Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis

Abstract

Purpose

Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy.

Methods

PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs.

Results

A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time.

Conclusions

This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

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Angiographic Appearance of Pulsatile Blister Aneurysm

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Ding Xu, Xiaodong Xie, Chao You
A male with detected subarachnoid hemorrhage was admitted to our center. During the first angiography, a pulsatile blister aneurysm was revealed and the aneurysm was also noticeably enlarged during the surveillance angiography. The patient accepted balloon-assisted clipping successfully. Blister aneurysms are at a high risk of rupture, high risk of regrowth, and need for multimodal management.



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Cerebral Hyperperfusion Syndrome After Endovascular Reperfusion Therapy in a Patient with Acute Internal Carotid Artery and Middle Cerebral Artery Occlusions

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Tetsuya Hashimoto, Shoji Matsumoto, Mitsushige Ando, Hideo Chihara, Atsushi Tsujimoto, Taketo Hatano
BackgroundCerebral hyperperfusion syndrome (CHS) is known to be a rare but devastating complication of carotid artery revascularization. Because patients with acute ischemic stroke due to acute major cerebral and/or cervical artery occlusion treated with endovascular reperfusion therapy may have impaired autoregulation in the cerebral vasculature, these patients may also develop CHS. Despite the growing number of endovascular reperfusion procedures for acute ischemic stroke, this complication has only rarely been reported.Case DescriptionA 77-year-old man developed acute cerebral infarction as the result of occlusions of the right internal carotid artery and right middle cerebral artery. After systemic intravenous injection of recombinant tissue-type plasminogen activator, endovascular reperfusion therapy was initiated. The occluded arteries were successfully recanalized with thrombectomy by using a stent retriever for the middle cerebral artery and stent placement for the origin of the internal carotid artery. However, head computed tomography obtained 12 hours after treatment showed acute intracranial hemorrhage that did not involve the ischemic lesions. Under evaluation with transcranial near-infrared spectroscopy and single-photon emission computed tomography, the hemorrhage was considered to have been caused by CHS after reperfusion therapy.ConclusionsCHS may lead to unfavorable outcomes after reperfusion therapy for acute ischemic stroke. Recognizing clinical deterioration caused by CHS can be challenging in patients with neurologic disorders of acute ischemic stroke. Therefore, it is important to perform routine monitoring of regional cerebral oxygen saturation by using near-infrared spectroscopy, perform single-photon emission computed tomography promptly to evaluate cerebral blood flow, and maintain strict antihypertensive therapy to prevent CHS after reperfusion therapy.



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What's New in Spinal Coccidioidomycosis?

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Salman Sharif, Nasr Hussain




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Dwell Time of Stentriever Influences Complete Revascularization and First-Pass TICI 3 Revascularization in Acute Large Vessel Occlusive Stroke

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Santhosh Kumar Kannath, Jayadevan Enakshy Rajan, P.N. Sylaja, P. Sankara Sarma, Sajith Sukumaran, Sapna Erat Sreedharan, Tirur Raman Kapilamoorthy
ObjectiveIn acute ischemic stroke with large vessel occlusion, the interaction between the clot retriever and the stent is critical for achieving successful recanalization. The ideal time of stent deployment (dwell time [DT]) to improve revascularization is currently unknown. We systematically analyzed the effect of different DT on final angiographic and clinical outcomes of patients who underwent mechanical thrombectomy.MethodsThe DT was progressively increased from 3 minutes to 5 minutes and then 8 minutes during the study period. The effect of DT on recanalization attempts, successful angiographic outcome (thrombolysis in cerebral ischemia [TICI] 2b or TICI 3), total revascularization time, and immediate and 3-month clinical outcomes were evaluated. The DT of 3 minutes and 5 minutes (DT3-5) was compared against DT of 8 minutes (DT8).ResultsForty patients were included in the analysis. Good angiographic outcome was observed in 94.1% of patients in the DT8 cohort with an average attempt of 1.2 compared with 78.3% with average attempts of 2.0 in other group. Single-pass good recanalization (TICI 2b or 3) and single-pass complete revascularization (TICI3) was significantly higher in the DT group compared with the DT3-5 group (82.4% vs. 43.5% [P = 0.013] and 42.9% vs. 8.7% [P = 0.003], respectively). A favorable trend toward a reduced overall procedural time (34.59 vs. 55.59 minutes) was observed, but was not statistically significant (P = 0.15).ConclusionsMild prolongation of DT to 8 minutes improves revascularization outcome with fewer attempts, possibly because of better clot–stent interaction.



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Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma: Endovascular Embolization Combined with Drainage Surgery and Use of Urokinase

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Yuhui Zhang, Qiang Li, Rui Zhao, Zhigang Yang, Yanan Li, Weijie Min, Zhijian Yue, Jianmin Liu
BackgroundHematoma evacuation is regular treatment for acute traumatic epidural hematoma (ATEDH) patients meeting with surgery indications. However, it is an invasive approach performed under general anesthesia. Here, a novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia.MethodsA novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia. Firstly, 23 ATEDH patients with hematomas in the temporal area underwent digital subtraction angiography detecting the bleeding point. Next, embolization was performed. After embolization, drainage surgery was taken and urokinase was injected into the hematoma cyst by drainage tube to lyse hematoma twice per day.ResultsThe results showed that the middle meningeal artery was the bleeding source. Embolization immediately ceased bleeding. Most clots were resolved and drained after treatment. No recurrence of hematoma or infection was observed.ConclusionThe findings suggest that the combined treatments can be an alternative minimally invasive option for ATEDHs, especially for elderly patients or those contraindicated for general anesthesia.



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Retrosigmoid Intradural Suprameatal-Inframeatal Approach for Complete Surgical Removal of a Giant Recurrent Vestibular Schwannoma with Severe Petrous Bone Involvement: Technical Case Report

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Yosuke Sato, Tohru Mizutani, Katsuyoshi Shimizu, Hans-Joachim Freund, Madjid Samii
BackgroundSurgical removal of giant vestibular schwannomas with severe petrous bone involvement remains challenging due to the high risk of complications. The retrosigmoid intradural suprameatal-inframeatal approach (RISIA) allows for safe exposure extending from Meckel's cave to the petrous internal carotid artery (ICA).Case DescriptionA 27-year-old man presented with recurrence of a giant vestibular schwannoma (4.5 cm) invading Meckel's cave and the left petrous ICA. Symptoms included complete left facial palsy and hearing loss due to tumor invasion and previous operations, as well as left-sided trigeminal hypesthesia, abducens nerve palsy, and lower cranial nerve dysfunction due to tumor compression. The patient also exhibited severe discoordination and ataxia. The tumor was completely resected via the RISIA, which involved drilling of the suprameatal and inframeatal portions of the petrous bone. No approach-related complications were observed. Full recovery of cranial nerve functions (with the exception of those related to the facial and cochlear nerves) and balance were observed postoperatively.ConclusionsThe RISIA allows for safe and effective surgical access during complete tumor resection, even when severe involvement of Meckel's cave and the petrous ICA are observed. The present report is the first to demonstrate the usefulness of this approach in patients with recurrent giant vestibular schwannoma.



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Microsurgical Treatment of Ruptured Intracranial Aneurysms in Sub-Saharan Africa: A Series of 102 Consecutive Cases Treated in Senegal

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Mbaye Thioub, Maguette Mbaye, Alioune Badara Thiam, Christophe Zirhumana, Cheikh Sy, Ndaraw Ndoye, Momar Codé Ba, Seydou boubakar Badiane
IntroductionIn sub-Saharan Africa, the management of ruptured intracranial aneurysms (RIAs) is difficult for many reasons. In this retrospective, 3-year study, the authors will demonstrate the particularities of the management of RIAs in Senegal.MethodsWe analyzed retrospectively 102 consecutive cases of RIAs operated on between May 2013 and December 2016 in Neurosurgical Department of Fann Hospital in Dakar, Senegal. Patients characteristics, imaging results, aneurysms, treatment, and outcome were analyzed.ResultsOne hundred two cases were operated in this 3-year period of a total of 129 cases of RIAs received in our department in the same period. A total of 65% of the patients were female. According to the World Federation of Neurosurgical Societies (WFNS) scale, 49% were WFNS I, and 33% WFNS III. Fisher scale showed 29% of Fisher 2 and 45% of Fisher 4. The aneurysms were located on anterior communicating complex in 38%, on the internal carotid artery in 28%, on the middle cerebral artery in 27% of cases and on posterior circulation in 9 cases. The pterional approach was used in 93 cases. According to the modified Rankin Scale, 67 patients (65.6%) had good outcome, 22 (21.5%) had poor outcome, and the mortality rate was 12.7% (13 patients) at last follow-up.ConclusionsThis study demonstrates encouraging results if one refers to the global patient postoperative outcomes. However, the large number of patients not undergoing treatment also requires us to improve preoperative management conditions.



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Efficiency and Safety of Autologous Fat Grafts in Reconstructing Skull Base Defects After Resection of Skull Base Meningiomas

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Hussam Metwali, Venelin Gerganov, Breno Nery, Ahmed Aly, Rodrigo Avila-Cervantes, Madjid Samii
BackgroundReconstruction of the skull base after resection of skull base meningiomas is of paramount importance. Here we describe a safe and effective method of skull base reconstruction using autologous free fat grafts.MethodsIn this retrospective analysis of patients operated for skull base meningioma from 2007 to 2014. We analyzed the surgical technique, efficiency and safety as well as the graft-related complications.ResultsAutologous free fat grafts were used in 55 patients, including 39 patients with posterior fossa meningiomas related to the petrous bone and 16 patients with anterior fossa meningiomas related to the paranasal sinuses. Three patients experienced postoperative cerebrospinal fluid (CSF) leak and were managed with temporary continuous lumbar drainage. One patient developed pneumocephalus and required revision. The occurrence of CSF leak was related to aggressive resection with resulting large skull base defects, especially in anterior skull base meningiomas. There were no donor site–related complications.ConclusionsThe use of autologous free fat grafts is an effective and safe technique for reconstructing skull base defects after microsurgical resection of skull base meningiomas.



