurgery for Arteriovenous Malformations [Original Contributions]

Background and Purpose—We evaluated risk factors associated with the development of adverse radiation effects (ARE) after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs).Methods—We evaluated 755 patients with AVM who underwent a single Gamma Knife SRS procedure with at least a 2-year minimum follow-up. Eighty-seven patients (12%) underwent previous resection and 128 (17%) had previous embolization. The median target volume was 3.6 mL (range, 0.1–26.3 mL). The median margin dose was 20 Gy (range, 13–27 Gy).Results—Fifty-five patients (7%) developed symptomatic ARE at a median follow-up of 75 months. The cumulative rates of symptomatic ARE were 3.2%, 5.8%, 6.7%, and 7.5% at 1, 2, 3, and 5 years, respectively. Factors associated with a higher rate of developing symptomatic ARE included larger AVM volume, higher margin dose, larger 12-Gy volume, higher Spetzler–Martin grade, and higher radiosurgery-based score. The rates of developing symptomatic ARE were higher in the brain stem (22%) or thalamus (16%), compared with AVMs located in other brain locations (4%–8%). Nineteen patients (3%) sustained irreversible new neurological deficits related to ARE, and 1 patient died. The rates of irreversible symptomatic ARE were 0.8%, 1.9%, 2.1%, and 2.8% at 1, 2, 3, and 5 years, respectively. The 5-year cumulative rates of irreversible symptomatic ARE were 9.1% in thalamus, 12.1% in brain stem, and 1.4% in other locations.Conclusions—The knowledge of ARE risk rates after AVM radiosurgery can assist informed consent for patients with AVM, their families, and healthcare providers.

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Association of Oxidized Low-Density Lipoprotein With Prognosis of Stroke and Stroke Subtypes [Original Contributions]

Background and Purpose—The association between oxidized low-density lipoprotein (oxLDL) and the long-term prognosis of stroke is unclear. The aim of this study is to investigate whether oxLDL levels contribute to the prognosis of stroke and stroke subtypes.Methods—All patients with ischemic stroke were recruited from the SOS-Stroke (Study of Oxidative Stress in Patients With Acute Ischemic Stroke) and classified into 5 different subtypes, according to the TOAST criteria (Trial of Org 10172 in Acute Stroke Treatment). We measured oxLDL levels and followed up with patients at 1 year after stroke onset. We analyzed the association between oxLDL and the clinical outcomes of death and poor functional outcome (modified Rankin Scale score of 3–6) of stroke and different stroke subtypes.Results—Among the 3688 patients included in this study, 293 (7.94%) were deceased at the 1-year follow-up and 1020 (27.66%) had a poor functional outcome. Patients in the highest oxLDL quartile had a higher risk of 1-year stroke mortality (hazard ratio, 1.61; 95% confidence interval, 1.10–2.33; P<0.001) and a poor functional outcome (odds ratio, 1.48; 95% confidence interval, 1.15–1.89; P<0.001) compared with the lowest oxLDL quartile. In the subgroup analyses, oxLDL was only significantly associated with death and poor functional outcome in the large-artery atherosclerosis subgroup (P<0.05) and small-artery occlusion subgroup (P<0.05).Conclusions—High levels of oxLDL were associated with the high risk of death and poor functional outcome within 1 year after stroke onset, especially in large-artery atherosclerosis and small-artery occlusion stroke subtypes.

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Temporal Evolution of Poststroke Cognitive Impairment Using the Montreal Cognitive Assessment [Original Contributions]

