Subcutaneous methotrexate in patients with moderate to severe psoriasis: a critical appraisal

Summary

Aim

Warren et al¹ set out to assess the effect of an intensified dosing schedule of subcutaneous methotrexate in patients with moderate to severe chronic plaque psoriasis.

Setting and design

This is a prospective, double-blind, randomised (3:1), placebo-controlled study, conducted across 16 centres in Germany, France, the Netherlands, and the UK.

Study exposure

Methotrexate-naïve adults with a diagnosis of moderate to severe chronic plaque psoriasis for at least 6 months before baseline were randomly assigned to receive weekly subcutaneous injections of either methotrexate at a starting dose of 17.5 mg, or placebo for 16 weeks (first phase).Dose escalation to 22.5 mg/week was implemented after 8 weeks if patients did not achieve PASI 50. Treatment was combined with folic acid 5 mg/week. The first phase of the study was followed by an open-label period from 16-52 weeks (second phase), in which both groups received weekly methotrexate injections. At week 24, dose escalation to 22.5 mg/week was possible in patients not achieving PASI 50.

Outcomes

Psoriasis severity was measured using the PASI (Psoriasis Area and Severity Index). The authors also used two other psoriasis severity measures and two quality of life measures, looked at safety indices and performed a sub-study analysing paired skin biopsies at baseline and week 16 (histopathology, immunohistochemistry and expression of interleukin (IL)17A, interferon-γ and tumour necrosis factor-α).

Primary outcome measures

The primary outcome was the proportion of patients reaching PASI 75 at week 16.

Results

120 patients were included in this trial, most of whom were middle-aged white men with longstanding psoriasis and a mean BMI of 30.1 kg/m². PASI 75 was achieved in 41% of patients receiving methotrexate vs. 10% of patients receiving placebo (RR 3.93, 95% CI 1.31–11.81; p=0.0026) at week 16. Subcutaneous methotrexate was generally well tolerated, with no serious adverse events related to this treatment over the 52-week study.

Conclusions

Warren et al conclude that the 52-week risk-benefit profile of subcutaneous methotrexate is favourable in patients with psoriasis.

This article is protected by copyright. All rights reserved.

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Oral retinoids and depression

Abstract

We are concerned about the content and possible misinterpretation of a research letter by Le Moigne et al. published on 19 June 2017 in the British Journal of Dermatology online.[1]

We share the concern expressed by the authors about possible psychiatric effects of oral retinoids. However, case reports rank low in the hierarchy of evidence, as a result of their inherent limitations, including publication bias and a lack of control groups.

This article is protected by copyright. All rights reserved.

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Improved artefact removal from EEG using Canonical Correlation Analysis and spectral slope

Publication date: 15 March 2018
Source:Journal of Neuroscience Methods, Volume 298
Author(s): Azin S. Janani, Tyler S. Grummett, Trent W. Lewis, Sean P. Fitzgibbon, Emma M. Whitham, Dylan DelosAngeles, Hanieh Bakhshayesh, John O. Willoughby, Kenneth J. Pope
BackgroundContamination of scalp measurement by tonic muscle artefacts, even in resting positions, is an unavoidable issue in EEG recording. These artefacts add significant energy to the recorded signals, particularly at high frequencies. To enable reliable interpretation of subcortical brain activity, it is necessary to detect and discard this contamination.New methodWe introduce a new automatic muscle-removal approach based on the traditional Blind Source Separation-Canonical Correlation Analysis (BSS-CCA) method and the spectral slope of its components. We show that CCA-based muscle-removal methods can discriminate between signals with high correlation coefficients (brain, mains artefact) and signals with low correlation coefficients (white noise, muscle). We also show that typical BSS-CCA components are not purely from one source, but are mixtures from multiple sources, limiting the performance of BSS-CCA in artefact removal. We demonstrate, using our paralysis dataset, improved performance using BSS-CCA followed by spectral-slope rejection.ResultThis muscle removal approach can reduce high-frequency muscle contamination of EEG, especially at peripheral channels, while preserving steady-state brain responses in cognitive tasks.Comparison with existing methodsThis approach is automatic and can be applied on any sample of data easily. The results show its performance is comparable with the ICA method in removing muscle contamination and has significantly lower computational complexity.ConclusionWe identify limitations of the traditional BSS-CCA approach to artefact removal in EEG, propose and test an extension based on spectral slope that makes it automatic and improves its performance, and results in performance comparable to competitors such as ICA-based artefact removal.



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Proposed consensus definitions for new-onset refractory status epilepticus (NORSE), febrile infection-related epilepsy syndrome (FIRES), and related conditions

Summary

We convened an international group of experts to standardize definitions of New-Onset Refractory Status Epilepticus (NORSE), Febrile Infection-Related Epilepsy Syndrome (FIRES), and related conditions. This was done to enable improved communication for investigators, physicians, families, patients, and other caregivers. Consensus definitions were achieved via email messages, phone calls, an in-person consensus conference, and collaborative manuscript preparation. Panel members were from 8 countries and included adult and pediatric experts in epilepsy, electroencephalography (EEG), and neurocritical care. The proposed consensus definitions are as follows: NORSE is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause. FIRES is a subcategory of NORSE, applicable for all ages, that requires a prior febrile infection starting between 2 weeks and 24 hours prior to onset of refractory status epilepticus, with or without fever at onset of status epilepticus. Proposed consensus definitions are also provided for Infantile Hemiconvulsion-Hemiplegia and Epilepsy syndrome (IHHE) and for prolonged, refractory and super-refractory status epilepticus. This document has been endorsed by the Critical Care EEG Monitoring Research Consortium. We hope these consensus definitions will promote improved communication, permit multicenter research, and ultimately improve understanding and treatment of these conditions.

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The Potential Role of Bile Acids in Acquired Laryngotracheal Stenosis

Objective

Gastroesophageal reflux is thought to be a risk factor for laryngotracheal stenosis. Bile acids are a component of gastric refluxate and have previously been implicated in the development of fibrosis in other airway subsites. There is clear evidence that bile acids reflux into the upper airway. We therefore investigated the potential role of bile acids in the pathophysiology of laryngotracheal fibrosis and stenosis, specifically investigating the highly conserved process of epithelial–mesenchymal transition (EMT).

Study Design

Translational research study.

Methods

Human primary tracheal epithelial cells (PTECs) were challenged with the four most common digestive bile acids (cholic, chenodeoxycholic, deoxycholic, and lithocholic). EMT markers transforming growth factor (TGF)-β1, Matrix metalloproteinase (MMP)-9, and procollagen proteins were measured in the supernatant at 48 hours via enzyme-linked immunosorbent assay. Real-time polymerase chain reaction was also used to measure E-cadherin and fibronectin expression.

Results

Significantly greater concentrations of TGF-β1 and MMP-9 were measured in the culture supernatants of cells treated with each bile acid at 10 µmol/L. Lithocholic acid and deoxycholic acid induced significantly increased expression of procollagen protein. Upregulation of fibronectin and downregulation of E-cadherin were observed with all bile acids, except for deoxycholic acid.

Conclusion

This is the first proof of principle demonstration that physiologically relevant bile acid challenge induces EMT mechanisms in PTECs. This implies a potential role for bile acids in laryngotracheal scarring and airway remodeling of potential translational significance in laryngotracheal stenosis.

Level of Evidence

NA. Laryngoscope, 00:000–000, 2018

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In Response to Should Infants Who Fail Their Newborn Hearing Screen Undergo Cytomegalovirus Testing?

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The survival impact of surgical therapy in squamous cell carcinoma of the hard palate

Objective

To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the hard palate (SCCHP) between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Retrospective, population-based cohort study of patients in the SEER tumor registry who were diagnosed with SCCHP from 1973 to 2014. Outcomes and measures included overall survival (OS) and disease-specific survival (DSS).

Results

A total of 1,489 cases of primary SCCHP were identified. Of those, 53.2% were females and 47.8% presented with stage IV disease. The mean age at diagnosis was 69.8 years. Overall survival at 2, 5, and 10 years was 44%, 33%, and 21%, respectively. A total of 66.2% of patients underwent surgery (with or without radiation therapy [RT]); 20.1% received RT; and 22.4% had both surgical and RT. On multivariate analysis, RT, advanced age, stage, and grade were associated with worse OS and DSS (P < 0.05). Surgical therapy (with or without radiation) was an independent favorable predictor of OS and DSS (P < 0.05).

Conclusion

SCCHP is relatively infrequent tumor that portends an overall poor prognosis when advanced stage and a greater prognosis when early stage. Surgical therapy was found to be an independent predictor for improved OS and DSS, whereas RT was associated with reduced OS and DSS.

Level of Evidence

4. Laryngoscope, 2018

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Stem cells enhance reperfusion following ischemia: Validation using laser speckle imaging in predicting tissue repair

Objectives

The lack of real-time assessment of vascular perfusion changes remains a major weakness in assessing the efficacy of bone marrow stromal cells (BMSC) therapeutic ischemia reperfusion (I/R) injury. This study provides for the first time the real-time in vivo perfusion monitoring in I/R mice with BMSC therapy.

Study Design

Animal model.

Methods

Surgically created cutaneous flaps perfused by the inferior epigastric vessels were subjected to 3.5 hours of ischemia/reperfusion. Wound healing and vascular perfusion were assessed by Image-J and laser speckle contrast analysis (LSCA) in three groups (sham, I/R, and I/R + BMSC). BMSC tracking was quantified in an additional two groups (with/without I/R) using intravital fluorescent microscopy. The histopathology of skin flaps was examined by hematoxylin and eosin stain. Infiltrated macrophages were analyzed by confocal immunofluorescent microscopy.