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Optic Nerve Meningioma Mimicking Cavernous Hemangioma

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Alexia Savignac, Augustin Lecler
A 38-year-old woman presented with rapidly worsening, painless right monocular vision loss. An examination revealed a visual acuity of 1.4/10 and a central scotoma in the right eye. The orbital magnetic resonance imaging (MRI) showed a well-delineated ovoid intraconal mass of the right eye, hyperintense on T2-weighted MRI with homogenous enhancement after contrast injection. The mass abutted and displaced the optic nerve. A diagnosis of cavernous hemangioma was evoked, which is the most common benign adult orbital mass with these MRI features. A biopsy was performed, and the histopathologic examination yielded a diagnosis of optic nerve sheath meningioma based on a positive antiprogesterone receptor antibody immunostaining.Our case highlights the problem with establishing a specific pathologic diagnosis based on MRI alone, even though the morphologic aspect is evocative. It is recommended to always conduct a histopathologic examination before establishing a specific diagnosis as pathology remains the gold standard, especially when the course of action or treatment may change, as in our case.



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History, Current Situation, and Future Development of Endoscopic Neurosurgery in China

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Chuzhong Li, Haibo Zhu, Xuyi Zong, Xinsheng Wang, Songbai Gui, Peng Zhao, Yazhuo Zhang
ObjectiveDuring the past few decades, Chinese endoscopic neurosurgery has rapidly developed in synchrony with the rest of the world. The aim of this article is to review the development of Chinese endoscopic neurosurgery, including its birth, growth, current situation, and prospects.MethodsThe history of Chinese endoscopic neurosurgery development can be divided into 3 stages: cognition and initial stage (1964–1995), exploration and maturity stage (1995–2006), and rapid development and promotion stage (2006–present).ResultsIn the first stage, we mainly began to become aware of endoscopic neurosurgery from the translation and review of literature. In the mid to late 1990s, Chinese neurosurgery pioneers began using neuroendoscopic techniques. In the following decade, many leading neurosurgeons made persistent efforts to push the development of Chinese endoscopic neurosurgery forward, focusing on advocating for and promoting and popularizing neuroendoscopic technology. In the rapid development and promotion stage, many representative national and regional neurosurgical centers became skilled and efficient in the application of neuroendoscopic technology and became new advocates of the technology. The number of cases, level of technology, and treatment effectiveness are gradually nearing international standards. However, future development requires promotion of balanced development to decrease regional disparities, further strengthen international exchanges, follow the latest developments, and constantly innovate for continuous improvement.ConclusionsFollowing the dramatic efforts of several pioneers, development of Chinese endoscopic neurosurgery has been considerable, and it has become an important component of neurosurgery worldwide.



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Systematic Review of Woven EndoBridge for Wide-Necked Bifurcation Aneurysms: Complications, Adequate Occlusion Rate, Morbidity, and Mortality

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Xianli Lv, Yupeng Zhang, Weijian Jiang
BackgroundAlthough the Woven EndoBridge (WEB [Sequent Medical, Aliso Viejo, California, USA]) is a highly innovative technique for the endovascular treatment of wide-necked bifurcation aneurysms (WNBAs), there are no studies available comparing this technique with surgical results or other endovascular results of stent-assisted coiling or balloon-assisted coiling for WNBAs. The purpose of this study was to assess complications, complete occlusion rate, and morbidity and mortality of the WEB in WNBA treatment.MethodsPublished literature citing embolization results for WNBAs using the WEB was reviewed. A systematic review was performed to evaluate the complications, complete occlusion rate, and morbidity and mortality.ResultsWe identified 19 studies, including 935 patients. The most frequent aneurysm locations were the bifurcation of the middle cerebral artery (MCA) (42.8%), the anterior communicating artery (23%), and the basilar bifurcation (20.8%). The technical success rate of the WEB was 97% (95% confidence interval [CI], 96%–98%). The thromboembolic complication rate was 8% (95% CI, 6%–11%). The thromboembolic complication rate was 10% (95% CI, 7%–13%) in cases before 2013, which was higher than in cases after 2013 (6%; 95% CI, 4%–9%; P = 0.045). MCA bifurcation aneurysm has a higher thromboembolic complication rate than posterior circulation aneurysm. The overall bleeding complication rate of the WEB was 2% (95% CI, 1%–3%). The adequate occlusion rate was 81% (95% CI, 76%–85%). Morbidity during follow-up was 3% (95% CI, 1%–4%) (I² = 30.4%), and mortality was 2% (95% CI, 1%–3%).ConclusionsAdequate aneurysm occlusion was found in 81% of WEB cases with low morbidity and mortality.



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Enterprise Deployment Through PulseRider To Treat Anterior Communicating Artery Aneurysm Recurrence

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Iacopo Valente, Nicola Limbucci, Sergio Nappini, Andrea Rosi, Antonio Laiso, Salvatore Mangiafico
BackgroundPulseRider (Pulsar Vascular, Los Gatos, California, USA) is a new endovascular device designed to treat wide-neck bifurcation intracranial aneurysms. Deployment of a stent through a PulseRider to treat an aneurysm's recurrence has never been described before.Case DescriptionWe report the case of a 55-year-old man who underwent coiling of an 8-mm anterior communicating artery aneurysm with assistance of a PulseRider neck reconstruction device. The 6-month digital subtraction angiography control showed aneurysm recurrence, so we deployed an Enterprise 2 closed-cell stent (Codman, Miami Lakes, Florida, USA) in the A1-A2 segment passing across the previously implanted PulseRider. Enterprise correctly expanded and allowed for adequate coiling of the aneurysm.ConclusionAn Enterprise stent can be safely opened through a PulseRider in order to treat aneurysm recurrence.



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Intraventricular Glioblastoma Multiforme in A Child with L2-Hydroxyglutaric Aciduria

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Ai Peng Tan, Kshitij Mankad
L2-hydroxyglutaric aciduria (L2-HGA) is a rare neurometabolic disease characterized by accumulation of L2-hydroxyglutarate (L2-HG), a potential oncometabolite resulting in significant lifetime risk for cerebral tumors. Herein, we present a case of intraventricular glioblastoma multiforme (GBM) in a 16-year-old child with L2-HGA who presented with rapid functional decline and persistent vomiting. The tumor was completely resected, and the patient remained well at 2-year follow-up. Clinicians should be aware of the usual insidious nature of the disease. Rapid deterioration is unusual and should raise the suspicion of tumor development. This case also illustrates the importance of surveillance neuroimaging in patients with L2-HGA. To the best of our knowledge, only 1 case of GBM has been reported and it was sited in the temporal lobe, unlike the unusual intraventricular location in our case.



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Pediatric Nonmissile Penetrating Head Injury: Case Series and Literature Review

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Drosos Evangelos, Giakoumettis Dimitrios, Blionas Alexandros, Mitsios Andreas, Sfakianos Georgios, Themistocleous Marios
BackgroundPediatric nonmissile penetrating head injury (NMPHI) is usually accidental attributed mainly to the softer skulls of growing children. However, it is a rare entity, and therefore no consensus exists regarding treatment to effectively prevent immediate and long-term complications. Throughout the literature, these injuries are mostly discussed in case reviews and case series in the general population. No data originating from randomized studies are available because of ethical and practical limitations.MethodsWe retrospectively studied and present 5 cases of children with NMPHI treated in the last 6 years in the Neurosurgery Department of Children's Hospital "Aghia Sofia". We performed a review of the literature in PubMed, using the key words "non-missile," "penetrating head injury," and "pediatric." We included case reports and case series involving pediatric cases since 2008 and selected older reports as well as certain literature reviews focusing on analysis of complications and treatment suggestions. We compared reported practice in various institutions with suggestions from the literature.ResultsIn the last year, 4 literature reviews were published suggesting treatment algorithms of NMPHIs. Surgery timing and method as well as anticonvulsant and antibiotic therapy still remain debatable. The only review concentrating on pediatric populations dates back to 1994, based on patient outcome studies from the 1980s. In our review, treatment steps were similar among various institutions and resembled recently suggested algorithms, with better treatment outcomes than originally reported 30 years ago.



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Self-Inflicted Drywall Screws in the Sagittal Sinus

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Kern H. Guppy, Calvin Ochi
A 30-year-old right-handed man with a history of schizophrenia presented with 2 self-inflicted drywall screws in the skull. The patient was sleepy but easily arousable; blood tests showed he had taken methamphetamines. Computed tomography and computed tomography angiography of the head showed the frontal screw abutted left of the superior sagittal sinus, and the posterior screw went through the superior sagittal sinus with no extravasation of contrast material at either site. Both screws were removed with exposure of the sagittal sinus using U-shaped craniectomies. There was no bleeding on the removal of the screws. It appears the posterior screw entered between the leaflets of the sagittal sinus dura mater. The patient had returned to work without any sequelae 1 month after injury.