Background and Purpose—The Montreal Cognitive Assessment (MoCA) is nowadays recommended for the screening of poststroke cognitive impairment. However, little is known about the temporal evolution of MoCA-assessed cognition after stroke. The objective of this study was to examine the temporal pattern of overall and domain-specific cognition at 2 and 6 months after stroke using the MoCA and to identify patient groups at risk for cognitive impairment at 6 months after stroke.Methods—Prospective cohort study in which 324 patients were administered the MoCA at 2 and 6 months post stroke. Cognitive impairment was defined as MoCA<26. Differences in cognitive impairment rates between 2 and 6 months post stroke were analyzed in different subgroups. Patients with MoCA score <26 at 2 months, who improved by ≥2 points by 6 months, were defined as reverters. Logistic regression analyses were used to identify determinants of (1) cognitive impairment at 6 months post stroke and (2) reverter status.Results—Between 2 and 6 months post stroke, mean MoCA score improved from 23.7 (3.9) to 24.7 (3.5), P<0.001. Prevalence of cognitive impairment at 2 months was 66.4%, compared with 51.9% at 6 months (P<0.001). More comorbidity and presence of cognitive impairment at 2 months were significant independent predictors of cognitive impairment 6 months post stroke. No significant determinants of reverter status were identified.Conclusions—Although cognitive improvement is seen ≤6 months post stroke, long-term cognitive deficits are prevalent. Identifying patients at risk of cognitive impairment is, therefore, important as well as targeting interventions to this group.

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Air Pollution Is Associated With Ischemic Stroke via Cardiogenic Embolism [Original Contributions]

Background and Purpose—The aim of the study was to assessed the impact of short-term exposure to air pollution on ischemic stroke subtype, while focusing on stroke caused via cardioembolism.Methods—From a nationwide, multicenter, prospective, stroke registry database, 13 535 patients with acute ischemic stroke hospitalized to 12 participating centers were enrolled in this study. Data on the hourly concentrations of particulate matter <10 μm, nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and carbon monoxide (CO) were collected from 181 nationwide air pollution surveillance stations. The average values of these air pollutants over the 7 days before stroke onset from nearest air quality monitoring station in each patient were used to determine association with stroke subtype. The primary outcome was stroke subtype, including large artery atherosclerosis, small-vessel occlusion, cardioembolism, and stroke of other or undetermined cause.Results—Particulate matter <10 μm and SO2 concentrations were independently associated with an increased risk of cardioembolic stroke, as compared with large artery atherosclerosis and noncardioembolic stroke. In stratified analyses, the proportion of cases of cardioembolic stroke was positively correlated with the particulate matter <10 μm, NO2, and SO2 quintiles. Moreover, seasonal and geographic factors were related to an increased proportion of cardioembolic stroke, which may be attributed to the high levels of air pollution.Conclusions—Our findings suggest that the short-term exposure to air pollutants is associated with cardioembolic stroke, and greater care should be taken for those susceptible to cerebral embolism during peak pollution periods. Public and environmental health policies to reduce air pollution could help slow down global increasing trends of cardioembolic stroke.

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Transcranial Direct Current Stimulation Potentiates Improvements in Functional Ability in Patients With Chronic Stroke Receiving Constraint-Induced Movement Therapy [Brief Reports]

Background and Purpose—Transcranial direct current stimulation may enhance effect of rehabilitation in patients with chronic stroke. The objective was to evaluate the efficacy of anodal transcranial direct current stimulation combined with constraint-induced movement therapy of the paretic upper limb.Methods—A total of 44 patients with stroke were randomly allocated to receive 2 weeks of constraint-induced movement therapy with either anodal or sham transcranial direct current stimulation. The primary outcome measure, Wolf Motor Function Test, was assessed at baseline and after the intervention by blinded investigators.Results—Both groups improved significantly on all Wolf Motor Function Test scores. Group comparison showed improvement on Wolf Motor Function Test in the anodal group compared with the sham group.Conclusions—Anodal transcranial direct current stimulation combined with constraint-induced movement therapy resulted in improvement of functional ability of the paretic upper limb compared with constraint-induced movement therapy alone.Clinical Trial Registration—URL: http://ift.tt/1xHjpsE. Unique identifier: NCT01983319.