Results

Postischemic tissues treated with BMSC demonstrated significantly greater survival than I/R control. On days 3 to 7 postreperfusion, both proximal and distal areas in BMSC-treated flaps demonstrated greater levels of perfusion than untreated I/R flaps (P < 0.05). Intravital fluorescent microscopy revealed that numbers of labeled BMSC were significantly increased in the distal area compared to the proximal area in both with and without ischemic mice. Histological examination showed lower necrosis and infiltrated inflammatory cells in I/R + BMSC-treated mice versus I/R controls.

Conclusion

BMSC accumulated in I/R flaps and exerted beneficial effects including: 1) improving vascular perfusion and 2) attenuating inflammatory cell infiltration. LSCA facilitates monitoring of the real-time restitution of perfusion during flap wound healing in experimental animals and could also similarly applied in clinical investigations.

Level of Evidence

NA. Laryngoscope, 2018

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Circadian anosmia: A rare clinical presentation

We report the case of a 27-year-old female who presented with a peculiar story of anosmia fluctuating in a circadian manner. Olfactory function appeared an hour after breakfast, was normal during daytime, and disappeared in the early evening. Imaging confirmed chronic rhinosinusitis (CRS). Initial systemic, followed by topical steroid treatment, rapidly and sustainably reversed this condition. The olfactory fluctuation paralleled the endogenous steroid production. This suggests that slight congestion changes in a chronically inflamed nasal mucosa may have been sufficient to induce this circadian anosmia. The importance of identifying fluctuation of olfactory function as a sign of CRS is emphasized and discussed. Laryngoscope, 2018

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Double-blind, placebo-controlled study with alginate suspension for laryngopharyngeal reflux disease

Objective

Treatment for laryngopharyngeal reflux disease (LPRD) is challenging because of delays in recognition and poor responsiveness to proton-pump inhibitor therapy. The aim of this study was to determine the efficacy and safety of liquid alginate suspension for treating LPRD.

Methods

A double-blind, placebo-controlled, prospective study comparing 8 weeks of treatment with Alginos Oral Suspension (TTY Biopharm Co. Ltd., Taipei, Taiwan) (sodium alginate 1,000 mg three times daily) with a placebo was conducted on patients who fulfilled the criteria of at least one symptom consistent with LPRD, a total reflux symptom index (RSI) score of > 10, and a total reflux finding score (RFS) of > 5. Those with erosive gastroesophageal reflux disease, as evidenced through screened transnasal upper gastrointestinal endoscopy, were excluded. Efficacy was assessed by RSI, RFS, and ambulatory multichannel intraluminal impedance and pH (MII-pH) monitoring.

Results

A total of 80 patients aged 22 to 72 years were enrolled. Compared with baseline, both Alginos (TTY Biopharm Co. Ltd.) and the placebo significantly reduced the total RSI (P < 0.001) and the total number of reflux episodes shown by MII-pH monitoring (P < 0.05) after 8 weeks of treatment. However, liquid alginate suspension was unable to show superiority over the placebo. The incidence of various adverse events from Alginos (TTY Biopharm Co. Ltd.) was relatively low (7.7%) and mild.

Conclusion

This study showed that liquid alginate suspension was well tolerated by LPRD patients. It effectively improved symptoms and reflux numbers but was unable to show superiority over placebo. As observed in previous studies, a great placebo effect was present. The importance of lifestyle modification could not be overlooked.

Level of Evidence

2. Laryngoscope, 00:000–000, 2018

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Managing the Mental Distress of the Hematopoietic Stem Cell Transplant (HSCT) Patient: a Focus on Delirium

Abstract

Purpose of Review

To highlight the breadth and types of mental distress experienced by hematopoietic stem cell transplant (HSCT) patients and highlight the need for better prevention and management of delirium.

Recent Findings

Recent publications highlight additional risks factors which predict for mental distress during the HSCT process. Despite new medications and additional psychological reports, there is little progress in non-pharmacologic or medication therapy in the prevention and treatment of delirium.

Summary

Mental distress, especially delirium, is common during the HSCT process. The morbidity associated with delirium and other mental distress can still be significant at 6–12 months after the completion of the procedure affecting patient functioning and quality of life (QOL). Medication interventions may be helpful but should be used sparingly for targeted patients during HSCT. Additional interventions are needed to prevent and treat delirium in HSCT patients.

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Role of Eustachian Dysfunction and Primary Sclerotic Mastoid Pneumatisation Pattern in Aetiology of Squamous Chronic Otitis Media: A Correlative Study

Abstract

Squamous chronic otitis media (COM) implies formation of a retraction pocket (inactive form) or frank cholesteatoma (active form) in pars tensa or pars flaccida of tympanic membrane. A retraction pocket or frank cholesteatoma are believed to occur due to tubal dysfunction. The present study was undertaken to investigate the pattern of mastoid pneumatisation and Eustachian dysfunction by dynamic slow motion videoendoscopy (DSVE) in cases of both, active and inactive type of squamous chronic otitis media (COM). 52 patients (65 ears) comprising of twenty-six ears with pars flaccida squamous disease and 39 ears with Pars Tensa squamous disease were enrolled for the study. DSVE findings, in terms of grade and type of Eustachian dysfunction were noted. Mastoid pneumatization pattern on CT-scans, and peroperative status of mastoid pneumatisation, especially contracted mastoid with anteriorly placed sigmoid sinus or low lying dura were also recorded for every case while performing tympano-mastoidectomy. Primary sclerotic/diploic type of mastoid pneumatisation pattern and Eustachian dysfunction were found to have inverse relationship in the cases of squamous otitis media. Eustachian dysfunction, diagnosed on DSVE, had significant association with both pars flaccida (P = 0.0001) and pars tensa disease (P = 0.0007). Primary sclerotic or diploic mastoid were found to be more common in ears with pars flaccida squamous disease than pars tensa COM (46.15% vs. 38.46%, P < 0.05).

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Neurological Complications of Acute and Chronic Sinusitis

Abstract

Purpose of Review

Acute and chronic sinusitis can give rise to a wide array of intracranial and orbital complications. These complications include brain abscess, subdural empyema, epidural abscess, meningitis, venous sinus thrombosis, frontal bone osteomyelitis, and orbital cellulitis and abscess. Despite numerous medical advances, these complications carry a risk of mortality and significant morbidity.

Recent Findings

Recent studies have shown improvement in both the mortality and the morbidity associated with the neurologic complications of acute and chronic sinusitis. However, there are still a large portion of patients with long-term sequelae, and the literature reports a morbidity rate of approximately 30%. The most common post-treatment morbidities include permanent changes in vision, seizures, and hemiparesis.

Summary

Although the overall incidence of neurologic complications from a sinogenic source are rare, the potential long-term complications can be devastating making prompt diagnosis and treatment vital to improving outcomes.

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Issue Information

Cover of this issue. Expression of 15-PGDH (brown) in pancreatic cancer is reduced by co-culture of activated macrophages (Green). See also Arima et al. (pp. 462–470 of this issue).

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In This Issue

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Intrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain

Abstract

Purpose of Review

The purpose of the present investigation is to summarize the body and quality of evidence including the most recent studies in support of intrathecal drug delivery systems and spinal cord stimulation for the treatment of cancer-related pain.

Recent Findings

In the past 3 years, a number of prospective studies have been published supporting intrathecal drug delivery systems for cancer pain. Additional investigation with adjuvants to morphine-based analgesia including dexmedetomidine and ziconotide support drug-induced benefits of patient-controlled intrathecal analgesia. A study has also been recently published regarding cost-savings for intrathecal drug delivery system compared to pharmacologic management, but an analysis in the Ontario, Canada healthcare system projects additional financial costs. Finally, the Polyanalgesic Consensus Committee has updated its recommendations regarding clinical guidelines for intrathecal drug delivery systems to include new information on dosing, trialing, safety, and systemic opioid reduction. There is still a paucity of clinical evidence for spinal cord stimulation in the treatment of cancer pain. There are new intrathecal drugs under investigation including various conopeptides and AYX1.

Summary

Large, prospective, modern, randomized controlled studies are still needed to support the use of both intrathecal drug delivery systems as well as spinal cord stimulation for cancer pain populations. There are multiple prospective and small randomized controlled studies that highlight a potential promising future for these interventional modalities. Related to the challenge and urgency of cancer pain, the pain practitioner community is moving toward a multimodal approach that includes discussions regarding the role of intrathecal therapies and spinal cord stimulation to the individualized treatment of patients.

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The Effect of Ketamine Infusion in the Treatment of Complex Regional Pain Syndrome: a Systemic Review and Meta-analysis

Abstract

Purpose of Review

Complex regional pain syndrome (CRPS) is a painful debilitating neurological condition that accounts for approximately 1.2% of adult chronic pain population. Ketamine, an NMDA receptor antagonist, is an anesthetic agent that has been used by some pain specialists for CRPS. There is a growing body of clinical evidence to support the use of ketamine in the treatment of neuropathic pain, especially CRPS. This meta-analysis study was aimed to examine the efficacy of ketamine in the treatment of CRPS.

Recent Findings

A search of Embase, Pubmed, Web of Knowledge, Cochrane, Clinical Trial.gov, and FDA.gov between Jan 1, 1950, and August 1, 2017, was conducted to evaluate ketamine infusion therapy in the treatment of CRPS. We selected randomized clinical trials or cohort studies for meta-analyses. I² index estimates were calculated to test for variability and heterogeneity across the included studies. The primary outcome is pain relief. The effect of ketamine treatment for complex regional pain syndrome was assessed by 0–10 scale numerical rating pain score. The secondary outcome is the pain relief event rate, which is defined as the percentage of participants who achieved 30% or higher pain relief in each of the qualified studies. Our meta-analysis results showed that the Ketamine treatment led to a decreased mean of pain score in comparison to the self-controlled baseline (p < 0.000001). However, there is a statistical significance of between-study heterogeneity. The immediate pain relief event rate was 69% (95% confidence interval (CI) 53%, 84%). The pain relief event rate at the 1–3 months follow-ups was 58% (95% CI 41%, 75%).