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Intraoperative Monitoring of the Integrity of the Anterior Visual Pathways: A Methodologic Review and Meta-Analysis

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Hussam Metwali, Katja Kniese, Rudolf Fahlbusch
BackgroundDiverse methods have been developed for intraoperative monitoring of the integrity of the visual pathways. We performed a review of the literature to determine the methodology of each technique as well as their recent development. The predictive power of each eligible technique was determined based on a meta-analysis.MethodsA literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Techniques adopted for intraoperative monitoring of the integrity of the visual pathways were extracted and described. The power of each eligible technique to predict the visual outcome was tested.ResultsVisual evoked potentials showed marked methodologic improvement in recent studies. Predictive power for visual deterioration after surgery was approximately 60% and reached 100% when coupled with simultaneous monitoring of electroretinography. The sensitivity of visual evoked potentials for detection of deterioration was 47.2%. The decrease of fractional anisotropy of the optic chiasma showed significant correlation with improvement of vision after chiasma compression and showed 100% predictive power for improvement.ConclusionEach technique had limitations. Visual evoked potentials had a high predictive power for detection of deterioration but with low sensitivity. Fractional anisotropy of the optic chiasma had high predictive power for improvement of vision with low predictive power for deterioration.



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Endovascular Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke Presenting with Low National Institutes of Health Stroke Scale: Systematic Review and Meta-Analysis

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Christoph J. Griessenauer, Caroline Medin, Julian Maingard, Ronil V. Chandra, Wyatt Ng, Duncan Mark Brooks, Hamed Asadi, Monika Killer-Oberpfalzer, Clemens M. Schirmer, Justin M. Moore, Christopher S. Ogilvy, Ajith J. Thomas, Kevin Phan
IntroductionMechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists.MethodsA systematic review and meta-analysis were performed to identify studies that focused on mechanical thrombectomy, either as a standalone treatment or with intravenous tissue plasminogen activator (IV tPA), in patients with mild strokes with LVO, defined as a baseline National Institutes of Health Stroke Scale score ≤5 at presentation. Data on methodology, quality criteria, and outcome measures were extracted, and outcomes were compared using odds ratio as a summary statistic.ResultsFive studies met the selection criteria and were included. When compared with medical therapy without IV tPA, mechanical thrombectomy and medical therapy with IV tPA were associated with improved 90-day modified Rankin Scale (mRS) score. Among medical patients who were not eligible for IV tPA, those who underwent mechanical thrombectomy were more likely to experience good 90-day mRS than those who were not. There was no significant difference in functional outcome between mechanical thrombectomy and medical therapy with IV tPA, and no treatment subgroup was associated with intracranial hemorrhage or death.ConclusionsIn patients with mild strokes due to LVO, mechanical thrombectomy and medical therapy with IV tPA led to better 90-day functional outcome. Mechanical thrombectomy plays an important role in the management of these patients, particularly in those not eligible for IV tPA.



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Rapid Progression of Ossification of the Posterior Longitudinal Ligament After Anterior Cervical Discectomy and Fusion

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Tarush Rustagi, Fernando Alonso, Cameron Schmidt, Rod J. Oskouian, Jens R. Chapman, R. Shane Tubbs, Christian Fisahn
BackgroundOssification of the posterior longitudinal ligament (OPLL) has a reported incidence of 1.9%–4.3%. Disease progression is associated with surgery, with most studies focusing on OPLL progression after laminoplasty. The continued range of motion following surgery is believed to place strain on adjacent levels, driving calcification of the ligament. We present a case of marked progression of OPLL at levels adjacent to a previous anterior cervical discectomy and fusion.Case ReportA 59-year-old man initially presented for progressive loss of balance and dexterity and underwent a C4-6 anterior cervical discectomy and fusion procedure. Computed tomography performed 1 year postoperatively showed fusion across C4-6 with no evidence of OPLL at any level. Two years following index surgery, the patient reported right-side arm pain. Computed tomography revealed new minimal OPLL opposite the C3-4 level that was not causing cord compression. A sparing midline bilateral C3-7 laminotomy was performed to correct stenosis seen on magnetic resonance imaging. At 7 years after the index procedure, the patient presented with myelopathic symptoms exceeding symptoms at his index presentation. Computed tomography revealed marked progression of OPLL. The patient underwent C2-T2 posterior fusion with laminectomy from C2-C7 and responded well with gradual improvements in balance and arm pain after surgery.ConclusionsOur report demonstrates that OPLL progression, which is largely reported following laminoplasty, may similarly occur following anterior cervical discectomy and fusion and supports the concept of motion-related OPLL progression.



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Adult Pilocytic Astrocytoma: An Institutional Series and Systematic Literature Review for Extent of Resection and Recurrence

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Kamila M. Bond, Joshua D. Hughes, Amanda L. Porter, Josiah Orina, Shanna Fang, Ian F. Parney
IntroductionPilocytic astrocytoma is a classically benign tumor that most often affects pediatric patients. Rarely, it occurs during adulthood. We present a case series and systematic literature review of adult pilocytic astrocytoma (APA) to examine the clinical presentation, extent of resection, and recurrence rate associated with this tumor in this population.Materials and MethodsOur institutional records were retrospectively reviewed for cases of pilocytic astrocytoma in adults. A PubMed search identified English-language studies of pathology-proven APA. A meta-analysis was performed to determine the relationship between extent of tumor resection and recurrence.ResultsForty-six patients with APA were diagnosed at our institution (mean age 33.6 ± 13.3; 24 [52%] female). Twenty-four patients (52%) underwent gross total resection, 11 (24%) subtotal resection, 4 (9%) near total resection, 4 (9%) observation after biopsy, and 3 (6%) radiotherapy alone. Tumors recurred or progressed in 6 (13%) patients, of whom 4 were treated by STR and 2 were treated by radiotherapy alone. Thirty-nine (95%) patients were still alive at last follow-up. A systematic literature review identified 415 patients with APA in 38 studies. Including our case series, 7 studies reported extent of resection, follow-up, and recurrence. Of 254 patients with a weighted mean follow-up of 77.7 ± 49.6 (31–250) months, 129 (51%) were treated with gross total resection, and 125 (49%) underwent subtotal resection. Tumor recurred in 79 (31%) patients, 22 (27%) after gross total resection and 57 (73%) after subtotal resection (P < 0.001).ConclusionsPilocytic astrocytoma rarely presents during adulthood. Overall, prognosis is favorable and survival rates are high. APA recurrence is more likely after STR, and the goal of surgery should always be GTR when feasible.



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Rare Concurrent Retroclival and Pan-Spinal Subdural Empyema: Review of Literature with an Uncommon Illustrative Case

Publication date: February 2018
Source:World Neurosurgery, Volume 110
Author(s): Martin M. Mortazavi, Syed A. Quadri, Sajid S. Suriya, Salman A. Fard, Shahram Hadidchi, Farzad H. Adl, Ian Armstrong, Richard Goldman, R. Shane Tubbs
BackgroundSubdural empyema can present as a spinal subdural empyema (SSE) or a cranial subdural empyema (CSE). Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together. The aim of this article is to review the literature concerning the clinical presentation, clinical course, and treatment options for managing concurrently occurring SSE and CSE.MethodsThe literature in the Medline database was reviewed with key words including but not limited to subdural empyema, retroclival empyema, and Streptococcus mitis. No similar reports were found in the database involving infection with this type of microorganism in this anatomical region.ResultsOnly 3 cases with concurrent CSE and SSE were found in the literature caused by various etiologic agents. Two of the patients recovered with no neurologic deficit, whereas one fatality was reported. One new illustrative case caused by Streptococcus mitis is also presented.ConclusionsCSE and SSE are neurosurgical emergencies, often requiring prompt surgical evacuation. Although very rare, Streptococcus mitis can cause spinal subdural empyema or retroclival abscesses. Natural history of this disease is grave without treatment. Delays in diagnosis and treatment are directly related to mortality and severe morbidity in patients with intracranial and spinal subdural empyema. Prompt recognition and treatment are essential to preclude severe neurologic disabilities or in rare cases a fatal outcome. A treatment paradigm for cranio-spinal empyema is proposed.



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Tyrosine kinase inhibitors in iodine-refractory differentiated thyroid cancer: experience in clinical practice

Abstract

Purpose

The aim of this study is to describe our clinical experience with tyrosine kinase inhibitors (TKIs) and to evaluate their efficacy and tolerability in patients with iodine-refractory differentiated thyroid cancer (DTC).

Methods

There were 17 patients (47.1% women, mean age: 65.7) with DTC iodine-refractory (9 papillary, 2 follicular and 3 Hürthle cell), treated with TKIs: 16 with sorafenib and 1 with lenvatinib as first-line treatment; 7 required second-line treatment (4 lenvatinib and 3 axitinib). Primary endpoints were progression-free survival (PFS) and radiographic response (determinate at 3, 6, 12, 18, and 24 months after the initiation of treatment) and second endpoints were determining differences in baseline characteristics depending on clinical course and describing toxicities and tolerability.

Results

Median PFS was 18 months. During the first 24 months of treatment with TKIs PR rate was 35.3% (only 5.8% ≥ 6 months) and SD ≥ 6 months was observed in 58.8%. There were no significant differences in baseline characteristics between patients with good and poor evolution. Adverse events (AEs) were present in 100% of patients, but most of them were grade 1 and 2.

Conclusions

In our population of patients with iodine-refractory DTC, treatment with sorafenib, lenvatinib, and axitinib allows the stabilization of the disease in a high percentage of cases, with acceptable tolerability.

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Correction to: Insulin and osteocalcin: further evidence for a mutual cross-talk

Correction to: Endocrine http://ift.tt/2BoOJ3L

The article Insulin and osteocalcin: further evidence for a mutual cross-talk, written by Francesco L. Bilotta, Biagio Arcidiacono, Sebastiano Messineo, Marta Greco, Eusebio Chiefari, Domenico Britti, Tomoko Nakanishi, Daniela P. Foti, Antonio Brunetti, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 2 September 2017 without open access.