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Coagulation Testing in Acute Ischemic Stroke Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants [Original Contributions]

Background and Purpose—In patients who present with acute ischemic stroke while on treatment with non–vitamin K antagonist oral anticoagulants (NOACs), coagulation testing is necessary to confirm the eligibility for thrombolytic therapy. We evaluated the current use of coagulation testing in routine clinical practice in patients who were on NOAC treatment at the time of acute ischemic stroke.Methods—Prospective multicenter observational RASUNOA registry (Registry of Acute Stroke Under New Oral Anticoagulants; February 2012–2015). Results of locally performed nonspecific (international normalized ratio, activated partial thromboplastin time, and thrombin time) and specific (antifactor Xa tests, hemoclot assay) coagulation tests were documented. The implications of test results for thrombolysis decision-making were explored.Results—In the 290 patients enrolled, nonspecific coagulation tests were performed in ≥95% and specific coagulation tests in 26.9% of patients. Normal values of activated partial thromboplastin time and international normalized ratio did not reliably rule out peak drug levels at the time of the diagnostic tests (false-negative rates 11%–44% [95% confidence interval 1%–69%]). Twelve percent of patients apparently failed to take the prescribed NOAC prior to the acute event. Only 5.7% (9/159) of patients in the 4.5-hour time window received thrombolysis, and NOAC treatment was documented as main reason for not administering thrombolysis in 52.7% (79/150) of patients.Conclusions—NOAC treatment currently poses a significant barrier to thrombolysis in ischemic stroke. Because nonspecific coagulation test results within normal range have a high false-negative rate for detection of relevant drug concentrations, rapid drug-specific tests for thrombolysis decision-making should be established.Clinical Trial Registration—URL: http://ift.tt/PmpYKN. Unique identifier: NCT01850797.

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Patent Foramen Ovale and Cryptogenic Strokes in the Stroke in Young Fabry Patients Study [Original Contributions]

Background and Purpose—A patent foramen ovale (PFO) is disproportionately prevalent in patients with cryptogenic stroke. Without alternative explanations, it is frequently considered to be causative. A detailed stratification of these patients may improve the identification of incidental PFO.Methods—We investigated the PFO prevalence in 3497 transient ischemic attack and ischemic stroke patients aged 18 to 55 years in the prospective multicenter SIFAP1 study (Stroke in Young Fabry Patients 1) using the ASCO classification. Patients without an obvious cause for transient ischemic attack/stroke (ASCO 0) were divided into subgroups with and without vascular risk factors (ASCO 0+ and 0−). In addition, we looked for PFO-related magnetic resonance imaging lesion patterns.Results—PFO was identified in 25% of patients. Twenty percent of patients with a definite or probable cause of transient ischemic attack/stroke (≥1 grade 1 or 2 ASCO criterion; n=1769) had a PFO compared with 29% of cryptogenic stroke patients (ASCO 0 and 3; n=1728; P<0,001); subdivision of cryptogenic strokes revealed a PFO in 24% of 978 ASCO 3 patients (n.s. versus ASCO 1 and 2) and a higher prevalence of 36% in 750 ASCO 0 cases (P<0.001 versus ASCO 3 and versus ASCO 1 and 2). PFO was more commonly observed in ASCO 0− (n=271) than in ASCO 0+ patients (n=479; 48 versus 29%; P<0.001). There was no PFO-associated magnetic resonance imaging lesion pattern.Conclusions—Cryptogenic stroke patients demonstrate a heterogeneous PFO prevalence. Even in case of less conclusive diseases like nonstenotic arteriosclerosis, patients should preferentially be considered to have a non-PFO-mediated stroke.Clinical Trial Registration—URL: http://ift.tt/PmpYKN. Unique identifier: NCT00414583.

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Circulating MicroRNAs as Novel Biomarkers of Stenosis Progression in Asymptomatic Carotid Stenosis [Original Contributions]

Background and Purpose—Progression of asymptomatic carotid artery stenosis (ACAS) in patients with >50% luminal narrowing is considered a potential risk factor for ischemic stroke; however, subclinical molecular biomarkers of ACAS progression are lacking. Recent studies suggest a regulatory function for several microRNAs (miRNAs) on the evolution of carotid plaque, but its role in ACAS progression is mostly unknown. The aim of our study was to investigate a wide miRNA panel in peripheral blood exosomes from patients with ACAS to associate circulating miRNA expression profiles with stenosis progression.Methods—The study included 60 patients with ACAS carrying >50% luminal narrowing. First, miRNA expression profiles of circulating exosomes were determined by Affymetrix microarrays from plasma samples of 16 patients from the cohort. Second, those miRNAs among the most differentially expressed in patients with ACAS progression were quantified by real-time polymerase chain reaction in a separate replication cohort of 39 subjects within the patient sample.Results—Our results showed that ACAS progression was associated with development of stroke. MiR-199b-3p, miR-27b-3p, miR-130a-3p, miR-221-3p, and miR-24-3p presented significant higher expression in those patients with ACAS progression.Conclusions—In conclusion, our study supports that specific circulating miRNA expression profiles could provide a new tool that complements the monitoring of ACAS progression, improving therapeutic approaches to prevent ischemic stroke.