Summary

The current available studies regarding ketamine infusion for CRPS were reviewed, and meta-analyses were conducted to evaluate the efficacy of ketamine infusion in the treatment of CRPS. Our findings suggested that ketamine infusion can provide clinically effective pain relief in short term for less than 3 months. However, because of the high heterogeneity of the included studies and publication bias, additional random controlled trials and standardized multicenter studies are needed to confirm this conclusion. Furthermore, studies are needed to prove long-term efficacy of ketamine infusion in the treatment of CRPS.

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Migraine and the Hippocampus

Abstract

Purpose of Review

The hippocampus is involved in pain processing, pain-related attention and anxiety, and stress response. The present review compiles the present knowledge of hippocampal volume, activity, and connectivity regarding migraine.

Recent Findings

For hippocampal volume, a longitudinal study discovered decreased volume in newly diagnosed migraine patients after 1 year. Two cross-sectional studies suggested an adaptive increase of volume at low headache frequency and a maladaptive decrease of volume at higher headache frequency. Patients who carried a COMT Val homozygous were found to have larger hippocampi on both sides compared with healthy controls with the same polymorphism. For hippocampal activation, one study showed greater nociceptive activation in patients with migraine compared to healthy controls, with the activity correlated to headache frequency. Another study showed greater deactivation and higher functional connectivity linked to other pain-processing regions in low frequency compared to high-frequency migraineurs. At resting state, intraregional functional connectivity of hippocampus was demonstrated to be lower, and connectivity of the hippocampus with other brain regions was different in patients carrying specific genetic variants. For structural connectivity, two studies suggest a stronger connectivity between the hippocampus and other corticolimbic regions, and the altered connectivities are responsible for migraine-associated allodynia or placebo effect of migraine.

Summary

Factors including headache frequency, accumulative number of migraine attacks, anxiety score, depression score, and genetic variants are related to hippocampal morphology and functional changes in people with migraine. Future studies should select participants precisely and appropriately control for genetic variants to investigate the complex relationship between the hippocampus and migraine.

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Chronification of Pain: Mechanisms, Current Understanding, and Clinical Implications

Abstract

Purpose of Review

The development of acute to chronic pain involves distinct pathophysiological changes in the peripheral and central nervous systems. This article reviews the mechanisms, etiologies, and management of chronic pain syndromes with updates from recent findings in the literature.

Recent Findings

Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible.

Summary

Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.

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Complex Regional Pain Syndrome, Current Concepts and Treatment Options

Abstract

Purpose of Review

Complex regional pain syndrome (CRPS) refers to a chronic pain condition that is characterized by progressively worsening spontaneous regional pain without dermatomal distribution. The symptomatology includes pain out of proportion in time and severity to the inciting event. The purpose of this review is to present the most current information concerning epidemiology, diagnosis, pathophysiology, and therapy for CRPS.

Recent Findings

In recent years, discovery of pathophysiologic mechanisms of CRPS has led to significant strides in the understanding of the disease process.

Summary

Continued elucidation of the underlying pathophysiological mechanisms will allow for the development of more targeted and effective evidence-based therapy protocols. Further large clinical trials are needed to investigate mechanisms and treatment of the disorder.

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Staging for Head and Neck Cancer: Purpose, Process and Progress

Abstract

With advancing knowledge and new data available, periodic revisions in the TNM staging system is essential. In addition, new disease entities entering in the spectrum of neoplastic diseases demand that a staging system be developed to facilitate their treatment algorithms and outcomes. The most recent revisions in the AJCC/UICC staging system were published in the eighth edition of the AJCC staging manual. This presentation gives a historical background on the AJCC/UICC staging process and highlights major changes introduced in the eighth edition for cancers of the head and neck.

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Vitamin D supplementation for bone health in adults with epilepsy: A systematic review

Summary

Objective

Several antiepileptic drugs (AEDs) have been associated with a detrimental effect on bone health through a reduction in serum vitamin D. Subsequently, several studies have investigated the effect of vitamin D supplementation in persons with epilepsy being treated with AEDs. The present systematic review of published literature was conducted to determine the effect of vitamin D intervention on bone health in adults with epilepsy.

Methods

The following databases were searched using keywords including but not limited to epilepsy, bone, and vitamin D: PubMed, Medline, Embase, Scopus, Cochrane Clinical Trials, International Pharmaceutical Abstracts, Health Canada Clinical Trials Database, ClinicalTrials.gov, EU Clinical Trials, and Google. Studies were eligible if there was an epilepsy diagnosis, participants were adults (18+ years old), and vitamin D treatment and bone outcome were provided. Articles were screened independently by 2 reviewers. Methodological quality was assessed using the Cochrane Collaboration's tool and a modified Newcastle Ottawa Scale for nonrandomized studies.

Results

Nine studies were found to be eligible for this review. After vitamin D treatment, there appeared to be positive changes in bone turnover markers; 3 of 8 studies found the increase in serum calcium to be significant, 6 of 8 studies found the decrease in alkaline phosphatase to be significant, and 2 of 4 studies found the decrease in parathyroid hormone to be significant. All 6 studies that investigated bone mineralization had significant findings; however, due to varying methodologies, the impact of vitamin D on bone mineralization was inconclusive.

Significance

Vitamin D does appear to have some benefit to bone health in adults with epilepsy, and therefore supplementation could potentially be a requisite to using some AEDs. To clarify the role of vitamin D supplementation to manage the adverse effect of AEDs on bone health in adults with epilepsy, long-term trials that use higher doses (>1800 IU) and measure bone mineral density are necessary.

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Recent advances in the reconstruction of cranio-maxillofacial defects using computer-aided design/computer-aided manufacturing

Abstract

With the development of computer-aided design/computer-aided manufacturing (CAD/CAM) technology, it has been possible to reconstruct the cranio-maxillofacial defect with more accurate preoperative planning, precise patient-specific implants (PSIs), and shorter operation times. The manufacturing processes include subtractive manufacturing and additive manufacturing and should be selected in consideration of the material type, available technology, post-processing, accuracy, lead time, properties, and surface quality. Materials such as titanium, polyethylene, polyetheretherketone (PEEK), hydroxyapatite (HA), poly-DL-lactic acid (PDLLA), polylactide-co-glycolide acid (PLGA), and calcium phosphate are used. Design methods for the reconstruction of cranio-maxillofacial defects include the use of a pre-operative model printed with pre-operative data, printing a cutting guide or template after virtual surgery, a model after virtual surgery printed with reconstructed data using a mirror image, and manufacturing PSIs by directly obtaining PSI data after reconstruction using a mirror image. By selecting the appropriate design method, manufacturing process, and implant material according to the case, it is possible to obtain a more accurate surgical procedure, reduced operation time, the prevention of various complications that can occur using the traditional method, and predictive results compared to the traditional method.

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Issue Information

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Cover

The cover image, by Jin Whan Lee et al., is based on the Original Research New bone formation and trabecular bone microarchitecture of highly porous tantalum compared to titanium implant threads: A pilot canine study, DOI: 10.1111/clr.13074.

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Oncologists and Breaking Bad News—From the Informed Patients’ Point of View. The Evaluation of the SPIKES Protocol Implementation

Abstract

The way that bad news is disclosed to a cancer patient has a crucial impact on physician-patient cooperation and trust. Consensus-based guidelines provide widely accepted tools for disclosing unfavorable information. In oncology, the most popular one is called the SPIKES protocol. A 17-question survey was administered to a group of 226 patients with cancer (mean age 59.6 years) in order to determine a level of SPIKES implementation during first cancer disclosure. In our assessment, the patients felt that the highest compliance with the SPIKES protocol was with Setting up (70.6%), Knowledge (72.8%), and Emotions (75.3%). The lowest was with the Perception (27.7%), Invitation (30.4%), and Strategy & Summary (56.9%) parts. There could be improvement with each aspect of the protocol, but especially in Perception, Invitation, and Strategy & Summary. The latter is really important and must be done better. Older patients felt the doctors' language was more comprehensible (r = 0.17; p = 0.011). Patients' satisfaction of their knowledge about the disease and follow-up, regarded as an endpoint, was insufficient. Privacy was important in improving results (p < 0.01). In practice, the SPIKES protocol is implemented in a satisfactory standard, but it can be improved in each area, especially in Perception, Invitation, and Summary. It is suggested that more training should be done in undergraduate and graduate medical education and the effectiveness of the disclosure continue to be evaluated and improved.