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A widespread visually-sensitive functional network relates to symptoms in essential tremor

Abstract

Essential tremor is a neurological syndrome of heterogeneous pathology and aetiology that is characterized by tremor primarily in the upper extremities. This tremor is commonly hypothesized to be driven by a single or multiple neural oscillator(s) within the cerebello-thalamo-cortical pathway. Several studies have found an association of blood-oxygen level-dependent (BOLD) signal in the cerebello-thalamo-cortical pathway with essential tremor, but there is behavioural evidence that also points to the possibility that the severity of tremor could be influenced by visual feedback. Here, we directly manipulated visual feedback during a functional MRI grip force task in patients with essential tremor and control participants, and hypothesized that an increase in visual feedback would exacerbate tremor in the 4–12 Hz range in essential tremor patients. Further, we hypothesized that this exacerbation of tremor would be associated with dysfunctional changes in BOLD signal and entropy within, and beyond, the cerebello-thalamo-cortical pathway. We found that increases in visual feedback increased tremor in the 4–12 Hz range in essential tremor patients, and this increase in tremor was associated with abnormal changes in BOLD amplitude and entropy in regions within the cerebello-thalamo-motor cortical pathway, and extended to visual and parietal areas. To determine if the tremor severity was associated with single or multiple brain region(s), we conducted a birectional stepwise multiple regression analysis, and found that a widespread functional network extending beyond the cerebello-thalamo-motor cortical pathway was associated with changes in tremor severity measured during the imaging protocol. Further, this same network was associated with clinical tremor severity measured with the Fahn, Tolosa, Marin Tremor Rating Scale, suggesting this network is clinically relevant. Since increased visual feedback also reduced force error, this network was evaluated in relation to force error but the model was not significant, indicating it is associated with force tremor but not force error. This study therefore provides new evidence that a widespread functional network is associated with the severity of tremor in patients with essential tremor measured simultaneously at the hand during functional imaging, and is also associated with the clinical severity of tremor. These findings support the idea that the severity of tremor is exacerbated by increased visual feedback, suggesting that designers of new computing technologies should consider using lower visual feedback levels to reduce tremor in essential tremor.

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

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



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

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



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Tyrosine kinase inhibitors in iodine-refractory differentiated thyroid cancer: experience in clinical practice

Abstract

Purpose

The aim of this study is to describe our clinical experience with tyrosine kinase inhibitors (TKIs) and to evaluate their efficacy and tolerability in patients with iodine-refractory differentiated thyroid cancer (DTC).

Methods

There were 17 patients (47.1% women, mean age: 65.7) with DTC iodine-refractory (9 papillary, 2 follicular and 3 Hürthle cell), treated with TKIs: 16 with sorafenib and 1 with lenvatinib as first-line treatment; 7 required second-line treatment (4 lenvatinib and 3 axitinib). Primary endpoints were progression-free survival (PFS) and radiographic response (determinate at 3, 6, 12, 18, and 24 months after the initiation of treatment) and second endpoints were determining differences in baseline characteristics depending on clinical course and describing toxicities and tolerability.

Results

Median PFS was 18 months. During the first 24 months of treatment with TKIs PR rate was 35.3% (only 5.8% ≥ 6 months) and SD ≥ 6 months was observed in 58.8%. There were no significant differences in baseline characteristics between patients with good and poor evolution. Adverse events (AEs) were present in 100% of patients, but most of them were grade 1 and 2.

Conclusions

In our population of patients with iodine-refractory DTC, treatment with sorafenib, lenvatinib, and axitinib allows the stabilization of the disease in a high percentage of cases, with acceptable tolerability.

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Correction to: Insulin and osteocalcin: further evidence for a mutual cross-talk

Correction to: Endocrine http://ift.tt/2BoOJ3L

The article Insulin and osteocalcin: further evidence for a mutual cross-talk, written by Francesco L. Bilotta, Biagio Arcidiacono, Sebastiano Messineo, Marta Greco, Eusebio Chiefari, Domenico Britti, Tomoko Nakanishi, Daniela P. Foti, Antonio Brunetti, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 2 September 2017 without open access.

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Cost comparison by treatment arm and center-level variations in cost and inpatient days on the phase III high-risk B acute lymphoblastic leukemia trial AALL0232

Abstract

The Children's Oncology Group (COG) develops and implements multi-institutional clinical trials with the primary goal of assessing the efficacy and safety profile of treatment regimens for various pediatric cancers. However, the monetary costs of treatment regimens are not measured. AALL0232 was a COG randomized phase III trial for children with acute lymphoblastic leukemia that found that dexamethasone (DEX) was a more effective glucocorticoid than prednisone (PRED) in patients younger than 10 years, but PRED was equally effective and less toxic in older patients. In addition, high-dose methotrexate (HD-MTX) led to better survival than escalating doses of methotrexate (C-MTX). Cost data from the Pediatric Health Information System database were merged with clinical data from the COG AALL0232 trial. Total and component costs were compared between treatment arms and across hospitals. Inpatient costs were higher in the HD-MTX and DEX arms when compared to the C-MTX and PRED arms at the end of therapy. There was no difference in cost between these arms at last follow-up. Considerable variation in total costs existed across centers to deliver the same therapy that was driven by differences in inpatient days and pharmacy costs. The more effective regimens were found to be more expensive during therapy but were ultimately cost-neutral in longer term follow-up. The variations in cost across centers suggest an opportunity to standardize resource utilization for patients receiving similar therapies, which could translate into reduced healthcare expenditures.

When comparing costs between treatment arms of the high-risk B acute lymphoblastic leukemia pediatric trial, high-dose methotrexate and dexamethasone arms were associated with higher costs when compared to the escalating methotrexate and prednisone arms during protocol therapy, but there was no difference in cost between the methotrexate or steroid arms at time of last follow up. We also found that costs vary significantly across hospitals to deliver identical therapy.

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Acquired Resistance of PTEN-Deficient Cells to PARP Inhibitor and Ara-C Mediated by 53BP1 Loss and SAMHD1 Overexpression

Summary

With increasing uses of PARP inhibitors (PARPis) for cancer therapy, understanding their resistance is becoming urgent. However, acquired PARPi resistance in the PTEN-deficient background is poorly understood. We generated 3 PARPi-resistant PTEN-deficient glioblastoma U251 variants separately with olaparib (U251/OP), talazoparib (U251/TP) and simmiparib (U251/SP). These variants displayed consistent resistance (2.46~71.78-fold) to all 5 PARPis including niraparib and rucaparib and showed higher degrees of resistance to the PARPis to which the parental cells were more sensitive. The resistance was characteristic of fast emergence and high stability. However, the resistance acquirement did not cause an increasingly aggressive phenotype. The resistance was not correlated to various factors including PTEN mutations. The PARPi-treated variants produced less γH2AX and G2/M arrest. Consistently, loss of 53BP1 occurred in all variants and its compensation enhanced their sensitivity to PARPis by ~76%. The variants revealed slightly different cross-resistance profiles to 13 non-PARPi anticancer drugs. All were resistant to Ara-C (6~8-fold) but showed differential resistance to 5-fluorouracil, gemcitabine and paclitaxel. Almost no resistance was observed to the rest drugs including cisplatin. SAMHD1 was overexpressed in all the variants and its knockout completely restored their sensitivity to Ara-C but did not affect their PARPi sensitivity. This study demonstrates a consistent resistance profile to PARPis and a unique cross-resistance profile to non-PARPi drugs in different PARPi-resistant U251 cells and reveals 53BP1 loss and SAMHD1 overexpression as the primary mechanisms responsible for their resistance to PARPis and Ara-C, respectively. These effects probably result from heritable gene change(s) caused by persistent PARPi exposure.

This article is protected by copyright. All rights reserved.

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SLC35F2 is indispensable for papillary thyroid carcinoma progression via activation of TGFBR1/ASK-1/MAPK signaling axis

Summary

Solute carrier family control essential physiological functions and are tightly linked to human diseases. Solute carrier family 35 member F2 (SLC35F2) is aberrantly activated in several malignancies. However, the biological function and molecular mechanism of SLC35F2 in papillary thyroid carcinoma (PTC) are yet to be fully explored. Here, we showed that SLC35F2 was prominently up-regulated in PTC tissues at both protein and mRNA expression level compared with matched adjacent normal tissues. Besides, the high expression of SLC35F2 was significantly associated with lymph node metastasis in patients with PTC. CRISPR/Cas9-mediated knockout of SLC35F2 attenuated the tumorigenic properties of PTC, including cell proliferation, migration and invasion and induced G1 phase arrest. In contrast, ectopic expression of SLC35F2 brought about aggressive malignant phenotypes of PTC cells. Moreover, SLC35F2 expedited the proliferation and migration of PTC cells by targeting TGFBR1 and p-ASK-1, thereby activating the mitogen-activated protein kinase (MAPK) signaling pathway. Besides, the malignant behaviors induced by over-expression of SLC35F2 could be abrogated by silencing of TGFBR1 using a specific inhibitor. We conducted the first study on SLC35F2 in thyroid cancer with the aim of elucidating the functional significance and molecular mechanism of SLC35F2. Our findings suggest that SLC35F2 exerts its oncogenic effect on PTC progression through the MAPK pathway, with dependence on activation of TGFBR-1 and ASK-1.

This article is protected by copyright. All rights reserved.