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Ticagrelor in Acute Stroke or Transient Ischemic Attack in Asian Patients [Original Contributions]

Background and Purpose—In the SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes), ticagrelor was not superior to aspirin. Because of differences in patient demographics and stroke disease pattern in Asia, outcomes of ticagrelor versus aspirin were assessed among Asian patients in a prespecified exploratory analysis.Methods—Baseline demographics, treatment effects, and safety of ticagrelor and aspirin were assessed among Asian patients. Differences in outcomes between groups were assessed using Cox proportional hazard model.Results—A total of 3858 (29.2%) SOCRATES participants were recruited in Asia. Among the Asian patients, the primary end point event occurred in 186 (9.6%) of the 1933 patients treated with ticagrelor, versus 224 (11.6%) of the 1925 patients treated with aspirin (hazard ratio, 0.81; 95% confidence interval, 0.67–0.99). The exploratory P value for treatment-by-region interaction was 0.27. The primary end point event rate in the Asian subgroup was numerically higher than that in the non-Asian group (10.6% versus 5.7%; nominal P<0.01). Among the Asian patients, the rate of PLATO (Platelet Inhibition and Patient Outcomes)–defined major bleeding was similar in the ticagrelor group and the aspirin group (0.6% versus 0.8%; hazard ratio, 0.76; 95% confidence interval, 0.36–1.61).Conclusions—The event rates were numerically higher in the Asian patients. Among the Asian patients with acute stroke or transient ischemic attacks, there was a trend toward a lower hazard ratio in reducing risk of the primary end point of stroke, myocardial infarction, or death in the ticagrelor group.Clinical Trial Registration—URL: http://ift.tt/1xHjpsE. Unique identifier: NCT01994720.

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Cannabinoid Type-2 Receptor Drives Neurogenesis and Improves Functional Outcome After Stroke [Original Contributions]

Background and Purpose—Stroke is a leading cause of adult disability characterized by physical, cognitive, and emotional disturbances. Unfortunately, pharmacological options are scarce. The cannabinoid type-2 receptor (CB2R) is neuroprotective in acute experimental stroke by anti-inflammatory mechanisms. However, its role in chronic stroke is still unknown.Methods—Stroke was induced by permanent middle cerebral artery occlusion in mice; CB2R modulation was assessed by administering the CB2R agonist JWH133 ((6aR,10aR)-3-(1,1-dimethylbutyl)-6a,7,10,10a-tetrahydro-6,6,9-trimethyl-6H-dibenzo[b,d]pyran) or the CB2R antagonist SR144528 (N-[(1S)-endo-1,3,3-trimethylbicyclo-[2.2.1]-heptan-2-yl]-5-(4-chloro-3-methylphenyl)-1-(4-methylbenzyl)-pyrazole-3-carboxamide) once daily from day 3 to the end of the experiment or by CB2R genetic deletion. Analysis of immunofluorescence-labeled brain sections, 5-bromo-2́-deoxyuridine (BrdU) staining, fluorescence-activated cell sorter analysis of brain cell suspensions, and behavioral tests were performed.Results—SR144528 decreased neuroblast migration toward the boundary of the infarct area when compared with vehicle-treated mice 14 days after middle cerebral artery occlusion. Consistently, mice on this pharmacological treatment, like mice with CB2R genetic deletion, displayed a lower number of new neurons (NeuN+/BrdU+ cells) in peri-infarct cortex 28 days after stroke when compared with vehicle-treated group, an effect accompanied by a worse sensorimotor performance in behavioral tests. The CB2R agonist did not affect neurogenesis or outcome in vivo, but increased the migration of neural progenitor cells in vitro; the CB2R antagonist alone did not affect in vitro migration.Conclusions—Our data support that CB2R is fundamental for driving neuroblast migration and suggest that an endocannabinoid tone is required for poststroke neurogenesis by promoting neuroblast migration toward the injured brain tissue, increasing the number of new cortical neurons and, conceivably, enhancing motor functional recovery after stroke.