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Socio-economic patterning in early mortality of patients aged 0–49 years diagnosed with primary bone cancer in Great Britain, 1985–2008

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Karen Blakey, Richard G. Feltbower, Peter W. James, Gillian Libby, Charles Stiller, Paul Norman, Craig Gerrand, Richard J.Q. McNally
BackgroundStudies have shown marked improvements in survival between 1981 and 2000 for Ewing sarcoma patients but not for osteosarcoma. This study aimed to explore socio-economic patterning in early mortality rates for both tumours.ProcedureThe study analysed all 2432 osteosarcoma and 1619 Ewing sarcoma cases, aged 0–49 years, diagnosed in Great Britain 1985–2008 and followed to 31/12/2009. Logistic regression models were used to calculate risk of dying within three months, six months, one year, three years and five years after diagnosis. Associations with Townsend deprivation score and its components were examined at small-area level. Urban/rural status was studied at larger regional level.ResultsFor osteosarcoma, after age adjustment, mortality at three months, six months and one year was associated with higher area unemployment, OR = 1.05 (95% CI 1.00, 1.10), OR = 1.04 (95% CI 1.01, 1.08) and OR = 1.04 (95% CI 1.02, 1.06) respectively per 1% increase in unemployment. Mortality at six months was associated with greater household non-car ownership, OR = 1.02 (95% CI 1.00, 1.03). For Ewing sarcoma, there were no significant associations between mortality and overall Townsend score, nor its components for any time period. For both tumours increasing mortality was associated with less urban and more remote rural areas.ConclusionsThis study found that for osteosarcoma, early mortality was associated with residence at diagnosis in areas of higher unemployment, suggesting risk of early death may be socio-economically determined. For both tumours, distance from urban centres may lead to greater risk of early death.



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The impact of rectal cancer tumor height on recurrence rates and metastatic location: A competing risk analysis of a national database

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Knut M. Augestad, Deborah S. Keller, Paul M. Bakaki, Johnie Rose, Siran M. Koroukian, Tom Øresland, Conor P. Delaney
BackgroundThe impact of rectal cancer tumor height on local recurrence and metastatic spread is unknown. The objective was to evaluate the impact of rectal cancer tumor height from the anal verge on metastatic spread and local recurrence patterns.MethodsThe Norwegian nationwide surgical quality registry was reviewed for curative rectal cancer resections from 1/1/1996-12/15/2006. Cancers were stratified into five height groups: 0–3 cm, >3–5 cm, >5–9 cm, >9–12 cm, 12 cm–HI. Competing risk and proportional hazards models assessed the relationship between tumor height and patterns of metastasis and survival.Results6859 patients were analyzed. After median follow-up of 52 months (IQR 20–96), 26.7% (n = 1835) experienced recurrence. With tumors >12 cm, the risk of liver metastases increased (crude HR 1.49, p = 0.03), while lung metastases decreased (crude HR 0.66, p = 0.03), and risk of death decreased (crude HR 0.81, p = 0.001) The cumulative incidence of pelvic recurrence were highest for the low tumors (p = 0.01). Median time to liver metastases was 14months (IQR 7–24), lung metastases 25months (IQR 13–39), pelvic recurrence 19months (IQR10-32), (p < 0.0001). Time to metastases in liver and lungs were significantly associated with tumor height (p < 0.001)ConclusionThere are distinct differences in metastatic recurrence patterns and time to recurrence from different anatomic areas of the rectum. In crude analyses, tumor height impacted metastatic spread to the liver and lungs. However, when adjusting for treatment variables, the hazard of metastatic spread to the liver and lungs are limited. Nevertheless, time to metastases in liver and lungs is significantly impacted by tumor height. Venous drainage of the rectal cancer may be a significant contributor of rectal cancer metastatic spread, but further research is warranted.

Graphical abstract

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Anaplastic thyroid carcinoma in Denmark 1996–2012: A national prospective study of 219 patients

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Gitte Bjørn Hvilsom, Stefano Christian Londero, Christoffer Holst Hahn, Sten Schytte, Henrik Baymler Pedersen, Peer Christiansen, Katalin Kiss, Stine Rosenkilde Larsen, Marie Louise Jespersen, Giedrius Lelkaitis, Christian Godballe
BackgroundAnaplastic thyroid carcinoma (ATC) is the least common but most malignant thyroid cancer. We aimed to examine the characteristics as well as evaluate the incidence, prognostic factors, and if introduction of a fast track cancer program might influence survival in a cohort of ATC patients.MethodsA cohort study based on prospective data from the national Danish thyroid cancer database DATHYRCA and the national Danish Pathology Register including 219 patients diagnosed from 1996 to 2012, whom were followed until death or through September 2014.ResultsWe found the median age in the 7th decade, the majority of patients being women presenting with a growing mass at the neck, diagnosed with stage T4b disease. At diagnosis, 56% of the patients had lymph node metastasis and 38% distant metastasis.We observed one- and five-year survival of 20.7% and 11.0%, respectively.Both univariate and multivariate analyses showed age (above 73.6 years), respiratory impairment, T4b stage, and distant metastasis at diagnosis to be significant prognostic factors. Further, introduction of a national fast track cancer program increased survival nearly two-fold.ConclusionAs new information, our study adds "respiratory impairment at diagnosis" and "introduction of a national fast track cancer program" to the list of already established prognostic indicators for ATC.



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Population risk factors for late-stage presentation of cervical cancer in sub-Saharan Africa

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Tessa S. Stewart, Jennifer Moodley, Fiona M. Walter
BackgroundCervical cancer is the most prevalent malignancy in sub-Saharan Africa (SSA) with many women only seeking professional help when they are experiencing symptoms, implying late-stage malignancy and higher mortality rates. This ecological study assesses population-level exposures of SSA women to the numerous risk factors for HPV infection and cervical cancer, against late-stage presentation of cervical cancer.Materials and methodA literature review revealed the relevant risk factors in SSA. Open-access databases were mined for variables closely representing each risk factor. A proxy for late-stage presentation was used (ratio of incidence-to-mortality, IMR), and gathered from IARC's GLOBOCAN 2012 database. Variables showing significant correlation to the IMR were used in stepwise multiple regression to quantify their effect on the IMR.ResultsCountries with high cervical cancer mortality rates relative to their incidence have an IMR nearer one, suggesting a larger proportion of late-stage presentation. Western Africa had the lowest median IMR (1.463), followed by Eastern Africa (IMR = 1.595) and Central Africa (IMR = 1.675), whereas Southern Africa had the highest median IMR (1.761). Variables selected for the final model explain 65.2% of changes seen in the IMR. Significant predictors of IMR were GDP (coefficient = 2.189 × 10⁻⁶, p = 0.064), HIV infection (−1.936 × 10⁻³, p = 0.095), not using a condom (−1.347 × 10⁻³, p = 0.013), high parity (−1.744 × 10⁻², p = 0.008), and no formal education (−1.311 × 10⁻³, p < 0.001).ConclusionUsing an IMR enables identification of factors predicting late-stage cervical cancer in SSA including: GDP, HIV infection, not using a condom, high parity and no formal education.



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A new approach to estimate time-to-cure from cancer registries data

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Olayidé Boussari, Gaëlle Romain, Laurent Remontet, Nadine Bossard, Morgane Mounier, Anne-Marie Bouvier, Christine Binquet, Marc Colonna, Valérie Jooste
BackgroundCure models have been adapted to net survival context to provide important indicators from population-based cancer data, such as the cure fraction and the time-to-cure. However existing methods for computing time-to-cure suffer from some limitations.MethodsCure models in net survival framework were briefly overviewed and a new definition of time-to-cure was introduced as the time TTC at which P(t), the estimated covariate-specific probability of being cured at a given time t after diagnosis, reaches 0.95. We applied flexible parametric cure models to data of four cancer sites provided by the French network of cancer registries (FRANCIM). Then estimates of the time-to-cure by TTC and by two existing methods were derived and compared. Cure fractions and probabilities P(t) were also computed.ResultsDepending on the age group, TTC ranged from to 8 to 10 years for colorectal and pancreatic cancer and was nearly 12 years for breast cancer. In thyroid cancer patients under 55 years at diagnosis, TTC was strikingly 0: the probability of being cured was >0.95 just after diagnosis. This is an interesting result regarding the health insurance premiums of these patients. The estimated values of time-to-cure from the three approaches were close for colorectal cancer only.ConclusionsWe propose a new approach, based on estimated covariate-specific probability of being cured, to estimate time-to-cure. Compared to two existing methods, the new approach seems to be more intuitive and natural and less sensitive to the survival time distribution.

Graphical abstract

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Neural correlates of sine-wave speech intelligibility in human frontal and temporal cortex

Publication date: Available online 4 February 2018
Source:Brain and Language
Author(s): Sattar Khoshkhoo, Matthew K. Leonard, Nima Mesgarani, Edward F. Chang
Auditory speech comprehension is the result of neural computations that occur in a broad network that includes the temporal lobe auditory cortex and the left inferior frontal cortex. It remains unclear how representations in this network differentially contribute to speech comprehension. Here, we recorded high-density direct cortical activity during a sine-wave speech (SWS) listening task to examine detailed neural speech representations when the exact same acoustic input is comprehended versus not comprehended. Listeners heard SWS sentences (pre-exposure), followed by clear versions of the same sentences, which revealed the content of the sounds (exposure), and then the same SWS sentences again (post-exposure). Across all three task phases, high-gamma neural activity in the superior temporal gyrus was similar, distinguishing different words based on bottom-up acoustic features. In contrast, frontal regions showed a more pronounced and sudden increase in activity only when the input was comprehended, which corresponded with stronger representational separability among spatiotemporal activity patterns evoked by different words. We observed this effect only in participants who were not able to comprehend the stimuli during the pre-exposure phase, indicating a relationship between frontal high-gamma activity and speech understanding. Together, these results demonstrate that both frontal and temporal cortical networks are involved in spoken language understanding, and that under certain listening conditions, frontal regions are involved in discriminating speech sounds.