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Reply to letter to the editor “Blood pressure variability in primary hyperparathyroidism: more data needed”

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Reply to letter to the editor “Blood pressure variability in primary hyperparathyroidism: more data needed”

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Contents

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Neurophysiology and cognitive reserve: A promising path

In the summer of 2017, a Lancet commission on Dementia prevention, intervention, and care (Livingston et al., 2017) identified nine risk factors for dementia that are potentially modifiable. Further, it estimated that if these nine factors are eliminated, one in three cases of dementia could be prevented. Among these nine factors, several are conceptually linked to cognitive reserve. Cognitive reserve refers to the brain capacity to cope with damage or diseases towards maintaining a stable level of function (Stern, 2002).

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Editorial Board

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Correlations between MUNIX and adapted multiple point stimulation MUNE methods

Motor unit number estimate (MUNE) usually represents the ratio of the maximal compound muscle action potential (CMAP) divided by the average surface-recorded motor unit potential (SMUP). MUNE techniques differ in how single motor units (MU) are obtained. McComas et al. (1971) introduced the first MUNE technique, referred as the incremental technique. Incremental stimulation was applied at one stimulation point on the nerve and the stimulus intensity was gradually increased from a subthreshold value until 11 increments in the muscle response were obtained.

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Tumor-associated CD204+ M2 macrophages is an unfavorable prognosticator in uterine cervical adenocarcinoma

Abstract

Uterine cervical adenocarcinoma is rare, but its prevalence has increased. To improve outcomes and ensure the suitability of recent immunotherapies, the aim of the study was to evaluate the clinicopathological impact of the tumor immune microenvironment of uterine cervical adenocarcinoma. We investigated 148 adenocarcinoma cases, including 21 cases of adenocarcinoma in situ (AIS) and 127 cases of invasive adenocarcinoma, using immunohistochemistry to detect tumor-infiltrating immune cells and the expression of PD-L1 and p16 on tumor cells, and we then conducted correlation and survival analyses. The density of immune cells and expression levels were compared between the tumor cell nest and stroma and between AIS and invasive adenocarcinoma using digital image analysis. A higher density of tumor-infiltrating CD204⁺ M2 macrophages was significantly associated with shorter disease-free survival, although no other tumor-infiltrating immune cells were prognostic, including CD4⁺, CD8⁺, FOXP3⁺, and PD-1⁺ lymphocytes and CD68⁺ macrophages. The density of stroma-infiltrating lymphocytes and macrophages was significantly higher in invasive adenocarcinoma than in AIS. The density of tumor-infiltrating lymphocytes in p16-expressing human papillomavirus (HPV)-positive tumors was significantly higher than that in HPV-negative tumors. HPV status was not associated with patient outcome. Expression of PD-L1 on tumor cells was found only in invasive adenocarcinoma cases (17.3%). A higher density of stroma-infiltrating lymphocytes and macrophages was found in PD-L1-positive tumors than in negative tumors. Patients with PD-L1-positive tumors tended to experience longer survival. It is suggested that tumor-infiltrating CD204⁺ M2 macrophages may predict poor prognoses in patients with cervical adenocarcinoma.

This article is protected by copyright. All rights reserved.

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Oncogenic Ras Isoforms Signaling Specificity at the Membrane

How do Ras isoforms attain oncogenic specificity at the membrane? Oncogenic KRas, HRas, and NRas (K-Ras, H-Ras, and N-Ras) differentially populate distinct cancers. How they selectively activate effectors and why is KRas4B the most prevalent are highly significant questions. Here, we consider determinants that may bias isoform-specific effector activation and signaling at the membrane. We merge functional data with a conformational view to provide mechanistic insight. Cell-specific expression levels, pathway cross-talk, and distinct interactions are the key, but conformational trends can modulate selectivity. There are two major pathways in oncogenic Ras-driven proliferation: MAPK (Raf/MEK/ERK) and PI3Kα/Akt/mTOR. All membrane-anchored, proximally located, oncogenic Ras isoforms can promote Raf dimerization and fully activate MAPK signaling. So why the differential statistics of oncogenic isoforms in distinct cancers and what makes KRas so highly oncogenic? Many cell-specific factors may be at play, including higher KRAS mRNA levels. As a key factor, we suggest that because only KRas4B binds calmodulin, only KRas can fully activate PI3Kα/Akt signaling. We propose that full activation of both MAPK and PI3Kα/Akt proliferative pathways by oncogenic KRas4B—but not by HRas or NRas—may help explain why the KRas4B isoform is especially highly populated in certain cancers. We further discuss pharmacologic implications. Cancer Res; 1–10. ©2017 AACR.

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New Horizons

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Individual Supervision to Enhance Reflexivity and the Practice of Patient-Centered Care: Experience at the Undergraduate Level

Abstract

This article reports on what is at work during individual supervision of medical students in the context of teaching breaking bad news (BBN). Surprisingly, there is a relative lack of research and report on the topic of supervision, even though it is regularly used in medical training. Building on our research and teaching experience on BBN at the undergraduate level, as well as interviews of supervisors, the following key elements have been identified: learning objectives (e.g., raising student awareness of structural elements of the interview, emotion (patients and students) handling), pedagogical approach (being centered on student's needs and supportive to promote already existing competences), essentials (e.g., discussing skills and examples from the clinical practice), and enhancing reflexivity while discussing specific issues (e.g., confusion between the needs of the patient and those of the student). Individual supervision has been identified as crucial and most satisfactory by students to provide guidance and to foster a reflexive stance enabling them to critically apprehend their communication style. Ultimately, the challenge is to teach medical students to not only connect with the patient but also with themselves.

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

Abstract

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

This article is protected by copyright. All rights reserved.

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

Abstract

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

This article is protected by copyright. All rights reserved.

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The insular cortex and QTc interval in HIV+ and HIV− individuals: Is there an effect of sympathetic nervous system activity?

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Michiaki Nagai, Keigo Dote, Masaya Kato, Noboru Oda




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Contents

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1





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High-resolution ultrasound in patients with Wartenberg’s migrant sensory neuritis, a case-control study

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Ingrid J.T. Herraets, H. Stephan Goedee, Johan A. Telleman, Jan-Thies H. van Asseldonk, Leo H. Visser, W. Ludo van der Pol, Leonard H. van den Berg
ObjectiveWartenberg's migrant sensory neuritis (WMSN) is a rare, patchy, pure sensory neuropathy of unknown etiology. High-resolution ultrasonography (HRUS) is an emerging diagnostic technique for neuropathies, but it has not been applied in WMSN. In this study we aimed to determine HRUS abnormalities in WMSN.MethodsWe performed a case-control study of 8 newly diagnosed patients with WMSN and 22 treatment-naive disease controls (16 patients with pure sensory axonal neuropathy and 6 with pure sensory chronic inflammatory demyelinating polyneuropathy (CIDP) or Lewis-Sumner syndrome (LSS)). All patients underwent routine diagnostic evaluations and a predefined HRUS protocol.ResultsWe found multifocal nerve enlargement in all 8 WMSN patients. The median nerve in the upper arm and the sural nerve were significantly larger in WMSN than in axonal controls (p = 0.01 and p = 0.04). In CIDP/LSS, sonographic enlargement was more extensive. Furthermore we found brachial plexus involvement in 3 of 8 (38%) WMSN patients.ConclusionHRUS showed enlargement of multiple nerves in all WMSN patients even if clinical testing and NCS were normal.SignificanceThe feature of multifocal nerve enlargement may be of additional value in establishing the diagnosis of WMSN and may support the suggestion of an auto-immune etiology.



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Oxyneurography: A non-invasive NIRS technique to measure nerve oxygenation

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Joe F. Jabre




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Editorial Board

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1





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Corrigendum to “Graph analysis of EEG resting state functional networks in dyslexic readers” [Clin. Neurophysiol. 127(9) (2016) 3165–3175]

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): G. Fraga González, M.J.W. Van der Molen, G. Žarić, M. Bonte, J. Tijms, L. Blomert, C.J. Stam, M.W. Van der Molen




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Utilization of independent component analysis for accurate pathological ripple detection in intracranial EEG recordings recorded extra- and intra-operatively

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Shoichi Shimamoto, Zachary J. Waldman, Iren Orosz, Inkyung Song, Anatol Bragin, Itzhak Fried, Jerome Engel, Richard Staba, Ashwini Sharan, Chengyuan Wu, Michael R. Sperling, Shennan A. Weiss
ObjectiveTo develop and validate a detector that identifies ripple (80–200 Hz) events in intracranial EEG (iEEG) recordings in a referential montage and utilizes independent component analysis (ICA) to eliminate or reduce high-frequency artifact contamination. Also, investigate the correspondence of detected ripples and the seizure onset zone (SOZ).MethodsiEEG recordings from 16 patients were first band-pass filtered (80–600 Hz) and Infomax ICA was next applied to derive the first independent component (IC1). IC1 was subsequently pruned, and an artifact index was derived to reduce the identification of high-frequency events introduced by the reference electrode signal. A Hilbert detector identified ripple events in the processed iEEG recordings using amplitude and duration criteria. The identified ripple events were further classified and characterized as true or false ripple on spikes, or ripples on oscillations by utilizing a topographical analysis to their time-frequency plot, and confirmed by visual inspection.ResultsThe signal to noise ratio was improved by pruning IC1. The precision of the detector for ripple events was 91.27 ± 4.3%, and the sensitivity of the detector was 79.4 ± 3.0% (N = 16 patients, 5842 ripple events). The sensitivity and precision of the detector was equivalent in iEEG recordings obtained during sleep or intra-operatively. Across all the patients, true ripple on spike rates and also the rates of false ripple on spikes, that were generated due to filter ringing, classified the seizure onset zone (SOZ) with an area under the receiver operating curve (AUROC) of >76%. The magnitude and spectral content of true ripple on spikes generated in the SOZ was distinct as compared with the ripples generated in the NSOZ (p < .001).ConclusionsUtilizing ICA to analyze iEEG recordings in referential montage provides many benefits to the study of high-frequency oscillations. The ripple rates and properties defined using this approach may accurately delineate the seizure onset zone.SignificanceStrategies to improve the spatial resolution of intracranial EEG and reduce artifact can help improve the clinical utility of HFO biomarkers.