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Long-Term Risk of Dementia Among Survivors of Ischemic or Hemorrhagic Stroke [Original Contributions]

Background and Purpose—Stroke is a risk factor for dementia, but the risk of dementia after different stroke types is poorly understood. We examined the long-term risk of dementia among survivors of any first-time stroke and of first-time ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.Methods—We conducted a 30-year nationwide population-based cohort study using data from Danish medical databases (1982–2013) covering all Danish hospitals. We identified 84 220 ischemic stroke survivors, 16 723 intracerebral hemorrhage survivors, 9872 subarachnoid hemorrhage survivors, and 104 303 survivors of unspecified stroke types. Patients were aged ≥18 years and survived for at least 3 months after diagnosis. We formed a comparison cohort from the general population (1 075 588 patients without stroke, matched to stroke patients by age and sex). We computed absolute risks and hazard ratios of dementia up to 30 years after stroke.Results—The 30-year absolute risk of dementia among stroke survivors was 11.5% (95% confidence interval, 11.2%–11.7%). Compared with the general population, the hazard ratio (95% confidence interval) for dementia among stroke survivors was 1.80 (1.77–1.84) after any stroke, 1.72 (1.66–1.77) after ischemic stroke, 2.70 (2.53–2.89) after intracerebral hemorrhage, and 2.74 (2.45–3.06) after subarachnoid hemorrhage. Younger patients regardless of stroke type faced higher risks of poststroke dementia than older patients. The pattern of hazard ratios by stroke type did not change during follow-up and was not altered appreciably by age, sex, or pre-existing diagnoses of vascular conditions.Conclusions—Stroke increases dementia risk. Survivors of intracerebral hemorrhage and subarachnoid hemorrhage are at particularly high long-term risk of poststroke dementia.

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Favorable Swallowing Outcomes following Vagus Nerve Sacrifice for Vagal Schwannoma Resection

Objective

To determine the impact of unilateral vagal sacrifice for vagal schwannoma on postoperative swallowing function.

Study Design

Case series, chart review.

Setting

Academic medical institution.

Subjects and Methods

Ten patients underwent vagus nerve sacrifice for vagal schwannoma resection. Archived pathology records dating from 1985 through 2012 at our institution were retrospectively queried for cases of vagal schwannoma with vagus nerve sacrifice. Medical records were abstracted for demographic and disease information as well as cranial nerve and swallowing function. Preoperative and postoperative cranial nerve function, subjective and objective measures of swallowing function, Functional Oral Intake Scale (FOIS) level, and need for vocal fold medialization were variables collected. Data were analyzed with summary statistics.

Results

The patients who underwent vagal sacrifice for vagal schwannoma at our institution had a mean age of 42.3 years (median, 44 years; range, 15-63 years) and follow-up of 35.6 months (median, 9 months; range, 1-115 months). Most presented with no preoperative cranial nerve deficit or difficulty swallowing. Immediately postoperatively, 90% had a vagus nerve deficit, but 50% had no subjective difficulty swallowing, and 70% had a FOIS level of 7 at postoperative hospital discharge. Within 1 month after surgery, 70% had normal swallowing function according to a modified barium swallow study. A full diet was tolerated by mouth within an average of 2.7 days (median, 2 days; range, 1-6 days) after surgery in this cohort. Seventy percent required vocal fold medialization postoperatively for incomplete glottic closure.

Conclusion

Vagal nerve sacrifice during resection of vagal schwannoma can be performed with normal postoperative swallowing function.