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Modulation of intra- and inter-hemispheric connectivity between primary and premotor cortex during speech perception

Publication date: Available online 4 February 2018
Source:Brain and Language
Author(s): Helen E. Nuttall, Dan Kennedy-Higgins, Joseph T. Devlin, Patti Adank
Primary motor (M1) areas for speech production activate during speechperception. It has been suggested that such activation may be dependent upon modulatory inputs from premotor cortex (PMv). If and how PMv differentially modulates M1 activity during perception of speech that is easy or challenging to understand, however, is unclear. This study aimed to test the link between PMv and M1 during challenging speech perception in two experiments. The first experiment investigated intra-hemispheric connectivity between left hemisphere PMv and left M1 lip area during comprehension of speech under clear and distorted listening conditions. Continuous theta burst stimulation (cTBS) was applied to left PMv in eighteen participants (aged 18–35). Post-cTBS, participants performed a sentence verification task on distorted (imprecisely articulated), and clear speech, whilst also undergoing stimulation of the lip representation in the left M1 to elicit motor evoked potentials (MEPs). In a second, separate experiment, we investigated the role of inter-hemispheric connectivity between right hemisphere PMv and left hemisphere M1 lip area. Dual-coil transcranial magnetic stimulation was applied to right PMv and left M1 lip in fifteen participants (aged 18–35). Results indicated that disruption of PMv during speech perception affects comprehension of distorted speech specifically. Furthermore, our data suggest that listening to distorted speech modulates the balance of intra- and inter-hemispheric interactions, with a larger sensorimotor network implicated during comprehension of distorted speech than when speech perception is optimal. The present results further understanding of PMv-M1 interactions during auditory-motor integration.



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Release of nickel and chromium ions from orthodontic wires following the use of teeth whitening mouthwashes

Corrosion resistance is an important requirement for orthodontic appliances. Nickel and chromium may be released from orthodontic wires and can cause allergic reactions and cytotoxicity when patients use vario...

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Supernumerary Abducens Nerves: A Comprehensive Review

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Joy M.H. Wang, Bryan Adam Edwards, Marios Loukas, Rod J. Oskouian, R. Shane Tubbs
BackgroundBranching and/or replication of the abducens nerve is not an uncommon occurrence. Although numerous variations have been documented, the rarest forms are duplicated or triplicated nerves, where multiple nerve roots originate from the brainstem, travel intracranially, and attach to the lateral rectus as separate entities.MethodsWe conducted a systematic literature search on the topic of supernumerary abducens nerve, using PubMed and Google Scholar.ResultsAfter screening, 16 studies were included: 11 cadaveric studies and 6 case reports.ConclusionsIn this paper, we review the literature on variations found, discuss current hypotheses and clinical relevance, and propose future studies. Neurosurgeons should be aware of such nerve variants when viewing imaging or operating in the regions traversed by the abducens nerve.



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Use of Pulsed Radiofrequency Energy Device (PEAK Plasmablade) in Neuromodulation Implant Revisions

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Ismail Ughratdar, Khandkar Ali Kawsar, Rosalind Mitchell, Richard Selway, Keyoumars Ashkan
BackgroundBattery replacement or revision surgery for neuromodulation implants is conventionally performed using sharp dissection. Meticulous dissection within thick scar tissue is vital to avoid damage to surrounding lead(s), which could result in more extensive revision surgery. Traditional electrosurgery devices are contraindicated as the emitted energy can be transferred to the hardware, resulting in implant or tissue damage with severe consequent complications.ObjectiveWe report our experience and potential applications of a novel, pulsed monopolar radiofrequency energy device (PEAK PlasmaBlade, Medtronic PLC, Minneapolis, Minnesota, USA), which facilitates dissection around implants without the risk of damaging or transmitting energy through the system.MethodsWe conducted a 2-center retrospective study to review the indications, safety, and efficacy of the PlasmaBlade in 57 cases requiring either neuromodulation system replacement or revision. Deep brain stimulator (DBS) battery replacements were undertaken in 45 cases, 8 vagal nerve stimulator battery revisions, 2 intrathecal baclofen system revision, 1 DBS extension revision, and 1 DBS scar revision around the cranial portion of the lead.ResultsAll cases proceeded without adverse event or damage to lead/generator and with a subjective and objective impression of significant time savings. Average operating times for battery replacements were reduced from 37 to 26 minutes (P = 0.015).ConclusionIn our experience, the PlasmaBlade is safe to use in revising/replacing neuromodulation implants. We observed no damage or transmission of energy to the implants or leads; additional advantages of the system include reduced operating times, less damage to surrounding tissue, and the potential to facilitate revision procedures in awake patients under local anesthesia.



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Tumefactive Multiple Sclerosis Masquerading as High Grade Glioma

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Michelle Lin, Patrick Reid, Joshua Bakhsheshian
Tumefactive multiple sclerosis is a demyelinating lesion that can radiographically mimic high-grade gliomas during acute episodes, thus affecting clinical decision making. A delay in appropriate diagnoses can result in unnecessary invasive resections. The following case is a patient with unilateral weakness and radiologic findings that were concerning for a high-grade glioma. Peripheral studies were equivocal. The decision was made to proceed with a stereotactic biopsy, yielding a definitive diagnosis of tumefactive demyelinating lesion (TDL). The patient responded robustly to medical management and made a full clinical recovery. While TDLs and gliomas may look radiologically identical during acute demyelinating episodes, unlike gliomas, TDLs will demonstrate evolvement over serial imaging and robust clinical response to high dose steroids. Clinicians should proceed with caution when considering invasive procedures with such lesions. Conservative medical management is often sufficient as seen in this patient. This case highlights the importance of timely diagnosis and management of TDLs.



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Hemorrhagic Cavernous Sinus Hemangioma with Sudden-Onset Abducens Palsy

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Fumihiko Nishimura, Young-Soo Park, Ichiro Nakagawa, Shuichi Yamada, Hiroyuki Nakase, Yasushi Nagatomo
BackgroundWe report a rare case of hemorrhagic cavernous sinus hemangioma with sudden onset of abducens palsy.Case DescriptionsSudden onset of diplopia occurred in a 49-year-old female. Head computed tomography findings revealed a high-density mass in the right cavernous sinus with protrusion to the sphenoid sinus. Endoscopic endonasal surgery was performed, though early recurrence was noted. A Gamma Knife surgical procedure was then performed to prevent early recurrence after histopathologic confirmation of cavernous sinus hemangioma. Thereafter, the tumor was controlled and abducens palsy disappeared.ConclusionsFor treatment of cavernous sinus hemangioma, stereotactic radiosurgery should be considered as primary or adjuvant treatment in the very early phase after removal, to avoid early recurrence.



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Intraoperative Magnetic Resonance Imaging–Guided Biopsy in the Diagnosis of Suprasellar Langerhans Cell Histiocytosis

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Kate T. Carroll, Bryson C. Lochte, James Y. Chen, Vivian S. Snyder, Bob S. Carter, Clark C. Chen
BackgroundMagnetic resonance imaging (MRI)-guided biopsy is an emerging diagnostic technique that holds great promise for otherwise difficult to access neuroanatomy.Case DescriptionHere we describe MRI-guided biopsy of a suprasellar lesion located posterior and superior to the pituitary stalk. The approach was implemented successfully in a 38-year-old woman who had developed progressive visual deterioration.ConclusionIntraoperative MRI revealed the need for trajectory adjustment due to an unintended, minor deviation in the burr hole entry point, demonstrating the benefit of an MRI-guided approach. Langerhans cell histiocytosis was diagnosed after biopsy, and the lesion regressed after cladribine treatment. Technical nuances of the case are reviewed in the context of the available literature.



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Simple Improvisation to Enhance Utility of Fluorescein Sodium in Resection of Intracranial Lesions at Routine Neurosurgical Centers

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Prakash Rao Gollapudi, Imran Mohammed, Sandeep R. Pittala, Arjun Reddy Kotha, Naga Raju Reddycherla, Dhanunjaya Rao Ginjupally
IntroductionFluorescein sodium is one of the fluorophores that is used in the resection of intracranial lesions. It is commonly used along with a customized microscope, which is expensive and not available universally. In this study, we describe a simple, inexpensive method for better visualization of intracranial and spinal cord lesions with fluorescein.Materials and MethodsAfter a test dose, 20 mg/kg of fluorescein sodium was administered intravenously at the time of intubation. A blue light source was used before resection for precise localization of the intracranial lesions after durotomy. Most of the resection was done under the white light, while the blue light was used intermittently to delineate the pathologic tissue from the normal tissue and to ensure safe maximal resection. The intensity of fluorescein staining under white light and blue light was noted.ResultsThe study comprised 40 cases of gliomas, meningiomas, abscesses, spinal cord tumors, and cerebellopontine angle lesions. Thirty-five lesions showed good fluorescence under the blue light, which helped us achieve better resection of the pathologic lesions.ConclusionsFluorescein sodium is a safe dye; it can be used to aid in precise localization and safe maximal resection of the pathologic tissue with the help of a blue light source at any center with challenged resources. The blue light enhances the fluorescence and visualization of the pathologic tissue, and this technique can be adopted by any surgeon without much difficulty even with a basic neurosurgical setup.



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Liponeurocytoma of the Cerebellopontine Angle

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Carmela Chiaramonte, Sylvain Rabaste, Timothee Jacquesson, David Meyronet, François Cotton, Emmanuel Jouanneau, Moncef Berhouma
BackgroundLiponeurocytoma is a very rare tumor classified as grade II (neuronal and mixed neuronal-glial tumors) according to 2016 World Health Organization classification of tumors of the central nervous system. The median age at detection is 50 years, and the most frequent location is the posterior cranial fossa, especially within the cerebellar hemispheres; liponeurocytomas arising in the cerebellopontine angle (CPA) are exceptional.Case DescriptionHere we report the clinical, radiological, and pathological characteristics of a CPA liponeurocytoma in a 35-year-old woman, as well as a review of the literature. This unusual cisternal location raises the issue of the differential imaging diagnosis with much more common CPA tumors (e.g., meningiomas, vestibular schwannomas, ependymomas, epidermoid cyst, hemangioblastomas, medulloblastomas).ConclusionTo the best of our knowledge, 59 cases of cerebellar liponeurocytomas have been reported to date, which include only 6 cases of CPA liponeurocytomas. Treatment relies on total removal whenever possible, with an excellent prognosis, but a high MIB-1 index (>10%) and/or incomplete tumor resection are the main adverse prognostic factors.