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A method for the topographical identification and quantification of high frequency oscillations in intracranial electroencephalography recordings

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Zachary J. Waldman, Shoichi Shimamoto, Inkyung Song, Iren Orosz, Anatol Bragin, Itzhak Fried, Jerome Engel, Richard Staba, Michael R. Sperling, Shennan A. Weiss
ObjectiveTo develop a reliable software method using a topographic analysis of time-frequency plots to distinguish ripple (80–200 Hz) oscillations that are often associated with EEG sharp waves or spikes (RonS) from sinusoid-like waveforms that appear as ripples but correspond with digital filtering of sharp transients contained in the wide bandwidth EEG.MethodsA custom algorithm distinguished true from false ripples in one second intracranial EEG (iEEG) recordings using wavelet convolution, identifying contours of isopower, and categorizing these contours into sets of open or closed loop groups. The spectral and temporal features of candidate groups were used to classify the ripple, and determine its duration, frequency, and power. Verification of detector accuracy was performed on the basis of simulations, and visual inspection of the original and band-pass filtered signals.ResultsThe detector could distinguish simulated true from false ripple on spikes (RonS). Among 2934 visually verified trials of iEEG recordings and spectrograms exhibiting RonS the accuracy of the detector was 88.5% with a sensitivity of 81.8% and a specificity of 95.2%. The precision was 94.5% and the negative predictive value was 84.0% (N = 12). Among, 1,370 trials of iEEG recording exhibiting RonS that were reviewed blindly without spectrograms the accuracy of the detector was 68.0%, with kappa equal to 0.01 ± 0.03. The detector successfully distinguished ripple from high spectral frequency 'fast ripple' oscillations (200–600 Hz), and characterize ripple duration and spectral frequency and power. The detector was confounded by brief bursts of gamma (30–80 Hz) activity in 7.31 ± 6.09% of trials, and in 30.2 ± 14.4% of the true RonS detections ripple duration was underestimated.ConclusionsCharacterizing the topographic features of a time-frequency plot generated by wavelet convolution is useful for distinguishing true oscillations from false oscillations generated by filter ringing.SignificanceCategorizing ripple oscillations and characterizing their properties can improve the clinical utility of the biomarker.



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The effect of reducing EEG electrode number on the visual interpretation of the human expert for neonatal seizure detection

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Nathan J. Stevenson, Leena Lauronen, Sampsa Vanhatalo
ObjectivesTo measure changes in the visual interpretation of the EEG by the human expert for neonatal seizure detection when reducing the number of recording electrodes.MethodsEEGs were recorded from 45 infants admitted to the neonatal intensive care unit (NICU). Three experts annotated seizures in EEG montages derived from 19, 8 and 4 electrodes. Differences between annotations were assessed by comparing intra-montage with inter-montage agreement (K).ResultsThree experts annotated 4464 seizures across all infants and montages. The inter-expert agreement was not significantly altered by the number of electrodes in the montage (p = 0.685, n = 43). Reducing the number of EEG electrodes altered the seizure annotation for all experts. Agreement between the 19-electrode montage (K19,19 = 0.832) was significantly higher than the agreement between 19 and 8-electrode montages (dK = 0.114; p < 0.001, n = 42) or 19 and 4-electrode montages (dK = 0.113, p < 0.001, n = 43). Seizure burden and number were significantly underestimated by the 4 and 8-electrode montage (p < 0.001). No significant difference in agreement was found between 8 and 4-electrode montages (dK = 0.002; p = 0.07, n = 42).ConclusionsReducing the number of EEG electrodes from 19 electrodes resulted in slight but significant changes in seizure detection.SignificanceFour-electrode montages for routine EEG monitoring are comparable to eight electrodes for seizure detection in the NICU.



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Correlating motor unit morphology with bioelectrical activity – A simulation study

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Ewa Zalewska, Irena Hausmanowa-Petrusewicz
ObjectivesThe aim was to determine motor unit morphology underpinning the various MUP waveforms using MUP analysis.MethodThe simulation method is based on the decomposition of MUP into single fiber potentials. Number of fibers, fiber diameters and fiber to electrode distances were determined. The impact of each muscle fiber on the MUP waveform was determined and quantified by its percentage contribution.ResultsThe origin of the four examined MUPs of distinct waveforms have been explained by showing the histograms of fiber diameters and their distance to the electrode. In the case of a low amplitude MUP it was found that it originated from fibers of smaller than normal diameters with no dominant fiber. In another case of a MUP of short duration its shape was due to a single fiber close to the electrode which contributed to about 80% of the MUP. In case of polyphasic MUP, muscle fiber diameters variability was responsible for MUP characteristic. MUP from normal muscle originated from few fibers of similar diameters. Correlation between MUP's characteristic and morphological features has been indicated. Our findings are consistent with the neurophysiological knowledge about the origins of MUP. The approximation method enables MUP analysis that provides quantitative description of motor unit morphology.ConclusionMUP analysis using an approximation method enables to get an insight into motor unit morphology and therefore increases understanding of the way the motor unit structure correlates with MUP waveform.SignificanceExtending the amount of information available from EMG examinations.



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Cognitive impairment measured by event-related potentials during early and late postoperative period following intravenous or inhalation anaesthesia

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Irena Holečková, Jakub Kletečka, David Štěpánek, Slavomír Žídek, David Bludovský, Jiří Pouska, Pavel Mautner, Vladimír Přibáň
ObjectiveThis study investigated modification in cognitive function following inhalation (IA) and total intravenous (TIVA) anaesthesia measured using auditory ERPs (Event Related Potentials).MethodsAuditory ERPs examination with N1, P3a and P3b component registration was carried out one day before surgery (D−1) and on the first (D+1), sixth (D+6) and 42nd (D+42) days after surgery. Results were compared between two anaesthetic groups.ResultsOn D+1, N1 latency was increased in the IA group. A significant reduction was observed in amplitude of the P3a component on D+6, which persisted up to D+42 for both IA and TIVA groups. A reduction in the amplitude of P3b on D+1 with normalization by D+6 was found in both groups as well.ConclusionsIntravenous and inhalation anaesthesia lead to similar changes in cognitive function as determined by ERPs, both during the early and late postoperative periods. It cannot be clearly confirmed whether the observed effects are due to anaesthesia or other unmonitored perioperative factors.SignificancePost anaesthetic changes represent a subclinical impairment; nevertheless, they represent a potential risk for subsequent development of cognitive difficulties.



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Reply to “Stimulus, response and excitability – What is new?”

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): François Charles Wang




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Reply to “The insular cortex and QTc interval in HIV+ and HIV− individuals: Is there an effect of sympathetic nervous system activity?“

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Roger C. McIntosh, Dominic C. Chow, Corey J. Lum, Cecilia M. Shikuma, Kalpana J. Kallianpur




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Tumour-like giant nerves in entrapment neuropathies

Publication date: Available online 22 December 2017
Source:Clinical Neurophysiology
Author(s): Anita Csillik, Marianna Tóth, Zsuzsanna Arányi




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Authors' response

Publication date: Available online 21 December 2017
Source:Brachytherapy
Author(s): Cameron M. Callaghan




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Image-guided interstitial high-dose-rate brachytherapy for locally recurrent uterine cervical cancer: A single-institution study

Publication date: Available online 21 December 2017
Source:Brachytherapy
Author(s): Rei Umezawa, Naoya Murakami, Satoshi Nakamura, Akihisa Wakita, Hiroyuki Okamoto, Keisuke Tsuchida, Tairo Kashihara, Kazuma Kobayashi, Ken Harada, Kana Takahashi, Koji Inaba, Yoshinori Ito, Hiroshi Igaki, Koji Masui, Ken Yoshida, Keiichi Jingu, Nikolaos Tselis, Jun Itami
PurposeThe aim of this study was to investigate the efficacy and safety of image-guided high-dose-rate (HDR) interstitial brachytherapy (ISBT) for reirradiation of locally recurrent uterine cervical cancer.Methods and MaterialsBetween 2008 and 2015, patients receiving reirradiation using HDR-ISBT for local gross recurrence of uterine cervical cancer after definitive or postoperative radiotherapy were analyzed retrospectively. The prescription doses per fraction ranged 2.5–6.0 Gy, whereas the cumulative equivalent doses in 2 Gy fractions ranged 48.6–82.5 Gy. The effects of prognostic factors on the local control (LC), progression-free survival, and overall survival were analyzed, and late toxicity data were evaluated.ResultsEighteen patients were included in the analysis, with a median followup of 18.1 months. A tumor response was obtained in all patients, with radiological and pathological complete remission seen in 12 (66.7%) patients. The 2-year LC, progression-free survival, and overall survival rates for all patients were 51.3%, 20.0%, and 60.8%, respectively. The hemoglobin level and maximum tumor diameter were shown to be statistically significant prognostic factors for LC (p = 0.028 and 0.009, respectively). Late ≥ Grade 2 adverse events were observed in 5 patients (27.8%).ConclusionsImage-guided HDR-ISBT for the reirradiation of locally recurrent uterine cervical cancer may play an important role for local tumor control in a subgroup of patients. However, the treatment indication must be weighed against the risk of higher-grade late toxicity.