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#PlasticSurgery

Background: Social media use is growing inexorably, and there is public appetite for evidence-based information. Little is known about engagement by plastic surgeons with social media. The aim of this study was to examine posting about plastic surgery on Twitter, to best inform how board-certified plastic surgeons could use the hashtag #PlasticSurgery as a tool to educate patients and the public. Methods: A prospective analysis of 2880 "tweets" containing the words "plastic surgery" was performed. The following were assessed: identity of author, use of the hashtag #PlasticSurgery, subject matter, whether link to study was provided, and whether posts by surgeons were self-promotional or educational. Results: Social media posting about plastic surgery is dominated by the public, accounting for 70.6 percent of posts versus only 6.0 percent by plastic surgeons. Only 5.4 percent of all tweets contained the hashtag #PlasticSurgery, although almost half of those that did were by plastic surgeons. Of these, 61.3 percent of posts by plastic surgeons were about aesthetic surgery; additional posts were about basic science, patient safety, and reconstruction (13.9, 4.0, and 2.3 percent, respectively). Eighteen scientific articles were referenced, with a link to the Journal site posted in two tweets. Of posts by plastic surgeons, 37.0 percent were self-promotional. Conclusions: The American Society of Plastic Surgeons and its Journal have recognized that social media may be used to educate and engage. Board-certified plastic surgeons have a great opportunity to promote evidence-based plastic practice by means of #PlasticSurgery in the interests of supporting patients and the profession.

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Separation, Aspiration, and Fat Equalization: SAFE Liposuction Concepts for Comprehensive Body Contouring

Background: Separation, aspiration, and fatty equilibration (SAFE) liposuction uses a process approach to body contouring and minimizes injury to surrounding structures. The multistep process allows for (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The purpose of this study was to review both outcomes and complications of primary SAFE liposuction. Methods: Retrospective chart review was completed of patients undergoing SAFE liposuction from January of 2006 to January of 2011. Patient selection was limited to those undergoing liposuction alone with no adjuvant excisional procedures. Data were collected regarding demographics, body mass index, operative details, and outcomes. Results: Seven hundred thirty-four patients were identified as having undergone SAFE liposuction. One hundred twenty-nine patients were found to have been treated with liposuction alone. Patient age ranged from 18 to 42 years and body mass index ranged from 18 to 42 kg/m2 (mean, 26.3 kg/m2). Seven patients (5.4 percent) underwent treatment of the face and neck, six patients (4.7 percent) underwent treatment of upper extremities, 13 patients (10.1 percent) underwent treatment of the chest, 20 patients (15.5 percent) underwent treatment of lower extremities, 32 patients (24.8 percent) underwent treatment of the circumferential trunk, and 51 patients (39.5 percent) underwent treatment of circumferential trunk and additional area(s). No major complications occurred. Five of the 129 patients (3.87 percent) developed the minor complication of seroma formation. Conclusions: SAFE liposuction is a multistep process approach to body contouring consisting of (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The results of this study show such technique to be safe and effective. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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The Essential Burn Unit Handbook, 2nd Edition

No abstract available

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Recurrent Massive Epistaxis from an Anomalous Posterior Ethmoid Artery

A 50-year-old man, with no previous history of epistaxis, was hospitalized at our facility for left recurrent posterior epistaxis. The patient underwent surgical treatment three times and only the operator's experience and radiological support (cranial angiography) allowed us to control the epistaxis and stop the bleeding. The difficult bleeding management and control was attributed to an abnormal course of the left posterior ethmoidal artery. When bleeding seems to come from the roof of the nasal cavity, it is important to identify the ethmoid arteries always bearing in mind the possible existence of anomalous courses.