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Coarctation of the Aorta Complicated with Intracranial Aneurysm: A Case Report and Literature Review

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Hui Zhang, Lei Feng
BackgroundCoarctation of the aorta (CoA) complicated with rupture and hemorrhage of intracranial aneurysms is not commonly seen in clinical practice. Here we report a middle-aged female patient who presented with acute severe headache.Case DescriptionHead computed tomography (CT) demonstrated an extensive subarachnoid hemorrhage. Digital subtraction angiography demonstrated coarctation and occlusion of the proximal thoracic aorta and occlusion of the terminal aortic arch. Aortic-intracranial CT angiography (CTA) confirmed a CoA complicated with an anterior communicating artery aneurysm. Clipping of the anterior communicating artery aneurysm was performed via a left lateral orbital approach. Postoperative intracranial CTA showed complete clipping of the aneurysm. The patient was discharged postoperatively with good recovery.ConclusionsThe pathophysiological mechanism of CoA complicated with intracranial aneurysm remains unclear, but attention should be given to the relationship between the 2 entities in clinical practice, and effective treatment should be provided according to specific conditions.



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Successful Use of Covered Stent for Carotid Artery Injury with Active Medial Projecting Extravasation

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Nobuhiko Arai, Hiroshi Kagami, Tomohiro Funabiki, Yutaka Mine, Makoto Inaba
BackgroundNontraumatic carotid artery injury with active extravasation, or carotid blowout syndrome (CBS), is relatively rare and highly difficult to treat because it is difficult to approach the lesions owing to anatomic factors. It also involves quick progression and a risk of cerebral embolization caused by thrombi and carotid artery occlusion. Recently, covered stents were revealed to be effective for CBS. However, they have several disadvantages, such as their costs, rebleeding complications, or cerebral embolic risks. A firm selection method of CBS types that are appropriate for covered-stent therapy is expected.Case DescriptionA 38-year-old man with esophageal cancer presented with massive hematemesis. Computed tomography revealed active extravasation from the left common carotid artery with medial projection. Initially, the open direct approach failed, which resulted in further bleeding and transient cardiopulmonary arrest. With tentative hemostasis using manual finger compression, emergency angiography was performed, and a covered stent, Fluency 8 mm × 60 mm, was placed at the rupture point. He was transferred to the rehabilitation hospital 36 days after admission with a modified Rankin score of 2 without major complications.ConclusionCBS cases having rupture points around the clavicle and having medial projection extravasation should be treated by covered stent placement under tentative hemostasis using manual finger pressure rather than conventional open surgical treatment.



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High-dose spaced theta-burst TMS as a rapid-acting antidepressant in highly refractory depression

Sir,

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Reply: High-dose spaced theta-burst TMS as a rapid-acting antidepressant in highly refractory depression

Sir,

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Review: Limb regeneration in humans: dream or reality?

Publication date: Available online 3 February 2018
Source:Annals of Anatomy - Anatomischer Anzeiger
Author(s): Lorenzo Alibardi
Appendage regeneration occurs by a sequence of events resembling those that take place during development in the embryo. This requires embryonic conditions such as hydration and hyaluronate content where Wnt and other signaling pathways, together with non- coding RNAs, can be re-expressed. These conditions among vertebrates are fully met only in amputated limbs of amphibians, likely because they are neotenic and maintain larval characteristics, including immaturity of their immune system and permanence of numerous stem cells. Although some key genes orchestrating limb regeneration are also present in amniotes, including humans, these genes are not expressed after injury. In amniotes a key problem for regeneration derives from the efficient immune system, largely deficient in anamniotes. As a consequence, wounds and appendage loss tend to scar instead of regenerating. Efforts of regenerative medicine in the attempt to induce the regrowth of limbs in humans must produce outgrowths with high hydration and hyaluronate content in order to create the immune-suppressed conditions similar to those present during development. The induced blastema must be manipulated for long periods of time in order to maintain the same regions present during limb development, an apical epidermal ridge and a polarizing region that forms gradients of expression of Wnt, Shh, FGF, BMP and Hox-genes. Pharmacological treatments to direct the regenerating limb into normal growth without risk of inducing abnormal or tumorigenic growth must be monitored during the course of the regeneration process − a medical treatment lasting years to fully regain the size of the lost appendage.



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Vitamin D deficiency in childhood: old lessons and current challenges

Journal Name: Journal of Pediatric Endocrinology and Metabolism
Issue: Ahead of print


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Prevalence of nasolacrimal canal obstruction and epiphora following maxillary orthognathic surgery

Publication date: Available online 4 February 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): E.M. Ozcan, G. Dergin, S. Basa
Acquired injuries of the nasolacrimal apparatus may be the result of craniomaxillofacial surgical procedures, facial trauma, or inflammation. Injury to the nasolacrimal duct system following maxillary orthognathic surgery is rarely reported. This study evaluated the importance of early diagnosis and treatment of epiphora developing after Le Fort I surgery. The records of 83 patients who underwent maxillary orthognathic surgery over a 2-year period were reviewed. The prevalence of postoperative epiphora was 3.6% and it persisted for a mean of 32.7 days. No patient required further surgical treatment of the nasolacrimal duct obstruction. Clinicians should evaluate the lacrimal canal position and schedule close postoperative follow-up of injuries to the nasolacrimal apparatus. These may become permanent, necessitating additional surgery.



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Pediatric Emergencies: Imaging of Pediatric Head Trauma

Pediatric head trauma is an important cause of morbidity and mortality in children and may be seen in the setting of accidental or abusive injuries. Although many of the patterns of head injury are similar to adults, the imaging manifestations of head injury in children are more complex due to the developing brain and calvarium. Additionally, there are unique considerations in terms of mechanisms of injury in children, to include abusive head trauma and birth-related injuries. The primary role of the radiologist is to identify and characterize the type and severity of head injury to help guide appropriate patient management.

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Clinical Utility of EEG in Diagnosing and Monitoring Epilepsy in Adults

Epilepsy is a common, chronic, complex group of neurological disorders. Worldwide, more than 50 million people have epilepsy, affecting humans of all ages, ethnicity, social background, and geographic location (Perucca et al., 2014a; England et al., 2012). It is characterized by an ongoing predisposition to recurrent seizures. Newer definitions of epilepsy include patients with reflex seizures, those with two or more unprovoked seizures greater than 24 hours apart, and high-risk individuals with a single seizure and at least a 60% likelihood of experiencing recurrent seizures over the ensuing 10 years as compared to the general population (Fisher et al., 2014).

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Right prefrontal cortex specialization for visuospatial working memory and developmental alterations in prefrontal cortex recruitment in school-age children

Working memory (WM) is a system for maintaining and manipulating information (Baddeley et al., 1974), which has a subsystem that specifically processes visuospatial information (i.e., visuospatial WM: VSWM). Cornoldi et al. (2004) have proposed a continuity model of WM assuming the existence of two dimensions: a horizontal continuum comprising different content types (e.g., verbal or visuospatial information) and a vertical continuum distinguishing between passive storage and active processing. Passive storage is the retention of information that is not modified after encoding, whereas active processing is associated with integration, transformation, modification, and/or manipulation of stored information (Cornoldi et al., 2000; Cornoldi et al., 2004).

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Symmetry of cortical planning for initiating stepping in sub-acute stroke

After stroke, many people exhibit altered movement patterns making normal performance of balance and walking difficult (Duncan et al., 1992). However, the influence of motor planning on performance of balance and walking post-stroke is not well understood. Motor planning is defined as the integration of sensory afferent information (Ghez et al., 1997), such as limb position and muscle force (Kandel et al., 2000), with a functional goal (Zimmermann et al., 2012) to generate a movement (Peters et al., 2015).

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Peripheral Neuropathies and the Vestibular System: Is there a role for Vestibular Rehabilitation?

Vestibular evoked myogenic potentials (VEMPs) are used to objectively evaluate function and dysfunction of the vestibular system, specifically the sacullo-collic pathway (mainly, with the use of cervical VEMPs (cVEMPs)) and the utriculo-ocular pathway (mainly, with the use of ocular VEMPs (oVEMPs) (Colebatch et al., 1994; Rosengren et al., 2005; Iwasaki et al., 2007; Todd et al., 2007; Rosengren et al., 2009; Zhang et al., 2011). Together with other paramedical examinations, notably the caloric test and the video head impulse test (vHIT), all parts of the vestibular labyrinth may now be objectively and quantitatively examined.

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Characterization of the stimulus waveforms generated by implantable pulse generators for deep brain stimulation

Deep brain stimulation (DBS) is an established therapy to treat several neurological disorders (e.g. essential tremor, Parkinson's disease, dystonia, obsessive-compulsive disorder) (Benabid et al., 1991; Greenberg et al., 2010; Obeso et al., 2001; Vidailhet et al., 2005) and its efficacy is being explored for a range of additional indications (e.g. epilepsy, treatment-resistant depression, neuropathic pain, Tourette syndrome) (Fisher et al., 2010; Holtzheimer, 2012; Lempka et al., 2017; Malone et al., 2009; Morrell and RNS System in Epilepsy Study Group, 2011; Schrock et al., 2015).