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Ruthenium brachytherapy for uveal melanomas: Factors affecting the development of radiation complications

Publication date: Available online 21 December 2017
Source:Brachytherapy
Author(s): Monica M. Pagliara, Luca Tagliaferri, Luigi Azario, Jacopo Lenkowicz, Angela Lanza, Rosa Autorino, Carmela G. Caputo, Maria A. Gambacorta, Vincenzo Valentini, Maria A. Blasi
PurposeTo investigate how treatment complications are related to dosimetric parameters after ruthenium-106 brachytherapy for uveal melanoma, in a large, clinically homogeneous population.Methods and MaterialsA retrospective review was performed to evaluate patients affected by small and medium size uveal melanoma, treated with ruthenium-106 brachytherapy from December 2006 to December 2014. We excluded tumors with posterior margin within 1 mm from the edge of the optic disc and foveola. Main outcome measures were occurrence and time to radiation-related maculopathy, cataract, and optic neuropathy. Secondary end points included local recurrence and distant metastases. Kaplan–Meier analysis with log-rank test and univariate Cox proportional hazards model at 3 years were performed to identify the covariates affecting the outcome of radiation complications.ResultsTwo hundred thirty-nine patients, with sufficient data to evaluate the end points, were enrolled. Three years after plaque treatment, radiation maculopathy was found in 61 (25.5%) patients, cataract developed in 10 patients (4.2%) receiving a dose of 27 Gy or higher to the lens, and optic neuropathy was observed in 13 patients (5.4%) with an optic nerve dose exceeding 50 Gy and tumor proximity to optic disc of less than 4 mm. Tumor recurrences and tumor-related metastasis were found respectively in 20 (8.36%) and 14 (5.85%) patients.ConclusionsRadiation maculopathy occurs within a median time of 31 months in 25% of cases after plaque treatment for uveal melanoma. The most significant risk factors are total dose and distance of tumor margin from the fovea. If the distance is greater than 11.22 mm, no signs of retinal damage are detected.



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Preface

Surgery for thyroid disease encompasses a broad spectrum of procedures involving multiple disease entities. Thyroid surgery may range from simple isthmusectomy/lobectomy to expansive procedures which involves bilateral cervical lymphadenectomy, resection of upper aerodigestive tract elements and mediastinal dissection. Accordingly, these procedures are accompanied by varying degrees of difficulty in the execution of many of the surgical maneuvers involved in performing a safe and successful operative procedure.

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Substernal thyroidectomy: the trans-cervical approach

Substernal thyroid goiters that require surgery may pose unique challenges to thyroid surgeons based on the size and inferior extent of the disease. Consequently, there are multiple variations to the approach and additional considerations in operative planning and technique that are often required. While there is some debate on the precise definition of substernal thyroid, for the purposes of this manuscript it is considered to be thyroid tissue below the sternal notch or clavicle. This article aims to provide thyroid surgeons who encounter the challenges of substernal thyroid a straightforward algorithm for planning and operative techniques that have proven successful in the safe and effective management of this condition.

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Techniques for thyroid cancer involving extreme superior thyroid pole

Standard operative techniques for thyroidectomy have become well refined and widely disseminated. However, special circumstances, such as superior pole thyroid cancers, can present unique difficulties for the unprepared surgeon. Appropriate workup and appreciation of the unique anatomic relationships in the superior-most extent of the thyroid gland is vital in surgical planning. The ability to anticipate and manage a variety of contingencies such as superior laryngeal nerve sacrifice, vascular isolation / repair, laryngectomy, and repair of pharyngeal defects are essential for safe surgery for cancers of the extreme superior thyroid pole.

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Revision central neck dissection

Recurrent well differentiated thyroid cancer is an important problem and incidence is on the rise. Recurrence preferentially involves lymph nodes of the central and lateral neck. Detection and surveillance of such disease is commonly performed via serum thyroglobulin and high frequency neck ultrasonography. Management options include: active surveillance, local ablative techniques, RAI, external beam radiotherapy, and surgery. The gold standard of care is surgical removal in the form of comprehensive neck dissection.

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

The ligament of Berry is a dense consolidation of pretracheal vascular fascia or suspensory ligament which anchors the thyroid to the trachea and is located medial and deep to the tubercle of Zuckerkandl. The ligament of Berry is closely related to the distal 2cm of the extralaryngeal course of the recurrent laryngeal nerve and to the superior parathyroid gland. When thyroid cancer is present in the ligament of Berry, proper preoperative imaging, meticulous dissection with extra caution in the area of the ligament of Berry and use of intraoperative nerve monitoring are helpful tools in preservation of recurrent laryngeal nerve.

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

Reoperative central neck dissection requires a concise set of steps to complete a comprehensive dissection of recurrent lymphadenopathy seen in thyroid cancer. The main considerations take into account the recurrent laryngeal nerve and the parathyroid glands. This chapter specifies those steps from a preoperative evaluation to the pearls during dissection to ensure a complete reoperative dissection that removes all residual thyroid tissue and lymphadenopathy while ensuring the best outcomes.

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Operative Techniques in Otolaryngology-Head and Neck Surgery

The worldwide incidence of thyroid cancer has increased and generated great debate and study concerning the proper evidence-based management strategies. Despite this increase, there has been no significant increase in advanced, invasive thyroid cancers, which continue to represent the primary cause of thyroid cancer specific death. This section provides an evidence-based management review for thyroid cancer invading the aero-digestive tract and addresses critical issues of diagnosis, preoperative evaluation, surgical management, and adjuvant treatment germane to this important subset of patients.

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Surgery for fibro adherent inflammatory thyroid disease

Inflammatory thyroid diseases include those which are mediated through autoimmune disorders such as Hashimoto′s thyroiditis and Grave′s disease, as well as inflammatory goiter and sub-acute thyroiditis. In patients with such disorders, the thyroid gland often becomes markedly enlarged with an associated fibro-vascular connective tissue reaction involving the thyroid capsule and surrounding soft tissues. This results in dense, adherent connective tissue which may compress and obscure critical central neck compartment structures and make capsular dissection challenging.

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Regulation of bioenergetics through dual inhibition of aldehyde dehydrogenase and mitochondrial complex I suppresses glioblastoma tumorspheres

Abstract

Background

Targeted approaches for treating glioblastoma (GBM) attempted to date have consistently failed, highlighting the imperative for treatment strategies that operate on different mechanistic principles. Bioenergetics deprivation has emerged as an effective therapeutic approach for various tumors. We have previously found that cancer cells preferentially utilize cytosolic NADH supplied by aldehyde dehydrogenase (ALDH) for ATP production through oxidative phosphorylation (OxPhos). This study is aimed to examine therapeutic responses and underlying mechanisms of dual inhibition of ALDH and OxPhos against GBM.

Methods

For inhibition of ALDH and OxPhos, the corresponding inhibitors, gossypol and phenformin were used. Biological functions, including ATP levels, stemness, invasiveness, and viability, were evaluated in GBM tumorspheres (TSs). Gene expression profiles were analyzed using microarray data. In vivo anticancer efficacy was examined in a mouse orthotopic xenograft model.

Results

Combined treatment of GBM TSs with gossypol and phenformin significantly reduced ATP levels, stemness, invasiveness, and cell viability. Consistently, this therapy substantially decreased expression of genes associated with stemness, mesenchymal transition, and invasion in GBM TSs. Supplementation of ATP using malate abrogated these effects, whereas knockdown of ALDH1L1 mimicked them, suggesting that disruption of ALDH-mediated ATP production is a key mechanism of this therapeutic combination. In vivo efficacy confirmed remarkable therapeutic responses to combined treatment with gossypol and phenformin.

Conclusion

Our findings suggest that dual inhibition of tumor bioenergetics is a novel and effective strategy for the treatment of GBM.

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Biological and therapeutic implications of multisector sequencing in newly diagnosed glioblastomas

Abstract

Background

Diagnostic workflows for glioblastoma (GBM) patients increasingly include DNA sequencing-based analysis of a single tumor site following biopsy or resection. We hypothesized that sequencing of multiple sectors within a given tumor would provide a more comprehensive representation of the molecular landscape and potentially inform therapeutic strategies.

Methods

10 newly diagnosed, IDH1 wildtype GBM tumor samples were obtained from two (n = 9) or four (n = 1) spatially distinct tumor regions. Tumor and matched blood DNA samples underwent whole-exome sequencing.

Results

Across all 10 tumors, 51% of mutations were clonal and 3% were subclonal and shared in different sectors, whereas 46% of mutations were subclonal and private. Two of the 10 tumors exhibited a regional hypermutator state despite being treatment naive, and remarkably, the high mutational load was predominantly limited to one sector in each tumor. Among the canonical cancer-associated genes, only TERT promoter mutations were observed in the founding clone in all tumors. Reconstruction of the clonal architecture in different sectors revealed regionally divergent evolution, and integration of data from two sectors increased the resolution of inferred clonal architecture in a given tumor. Predicted therapeutic mutations differed in presence and frequency between tumor regions. Similarly, different sectors exhibited significant divergence in the predicted neoantigen landscape.

Conclusions

The substantial spatial heterogeneity observed in different glioblastoma tumor sectors, especially in spatially-restricted hypermutator cases, raise important caveats to our current dependence on single-sector molecular information to guide either targeted or immune-based treatments.

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Tumour-like giant nerves in entrapment neuropathies

High resolution ultrasound has recently become a useful complementary method to electrophysiology for the confirmation of various entrapment neuropathies. The ultrasonographic signs of entrapment neuropathies include the segmental enlargement of the cross-sectional area (CSA) and the change of the echotexture of the nerve proximal and sometimes distal to the site of compression (Cartwright and Walker, 2013; Csillik et al., 2016). On longitudinal scans, an abrupt caliber change and a spindle-like segmental swelling of the nerve is typically seen.