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Neural Correlates of the Binaural Masking Level Difference in Human Frequency-Following Responses

Abstract

The binaural masking level difference (BMLD) is an auditory phenomenon where binaural tone-in-noise detection is improved when the phase of either signal or noise is inverted in one of the ears (S_πN_o or S_oN_π, respectively), relative to detection when signal and noise are in identical phase at each ear (S_oN_o). Processing related to BMLDs and interaural time differences has been confirmed in the auditory brainstem of non-human mammals; in the human auditory brainstem, phase-locked neural responses elicited by BMLD stimuli have not been systematically examined across signal-to-noise ratio. Behavioral and physiological testing was performed in three binaural stimulus conditions: S_oN_o, S_πN_o, and S_oN_π. BMLDs at 500 Hz were obtained from 14 young, normal-hearing adults (ages 21–26). Physiological BMLDs used the frequency-following response (FFR), a scalp-recorded auditory evoked potential dependent on sustained phase-locked neural activity; FFR tone-in-noise detection thresholds were used to calculate physiological BMLDs. FFR BMLDs were significantly smaller (poorer) than behavioral BMLDs, and FFR BMLDs did not reflect a physiological release from masking, on average. Raw FFR amplitude showed substantial reductions in the S_πN_o condition relative to S_oN_o and S_oN_π conditions, consistent with negative effects of phase summation from left and right ear FFRs. FFR amplitude differences between stimulus conditions (e.g., S_oN_o amplitude–S_πN_o amplitude) were significantly predictive of behavioral S_πN_o BMLDs; individuals with larger amplitude differences had larger (better) behavioral B MLDs and individuals with smaller amplitude differences had smaller (poorer) behavioral B MLDs. These data indicate a role for sustained phase-locked neural activity in BMLDs of humans and are the first to show predictive relationships between behavioral BMLDs and human brainstem responses.

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Natural Compounds as Occult Ototoxins? Ginkgo biloba Flavonoids Moderately Damage Lateral Line Hair Cells

Abstract

Several drugs, including aminoglycosides and platinum-based chemotherapy agents, are well known for their ototoxic properties. However, FDA-approved drugs are not routinely tested for ototoxicity, so their potential to affect hearing often goes unrecognized. This issue is further compounded for natural products, where there is a lack of FDA oversight and the manufacturer is solely responsible for ensuring the safety of their products. Natural products such as herbal supplements are easily accessible and commonly used in the practice of traditional eastern and alternative medicine. Using the zebrafish lateral line, we screened a natural products library to identify potential ototoxins. We found that the flavonoids quercetin and kaempferol, both from the Gingko biloba plant, demonstrated significant ototoxicity, killing up to 30 % of lateral line hair cells. We then examined a third Ginkgo flavonoid, isorhamnetin, and found similar levels of ototoxicity. After flavonoid treatment, surviving hair cells demonstrated reduced uptake of the vital dye FM 1-43FX, suggesting that the health of the remaining hair cells was compromised. We then asked if these flavonoids enter hair cells through the mechanotransduction channel, which is the site of entry for many known ototoxins. High extracellular calcium or the quinoline derivative E6 berbamine significantly protected hair cells from flavonoid damage, implicating the transduction channel as a site of flavonoid uptake. Since known ototoxins activate cellular stress responses, we asked if reactive oxygen species were necessary for flavonoid ototoxicity. Co-treatment with the antioxidant D-methionine significantly protected hair cells from each flavonoid, suggesting that antioxidant therapy could prevent hair cell loss. How these products affect mammalian hair cells is still an open question and will be the target of future experiments. However, this research demonstrates the potential for ototoxic damage caused by unregulated herbal supplements and suggests that further supplement characterization is warranted.

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A Cure for Congenital Hearing Loss

Kazusaku Kamiya, MD, PhD, and his colleagues replicated cochlear cells that could potentially be used to replace faulty ones in patients with hearing loss caused by mutation of the Gap Junction Beta 2 (GJB2) gene (Stem Cell Reports. 2016). The researchers from Jutendo University in Tokyo, Japan, produced induced pluripotent stem cells aimed at correcting this inherited condition, which causes disruption of gap junction plaques in the cochlea and leads to profound sensorineural hearing loss. They demonstrated in a mouse model that the stem-cell-derived gap junction cells were functional for forming gap junction intercellular communication networks and transient ion species typical of the developing cochlea. The authors of the study hoped the in vitrol models could be used to develop inner-ear therapies and drug screening that target GJB2-related hearing loss.