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Functional cortical source connectivity of resting state electroencephalographic alpha rhythms shows similar abnormalities in patients with mild cognitive impairment due to Alzheimer’s and Parkinson’s diseases

About 50-70% of 46 million of cases of dementia worldwide are due to Alzheimer's (ADD) and Parkinson's (PDD) neurodegenerative diseases across aging (Prince et al., 2015). ADD typically presents a major amnesic syndrome and minor linguistic, visuospatial, and visual disease variants (Dubois et al., 2014). PDD manifest attentional, verbal, and executive cognitive deficits in association with motor manifestations such as akinesia, tremor, postural instability, and rigidity (Aarsland et al., 2003; Buter et al., 2008; Dubois and Pillon, 1996; Emre et al., 2007; Huber et al., 1989; Hughes et al., 2000; Levy et al., 2000; Walker et al., 2015; Wolters, 2001).

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Corrigendum to “Ultrasound in polyneuropathies – Is size or structure all that matters?” [Clin. Neurophysiol. 128 (2017) 2519–2520]

The authors regret that author the name of author K. Pitarokoili was misspelled as 'K. Pitarokoilli' in the original article. This has now been corrected.

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Reconstruction after resection of carcinoma of the lower lip

Malignant tumours of the lip account for only 0.9%-1.5% of cancers of the head and neck in Japan.1 Reconstruction is necessary in some cases because of the large defects left in the lip after resection, which are treated by reconstruction using free mucosal transplantation in addition to mucosal and skin flaps. However, the results are often not aesthetically pleasing. We describe the case of a 79-year-old man who had the corner of his mouth reconstructed after resection of a carcinoma.

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Monitoring of free flaps and reconstruction for oral cancer

Clinical monitoring of free flaps is essential after reconstruction for cancer of the head and neck. We read with interest the paper by Nazir et al,1 who noted that one third of patients (34/106, 32%) reported disturbed sleep and almost all (99/101, 98%) were relieved when the monitoring changed from hourly to every four hours. They suggested that clinical teams should consider reducing the frequency of checks during the second night after operation. To the best of our knowledge, this is one of the few papers that have described patients' experience in relation to the monitoring of free flaps and it has also provided further insight into another aspect of treatment.

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Buccal fat pad and subperiosteal midface lifts in conjunction with open reduction and internal fixation to treat fractures of the zygomaticomaxillary complex

When the zygomaticomaxillary complex is fractured, the delicate soft tissues of the cheek may be bruised and lacerated. There may also be soft tissue injuries when the bones are exposed for open reduction and internal fixation.

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Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease?

Effusions are common among patients with disorders of the temporomandibular joint (TMJ), but publications are limited and results inconsistent about the correlation between them and important clinical variables, in particular severity of pain and degenerative disease. We organised a retrospective study of patients who presented for the evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Inclusion criteria were: patients who had pain that was primarily arthrogenous, and coexisting myogenous pain, who had had initial non-surgical treatment, and arthroscopy of the TMJ with or without intramuscular injection of onabotulinumtoxinA (Botox,® Allegan, Weston, Fl, USA).

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Hard lumps in the neck: diagnostic essentials

We read the paper by Ammar et al1 with great interest, and think that the information that they reviewed should be focused towards education of trainees and the understanding of various presentations of lumps in the neck. We would like to add to this three of our own publications that described unusual lumps in the anterior and lateral neck.2–4 All lumps initially mimicked more serious presentations, such as primary or metastatic cancer.

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Outcomes of Endoscopic Intervention for Overt Gastrointestinal Bleeding in Severe Thrombocytopenia

Gastrointestinal bleeding (GIB) in the setting of thrombocytopenia raises concerns about endoscopic procedure risk. We aimed to assess the safety and outcomes of endoscopy for overt GIB in the setting of severe thrombocytopenia in liver cirrhosis (LC) and non-liver cirrhosis (NLC).

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Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in west Japan

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) is often performed after unsuccessful endoscopic transpapillary stent placement (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS and EUS-BD in patients with an indwelling gastroduodenal stent (GDS).

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Prevalence of nasolacrimal canal obstruction and epiphora following maxillary orthognathic surgery

Acquired injuries of the nasolacrimal apparatus may be the result of craniomaxillofacial surgical procedures, facial trauma, or inflammation. Injury to the nasolacrimal duct system following maxillary orthognathic surgery is rarely reported. This study evaluated the importance of early diagnosis and treatment of epiphora developing after Le Fort I surgery. The records of 83 patients who underwent maxillary orthognathic surgery over a 2-year period were reviewed. The prevalence of postoperative epiphora was 3.6% and it persisted for a mean of 32.7 days.

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An innovative virtual reality training tool for orthognathic surgery

Virtual reality (VR) surgery using Oculus Rift and Leap Motion devices is a multi-sensory, holistic surgical training experience. A multimedia combination including 360° videos, three-dimensional interaction, and stereoscopic videos in VR has been developed to enable trainees to experience a realistic surgery environment. The innovation allows trainees to interact with the individual components of the maxillofacial anatomy and apply surgical instruments while watching close-up stereoscopic three-dimensional videos of the surgery.

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Factors Associated with Insomnia and Complementary Medicine Use in Children: Results of a National Survey

Sleep difficulties are a serious health problem in children, and interest in using complementary and alternative medicine (CAM) therapies to treat sleep is growing. We aimed to identify: a) the prevalence of sleep difficulties in children, and b) the prevalence and patterns of CAM use among children with trouble sleeping.

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RBD: a red flag for cognitive impairment in Parkinson’s disease?

The increasing evidence indicates that there is a strong association between rapid eye movement sleep behavior disorder (RBD) and Parkinson's disease - cognitive impairment (PD-CI). Numerous longitudinal and cross-sectional studies have shown that RBD may be an important risk factor and predictor of Parkinson's disease – mild cognitive impairment (PD-MCI) and Parkinson's disease dementia (PDD), which may be explained by association of mechanisms between RBD and PD-CI including neurotransmitter alterations, genetic mutation, neuroinflammation, alpha-synuclein inclusion, abnormal cerebral metabolism and slowing of cortical activity.

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Assessing the influence of chin prominence on profile esthetics: A survey study

The aim of this survey study was to assess the influence of chin prominence on the perception of profile esthetics between genders by orthodontists, oral and maxillofacial surgeons (OMF), plastic surgeons, orthognathic patients and laypersons.

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An improved technique for zygoma reduction malarplasty

Zygoma reduction malarplasty is a standard procedure primarily performed in Asia on patients who prefer an oval facial shape. The technique is well established and standardized. However, the esthetic results are frequently unsatisfactory or accompanied by complications such as nonunion, malunion, and cheek drooping. These complications are generally attributed to postoperative bone fragment movement.In this study, we present an improvement to this standard procedure that involves modifying the surgical technique.

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Surgical treatment of axillary bromhidrosis by combining suction-curettage with subdermal undermining through a miniature incision

The suction-curettage technique has been widely applied in the treatment of axillary bromhidrosis. However, it can only moderately eradicate the malodor. From 2011 to 2013, we performed the suction-curettage procedure alone in 91 patients with primary axillary bromhidrosis (group A). From 2014 to 2016, we refined the suction-curettage technique by performing wide subdermal scissors undermining through a miniature incision in 80 patients (group B). Through a miniature incision at the inferior pole of the central axillary crease, the entire subcutaneous tissues containing apocrine glands were initially dissected with scissors within the axillary area and then the undermined apocrine glands were removed by suction-curettage.

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Quality of life improvement after chest wall masculinization in female-to-male transgender patients: a prospective study using the BREAST-Q and body uneasiness test

Background: Chest reconstruction in many female-to-male (FTM) transgender individuals is an essential element of treatment for their gender dysphoria. In existing literature, there are very few longitudinal studies utilizing validated survey tools to evaluate patient reported outcomes surrounding this surgery. The purpose of our study is to prospectively evaluate patient reported satisfaction, improvement in body image, and quality of life following FTM chest wall reconstruction. Methods: Our study was a prospective analysis of FTM patients who underwent chest reconstruction by a single surgeon (C.A.) between April 2015 and June 2016.

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Does drug-induced sleep endoscopy predict surgical success of limited palatal muscle resection in patients with obstructive sleep apnea?

The aims of this study were to determine the associated factors affecting the success rate of limited palatal muscle resection (LPMR), and to investigate whether drug-induced sleep endoscopy (DISE) could predict the therapeutic response to LPMR in patients with obstructive sleep apnea obstructive sleep apnea (OSA).

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Coverage of the dorsal surface of a digit based on a pedicled free-style perforator flap concept

Reconstruction of the finger and thumb dorsum has been considered difficult due to the need for a thin and flexible flap, and the surrounding tissue is sometimes insufficient for a local flap. The purpose of this report is to describe our concept for finger and thumb dorsum reconstruction with free-style perforator flaps and our clinical experience with transfer of various perforator flaps.

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“Reply - preventing the cheese-wire effect by combining steri-strips” and sutures for the management of lacerations in thin-skinned individuals. january 2017 volume 70, issue 1, pages 134-136.”

We read with interest the experimental results attaining to the technical tip of using the Steri-Strip/Suture combination. This method is indeed a useful technique in helping prevention of the cheese-wiring seen in frail skinned individuals although the application of this can be sometimes difficult, particularly if the wound is moist. The application of Steri-Strips can be quite problematic in the actively, or prone to, bleeding wound and in this instance, we would advocate the simple adjunct of using tincture of benzoin as a topical adhesive agent.