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Intraoperative cortico-cortical evoked potentials shows disconnection of the motor cortex from the epileptogenic network during subtotal hemispherotomy

Epileptic spasms (ES) are a unique seizure type, comprising of sudden tonic movements of predominantly proximal and truncal muscles. In the revised operational classification of seizure types by the International League Against Epilepsy (ILAE) (Fisher et al., 2017), ES are classified as into focal, generalized, and unknown onset categories. Iimura et al. reported that ten of 23 patients who underwent subtotal hemispherectomy or multilobar resection presented with ES (Iimura et al., 2017). They found extensively distributed interictal epileptogenic high-frequency oscillations (HFOs) which skipped the motor area.

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Differential changes in the spinal segmental locomotor output in Hereditary Spastic Paraplegia

Hereditary spastic paraplegia (HSP) includes a heterogeneous group of inherited neurodegenerative disorders resulting from primary retrograde degeneration of corticospinal fibers originating from many areas of the brain (de Souza et al., 2016). Most of the corticospinal neurons originate in the primary motor cortex and premotor frontal areas. Corticospinal axons originating from layer V pyramidal neurons synapse directly or via spinal interneurons with alpha-motor neurons (MN) innervating skeletal muscles and controlling movements of the limbs and trunk.

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Response to: Commentary: “Gluteal Augmentation with Silicone Implants: A New Proposal for Intramuscular Dissection”

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Treatment of Gigantomastia Using a Medial–Lateral Bipedicle Reduction Mammoplasty: The Role of Doppler-Assisted Preoperative Perforator Identification

Abstract

The purpose of this study is to introduce a breast reduction technique designed to reduce the incidence of postoperative nipple–areola complex ischemia and necrosis following reduction mammoplasty, while at the same time allowing all the other goals of breast reduction to be realized. This is achieved through preoperative detection of perforating vessels supplying the nipple–areola complex using a hand-held Doppler. The horizontally based parenchymal pedicle is designed to include these perforators whether originating from the internal mammary artery, lateral thoracic artery or both. This technique provides freedom in pedicle shaping and fixation to the pectoral fascia to achieve the best breast contour. The study included 50 patients equally divided into two groups: the study group (using preoperative Doppler for detection of perforators) and control group (without preoperative Doppler). The average body mass index of our patients was 32.4 and 29.8 for study and control groups, respectively. The average suprasternal notch to nipple distance was 40.8 cm in the study group and 38.9 cm in the control group. In all cases of the study group, both medial and lateral pedicles were used each of them containing one perforator. The average resection weight per side was 1433.6 g for the study group and 1173.2 g for the control group. None of the study group cases experienced NAC necrosis, while four cases of the control group experienced NAC necrosis (3 partial and 1 total). The horizontally based parenchymal pedicle constructed with the aid of preoperative perforator identification with a Doppler is an effective technique for breast reduction that results in a very low rate of postoperative ischemia and necrosis of the nipple–areola complex.

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Neck Contouring Without Rhytidectomy in the Presence of Excess Skin

Abstract

Background

Patients with severe neck skin laxity due to excess submental adipose tissue have required either standard rhytidectomy or direct excision of neck skin with Z-plasty and submental lipectomy. Our recent experiences with four patients who declined cervicofacial rhytidectomy demonstrate that submental lipectomy and platysmarrhaphy appear to obtain sufficient improvement.

Methods

The submental area, submandibular area, and lateral neck are injected with local anesthetic. An incision is made in the submental area anterior to the existing crease, and the incision is taken through the subcutaneous tissue to the underlying fat. The skin is undermined in the deep subcutaneous plane. The lateral fat that cannot be visualized directly is suctioned using a number 2 cannula. Supra-platysmal and subplatysmal excess fat are excised under direct vision. The anterior bellies of the digastric muscle are excised partially or completely to obtain a flat contour if necessary. The submaxillary gland is partially or totally removed as indicated. The platysmarrhaphy is performed, and a TLS drain is placed in position and brought out through the left post-auricular sulcus using the attached trocar. The submental incision is then closed without skin excision.

Result

Non-excisional surgical neck rejuvenation was performed on four patients with significant skin laxity. There was adequate improvement in the cervicomental angle and neck profile contour in all patients, indicating that significant improvement may be achieved without skin excision.

Conclusion

Patients with excess skin can achieve acceptable results with submental lipectomy and platysmarrhaphy without rhytidectomy or direct excision of neck skin.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Correcting Nasojugal Groove with Autologous Cultured Fibroblast Injection: A Pilot Study

Abstract

Background

A new commercial drug that contains autologous cultured fibroblasts has been developed and approved by the United States Food and Drug Administration for improving the appearance of nasolabial folds. However, the treatment requires three sessions every 3–6 weeks. It is known that the skin overlying the nasojugal groove is thinner, and the wrinkle is generally shallower than nasolabial folds. Therefore, we hypothesized that the nasojugal groove could be improved by just one treatment session. Therefore, the purpose of this study was to evaluate the efficacy and safety of autologous cultured fibroblast injection to correct nasojugal grooves.

Methods

Forty-six subjects with nasojugal grooves were enrolled in this study. They were injected with autologous cultured fibroblasts or placebo in one session. Blinded evaluators and subjects assessed the efficacy using a validated wrinkle assessment scale at 4, 12, and 24 weeks after the injection. Information of adverse events was collected at each visit.

Results

Based on the evaluators' assessment at 24 weeks after the injection, 76% of subjects treated with autologous cultured fibroblasts showed improvement whereas 0% of subjects treated with placebo showed improvement (P < 0.0001). Based on self-assessment at 24 weeks after the injection, 72% of subjects treated with autologous cultured fibroblasts and 45% of subjects treated with placebo showed improvement (P = 0.0662). There were no serious adverse events related to autologous cultured fibroblast injection.

Conclusions

Autologous cultured fibroblast injection might be effective and safe to correct nasojugal grooves.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Response to: Commentary on: “Gluteal Augmentation with Silicone Implants: A New Proposal for Intramuscular Dissection”

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Ethnic Rhinoplasty in Female Patients: The Neoclassical Canons Revisited

Abstract

Background

Despite the substantial amount of research devoted to objectively defining facial attractiveness, the canons have remained a paradigm of aesthetic facial analysis, yet their omnipresence in clinical assessments revealed their limitations outside of a subset of North American Caucasians, leading to criticism about their validity as a standard of facial beauty. In an effort to introduce more objective treatment planning into ethnic rhinoplasty, we compared neoclassical canons and other current standards pertaining to nasal proportions to anatomic proportions of attractive individuals from seven different ethnic backgrounds.

Methods

Beauty pageant winners (Miss Universe and Miss World nominees) between 2005 and 2015 were selected and assigned to one of seven regionally defined ethnic groups. Anteroposterior and lateral images were obtained through Google, Wikipedia, Miss Universe, and Miss World Web sites. Anthropometry of facial features was performed via Adobe Photoshop TM. Individual facial measurements were then standardized to proportions and compared to the neoclassical canons.

Results

Our data reflected an ethnic-dependent preference for the multiple fitness model. Wide-set eyes, larger mouth widths, and smaller noses were significantly relevant in Eastern Mediterranean and European ethnic groups. Exceptions lied within East African and Asian groups.

Conclusion

As in the attractive face, the concept of the ideal nasal anatomy varies between different ethnicities. Using objective criteria and proportions of beauty to plan and execute rhinoplasty in different ethnicities can help the surgeon plan and deliver results that are in harmony with patients' individual background and facial anatomy.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Comparison of Periorbital Anthropometry Between Beauty Pageant Contestants and Ordinary Young Women with Korean Ethnicity: A Three-Dimensional Photogrammetric Analysis

Abstract

Background

The purpose of this study is to investigate the differences in the periorbital anthropometry between national Beauty Pageant Contestants and Ordinary Young Women with Korean ethnicity.

Methods

Forty-three Beauty Pageant Contestants who were elected for the national beauty contest and forty-eight Ordinary Young Women underwent 3D photography. The authors analyzed 3D photogrammetric measures regarding periorbital soft tissue.

Results

The palpebral fissure width was significantly higher in the Beauty Pageant Contestants than the Ordinary Young Women (27.7 ± 1.2 vs. 26.3 ± 1.6 mm) (p < 0.001). The palpebral fissure height was also significantly higher in the Beauty Pageant Contestants (11.5. ± 1.0 vs. 9.1 ± 1.2 mm) (p < 0.001). The intercanthal width and upper eyelid height were smaller for the Beauty Pageant Contestants (intercanthal width, 34.3 ± 1.86 mm vs. 36.7 ± 3.1 mm; upper eyelid height, 11.5 ± 1.4 mm vs. 13.4 ± 2.3 mm) (p < 0.05). The nasal width and midfacial width were significantly smaller in the Beauty Pageant Contestants (nasal width, 38.0 ± 1.8 vs. 39.5 ± 2.2 mm; midfacial width 144.5 ± 3.9 vs. 146.9 ± 5.2 mm) (p < 0.05). The eyebrow showed significantly different features between the two groups in terms of vertical position in the upper face and the shape of the brow apex. The interpupillary distance, binocular distance, slant of palpebral fissure and width of pretarsal crease showed no significant difference between the two groups.

Conclusion

Periorbital features in Beauty Pageant Contestants are wide-set eyes, larger palpebral fissure in width and height, relatively small upper eyelid height and intercanthal width, and relatively small nose and facial width compared to normal women. Our anthropometric results can be referable values for Asian eyelid surgery and help surgeons to establish individualized surgical planning.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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