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Figure. Schematic of In Vitro iPSC Differentiation into Functional iCx26GJCs and Disease Model Cells for GJB2-Related Hearing Loss

Approximately one in 1,000 children has severe hearing loss at birth or during early childhood, with about half of the cases attributable to genetic causes. Mutation of the GJB2 gene is the most common cause of hereditary hearing loss worldwide and accounts for up to 50 percent of non-syndromic sensorineural hearing loss cases in some populations.

Published: 11/28/2016 11:34:00 AM

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Neural Correlates of the Binaural Masking Level Difference in Human Frequency-Following Responses

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Natural Compounds as Occult Ototoxins? Ginkgo biloba Flavonoids Moderately Damage Lateral Line Hair Cells

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How Deleterious Is Facial Nerve Dissection for the Facial Nerve in Parotid Surgery: An Electrophysiological Evaluation.

Objective: This study was conducted to investigate subclinical electrophysiological deleterious effect due to microtrauma to the nerve in response to the dissection of a tumor and parotid tissue from the facial nerve and its branches and surgical traction experienced during the operation. Methods: The study included 34 adult patients who underwent parotidectomy operations under intraoperative facial nerve monitoring. Three measurements were taken from each patient to evaluate facial nerve functions, with 3 stimuli of different intensities applied with different timing. An initial stimulus of 1 mA was applied to confirm the identification of the main trunk of the facial nerve (Group 1: Initial-Normal). Then, a threshold value was found by stimulating the main trunk until muscle fasciculations were observed on facial muscles (Group 2: Basal-Minimal). The same procedure was repeated after the tumor was resected (Group 3: Final-Minimal). Results: There was no significant difference between the stimulus thresholds of Group 2 (0.31 mA) and Group 3 (0.30 mA). The highest amplitude in all 3 groups was observed at the mental branch, and the lowest at the frontal. The highest latency value was measured at the frontal branch and the lowest at the mental branch. Five (14.7%) of the patients developed postoperative pareses that was completely resolved by the seventh postoperative day visit in these patients. Conclusion: This study demonstrated that the surgical trauma of a meticulously conducted dissection and surgical traction did not cause any deleterious electrophysiological alteration on the facial nerve. (C) 2016 by Mutaz B. Habal, MD.

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Application of Dexamethasone in the Masseter Muscle During the Surgical Removal of Lower Third Molars.

Purpose: The aim of the present study was to analyze the effect of the application of dexamethasone in the masseter muscle during third molar surgery. Methods: This randomized, clinical trial used dependent samples and the split-mouth method. A sample of 30 patients, with impacted or semi-impacted third molars, as well as vertical and mesioangular positions of a similar surgical difficulty (on both sides), was subjected to 2 operations: an experimental operation and a control procedure, with a 30-day wash-out. The choice of which group would be experimental or control was random. The experimental group received 8 mg of dexamethasone, which was applied directly to the masseter muscle immediately after surgery. The control group did not receive corticosteroids. Seven and 15 days after the surgery, the patients were assessed in relation to their levels of pain, trismus, and edema. Results: Concerning edema and trismus, there was a significant difference (P

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Mid-Face Degloving: An Alternate Approach to Extended Osteotomies of the Midface.

Extended osteotomies for mid-face advancement require generous exposure of the anterior maxilla, nasal bones, infraorbital rims, orbital floor, zygoma, and the anterior third of the zygomatic arches. This cannot be obtained with an exclusive transoral approach. Hence, the surgeon is usually compelled to utilize supplemental cutaneous incisions that are a compromise on the purpose behind a cosmetic surgery. In order to alleviate the need for such compromise, the authors advocate the mid face degloving approach for extended osteotomies at Lefort II and Lefort III levels. Mid face degloving involves a combination of circumvestibular incision, with inter cartilaginous and transfixation components from a nasal incision. The authors have utilized this technique for 9 patients and documented favorable results. The purpose of this paper is to focus the utility of this approach in orthognathic surgery and promote this as a viable alternative to traditional approaches in surgery of the mid face because of the absence of external scars. (C) 2016 by Mutaz B. Habal, MD.

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Πληροφορίες

Τετάρτη 30 Νοεμβρίου 2016

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Τρίτη 29 Νοεμβρίου 2016

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