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Mutual inhibition of lateral inhibition: a network motif for an elementary computation in the brain

Publication date: April 2018
Source:Current Opinion in Neurobiology, Volume 49
Author(s): Minoru Koyama, Avinash Pujala
A series of classical studies in non-human primates has revealed the neuronal activity patterns underlying decision-making. However, the circuit mechanisms for such patterns remain largely unknown. Recent detailed circuit analyses in simpler neural systems have started to reveal the connectivity patterns underlying analogous processes. Here we review a few of these systems that share a particular connectivity pattern, namely mutual inhibition of lateral inhibition. Close examination of these systems suggests that this recurring connectivity pattern ('network motif') is a building block to enforce particular dynamics, which can be used not only for simple behavioral choice but also for more complex choices and other brain functions. Thus, a network motif provides an elementary computation that is not specific to a particular brain function and serves as an elementary building block in the brain.



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A disinhibitory circuit motif and flexible information routing in the brain

Publication date: April 2018
Source:Current Opinion in Neurobiology, Volume 49
Author(s): Xiao-Jing Wang, Guangyu Robert Yang
In the mammalian neocortex, an area typically receives inputs from, and projects to, dozens of other areas. Mechanisms are needed to flexibly route information to the right place at the right time, which we term 'pathway gating'. For instance, a region in your brain that receives signals from both visual and auditory pathways may want to 'gate in' the visual pathway while 'gating out' the auditory pathway when you try to read a book surrounded by people in a noisy café. In this review, we marshall experimental and computational evidence in support of a circuit mechanism for flexible pathway gating realized by a disinhibitory motif. Moreover, recent work shows an increasing preponderance of this disinhibitory motif from sensory areas to association areas of the mammalian cortex. Pathway input gating is briefly compared with alternative or complementary gating mechanisms. Predictions and open questions for future research on this puzzle about the complex brain system will be discussed.



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The promise and perils of causal circuit manipulations

Publication date: April 2018
Source:Current Opinion in Neurobiology, Volume 49
Author(s): Steffen BE Wolff, Bence P Ölveczky
The development of increasingly sophisticated methods for recording and manipulating neural activity is revolutionizing neuroscience. By probing how activity patterns in different types of neurons and circuits contribute to behavior, these tools can help inform mechanistic models of brain function and explain the roles of distinct circuit elements. However, in systems where functions are distributed over large networks, interpreting causality experiments can be challenging. Here we review common assumptions underlying circuit manipulations in behaving animals and discuss the strengths and limitations of different approaches.



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Prevention and Management of Complications in Otosclerosis Surgery

Surgical management of otosclerosis is a relatively safe and effective procedure, with a high rate of hearing improvement and a low rate of undesirable outcomes and complications. Many of these potential complications are common to any middle ear surgery, but many are unique to surgery involving the stapes footplate. Preventing complications with stapes surgery and minimizing their impact may be achieved by preparation as well as surgical experience.

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Special Anatomic Considerations in Otosclerosis Surgery

The anatomy of the vestibular organs together with considerations of the middle and inner ear anatomy relevant to stapes surgery is discussed. An archival collection of macerated and freshly frozen human temporal bones underwent micro–computed tomography (CT) with subsequent volume-rendering. Three-dimensional (3D) reconstructions and the topographic anatomy of the oval window were considered. Micro-CT and 3D rendering revealed the relationship between the otolith organs and the oval window. Anatomic variations were extensive and included the distance between the footplate and the reconstructed macula margins. A "no-go" zone is suggested for the surgeon to avoid injury during stapes surgery.

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iSepsis – Patients with sepsis have SCURVY

Patients with sepsis have SCURVY

EMCrit Project by Paul Marik.

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Oral carcinoma cuniculatum presenting with moth-eaten destruction of the mandible

Publication date: Available online 3 February 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Chunye Zhang, Yuhua Hu, Zhen Tian, Ling Zhu, Chenping Zhang, Jiang Li
Objective.Carcinoma cuniculatum(CC) is a rare variant of squamous cell carcinoma. We describe the clinicopathological findings in a new case.Study Design.Literature review and retrospective study of a case with CC.Results.The clinical and imaging findings of CC are diverse; some cases might be challenging to diagnose accurately by biopsy. This article reports a case of CC that occurred in the retromolar region with involvement of the mandible. The patient was a 39-year-old man. Clinically, the lesion manifested as an ulcerative mass in the mandibular molar region. Imaging results showed that the lesion in the jaw exhibited moth-eaten destruction without obvious expansion of the jaw bone. The postoperative pathological examinations were consistent with CC; additionally, metastases were present in one level II lymph node and one submandibular lymph node. Left soft tissue metastasis and right cervical lymph node metastases were detected after 10 and 27 months after surgery, respectively.Conclusions.CC is a rare epithelial malignant tumor and has variable clinical manifestations. The diagnosis of CC mainly depends upon pathological features. Most patients with CC have a good prognosis; only a small percentage of patients might experience lymph node metastasis.



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The influence of concomitant medial wall fracture on the results of orbital floor reconstruction

Publication date: Available online 3 February 2018
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Agata Joanna Ordon, Marcin Kozakiewicz, Michal Wilczynski, Piotr Loba
IntroductionUp to 35% of orbital floor fractures extend to the medial wall. This results in restriction of both abduction and adduction, leading to horizontal diplopia. The greater the defect, the more pronounced the enophthalmos.Aim of the studyThe aim of the study was to determine the influence of concomitant medial wall defects on enophthalmos and diplopia, and the influence of intraoperative revision on the results of surgical reconstruction in patients with orbital floor fracture.Material and methods78 cases of orbital floor fracture, with or without concomitant medial wall defect, were retrospectively analyzed. Reconstruction surgeries were performed in a similar fashion, but with variation in the alloplastic materials used. Careful investigation of the area was performed during the surgery.ResultsPatients with associated medial wall defects had significantly more pronounced enophthalmos than those with isolated floor fracture, with no such difference after the orbital reconstruction. Postoperative vertical diplopia was more common in patients with an associated medial defect.ConclusionsAssociated medial wall defect leads to more severe enophthalmos at presentation. However, if the medial aspect of the orbital wall is revised properly, postoperative outcomes are not inferior to those in cases of isolated floor fracture.



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Eosinophilic esophagitis and symptoms possibly related to eosinophilic esophagitis in oral immunotherapy

Food allergy is seen in 2% to 8% of the US population and continues to increase.1–3 Patients with food allergy often have an impaired quality of life and may experience nutritional deficiencies.4,5 Currently, there are no US Food and Drug Administration–approved treatments for food allergy, and it is recommended that patients practice allergen avoidance and carry epinephrine for use in case of severe reaction to unintentional allergen exposure.6 The lifestyle of allergen avoidance presents a challenge and often causes anxiety for patients and caregivers.

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The influence of concomitant medial wall fracture on the results of orbital floor reconstruction

Publication date: Available online 3 February 2018
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Agata Joanna Ordon, Marcin Kozakiewicz, Michal Wilczynski, Piotr Loba
IntroductionUp to 35% of orbital floor fractures extend to the medial wall. This results in restriction of both abduction and adduction, leading to horizontal diplopia. The greater the defect, the more pronounced the enophthalmos.Aim of the studyThe aim of the study was to determine the influence of concomitant medial wall defects on enophthalmos and diplopia, and the influence of intraoperative revision on the results of surgical reconstruction in patients with orbital floor fracture.Material and methods78 cases of orbital floor fracture, with or without concomitant medial wall defect, were retrospectively analyzed. Reconstruction surgeries were performed in a similar fashion, but with variation in the alloplastic materials used. Careful investigation of the area was performed during the surgery.ResultsPatients with associated medial wall defects had significantly more pronounced enophthalmos than those with isolated floor fracture, with no such difference after the orbital reconstruction. Postoperative vertical diplopia was more common in patients with an associated medial defect.ConclusionsAssociated medial wall defect leads to more severe enophthalmos at presentation. However, if the medial aspect of the orbital wall is revised properly, postoperative outcomes are not inferior to those in cases of isolated floor fracture.



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Incidence and Predictive Model for Lateral Pelvic Lymph Node Metastasis in Lower Rectal Cancer

Abstract

The lateral pelvic lymph node recurrence after curative resection in rectal cancer has been reported in more than 20% of cases and the lateral pelvic lymph node (LPLN) metastasis is an independent risk factor for local recurrence. A prospective cohort study with diagnosis of lower rectal cancer stages II and III performed to identify the factors with significant correlation with LPLN metastasis was categorised based on the number of positive factors and proposed a risk stratification model to uncover a possible benefit of LPLD in specific patient subgroups. Forty-three patients with lower rectal cancer underwent curative surgery, total mesorectal excision with bilateral lateral pelvic lymph node dissection. Pre-operative, female gender, raised serum CEA (> 5 ng/mL), cT4, enlarged mesorectal lymph nodes, borderline enlarged LPLN on MRI, lower location (< 5 cm from anal verge), large size (> 5 cm) and non-circumferential lesion were significant predictors for LPLN metastasis. Histopathological, higher tumour grade, higher pT and pN stage, and the presence of LVI were significant factors. On cox-proportional hazard model analysis, female gender, large tumour, cT4, enlarged mesorectal lymph nodes, borderline enlarged LPLN, pN1 and positive LVI were associated with significant hazard. In conclusion, a specific group of patients with lower rectal cancer of stages II and III might be have treated with LPND in spite of concurrent chemo-radiation to achieve satisfactory oncological outcome. The proposed stratification grouping is strongly guiding the patient for lateral pelvic lymph node dissection. Further study to prove the oncological advantage of LPND is warranted at large scale.

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