Cochlear implantation using the underwater technique: long-term results

Abstract

Introduction

The opening of the round window and the insertion of the electrode array into the scala tympani during cochlear implant surgery can lead to a pressure shock of the delicate inner ear structures. By filling the tympanic cavity with Ringer Solution during these surgical steps (underwater technique), the hydrostatic pressure of the fluid acts as a smooth pressure stabilizer, avoiding a pressure shock of the inner ear structures. The aim of this retrospective study was to present long-term results of this new method of cochlear implantation in underwater technique.

Methods

Altogether, 47 implantations in 43 patients with residual hearing at the frequencies 250, 500 and 1000 Hz in the unaided preoperative pure tone audiometry were included. A cochlear implantation via round window with a conventional full-length electrode was performed in underwater technique. Changes of residual hearing 7 weeks and 24 months after surgery were analyzed.

Results

Overall postimplant hearing preservation 7 weeks after implantation was achieved in 22 ears (47%). Subsequent follow-up was performed on average 24 months after surgery (range 12 months–4.2 years) in all patients. At this late postoperative evaluation, preservation of hearing was recorded in 18 ears (38%). Neither the follow-up time nor the type of electrode had a significant impact on the postoperative hearing loss.

Conclusion

The underwater technique is an atraumatic cochlear implantation technique with hearing preservation rates comparable to results in literature and a very small hearing preservation decline rate over time even when using full-length CI electrodes.

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Cochlear implantation using the underwater technique: long-term results

Abstract

Introduction

The opening of the round window and the insertion of the electrode array into the scala tympani during cochlear implant surgery can lead to a pressure shock of the delicate inner ear structures. By filling the tympanic cavity with Ringer Solution during these surgical steps (underwater technique), the hydrostatic pressure of the fluid acts as a smooth pressure stabilizer, avoiding a pressure shock of the inner ear structures. The aim of this retrospective study was to present long-term results of this new method of cochlear implantation in underwater technique.

Methods

Altogether, 47 implantations in 43 patients with residual hearing at the frequencies 250, 500 and 1000 Hz in the unaided preoperative pure tone audiometry were included. A cochlear implantation via round window with a conventional full-length electrode was performed in underwater technique. Changes of residual hearing 7 weeks and 24 months after surgery were analyzed.

Results

Overall postimplant hearing preservation 7 weeks after implantation was achieved in 22 ears (47%). Subsequent follow-up was performed on average 24 months after surgery (range 12 months–4.2 years) in all patients. At this late postoperative evaluation, preservation of hearing was recorded in 18 ears (38%). Neither the follow-up time nor the type of electrode had a significant impact on the postoperative hearing loss.

Conclusion

The underwater technique is an atraumatic cochlear implantation technique with hearing preservation rates comparable to results in literature and a very small hearing preservation decline rate over time even when using full-length CI electrodes.

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Cochlear implantation using the underwater technique: long-term results

Abstract

Introduction

The opening of the round window and the insertion of the electrode array into the scala tympani during cochlear implant surgery can lead to a pressure shock of the delicate inner ear structures. By filling the tympanic cavity with Ringer Solution during these surgical steps (underwater technique), the hydrostatic pressure of the fluid acts as a smooth pressure stabilizer, avoiding a pressure shock of the inner ear structures. The aim of this retrospective study was to present long-term results of this new method of cochlear implantation in underwater technique.

Methods

Altogether, 47 implantations in 43 patients with residual hearing at the frequencies 250, 500 and 1000 Hz in the unaided preoperative pure tone audiometry were included. A cochlear implantation via round window with a conventional full-length electrode was performed in underwater technique. Changes of residual hearing 7 weeks and 24 months after surgery were analyzed.

Results

Overall postimplant hearing preservation 7 weeks after implantation was achieved in 22 ears (47%). Subsequent follow-up was performed on average 24 months after surgery (range 12 months–4.2 years) in all patients. At this late postoperative evaluation, preservation of hearing was recorded in 18 ears (38%). Neither the follow-up time nor the type of electrode had a significant impact on the postoperative hearing loss.

Conclusion

The underwater technique is an atraumatic cochlear implantation technique with hearing preservation rates comparable to results in literature and a very small hearing preservation decline rate over time even when using full-length CI electrodes.

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Issue Information

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A single channel sleep-spindle detector based on multivariate classification of EEG epochs: MUSSDET

Publication date: 1 March 2018
Source:Journal of Neuroscience Methods, Volume 297
Author(s): Daniel Lachner-Piza, Nino Epitashvili, Andreas Schulze-Bonhage, Thomas Stieglitz, Julia Jacobs, Matthias Dümpelmann
BackgroundStudies on sleep-spindles are typically based on visual-marks performed by experts, however this process is time consuming and presents a low inter-expert agreement, causing the data to be limited in quantity and prone to bias. An automatic detector would tackle these issues by generating large amounts of objectively marked data.New MethodOur goal was to develop a sensitive, precise and robust sleep-spindle detection method. Emphasis has been placed on achieving a consistent performance across heterogeneous recordings and without the need for further parameter fine tuning. The developed detector runs on a single channel and is based on multivariate classification using a support vector machine. Scalp-electroencephalogram recordings were segmented into epochs which were then characterized by a selection of relevant and non-redundant features. The training and validation data came from the Medical Center-University of Freiburg, the test data consisted of 27 records coming from 2 public databases.ResultsUsing a sample based assessment, 53% sensitivity, 37% precision and 96% specificity was achieved on the DREAMS database. On the MASS database, 77% sensitivity, 46% precision and 96% specificity was achieved. The developed detector performed favorably when compared to previous detectors. The classification of normalized EEG epochs in a multidimensional space, as well as the use of a validation set, allowed to objectively define a single detection threshold for all databases and participants.ConclusionsThe use of the developed tool will allow increasing the data-size and statistical significance of research studies on the role of sleep-spindles.



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Intracranial rat glioma model for tumor resection and local treatment

Publication date: Available online 6 February 2018
Source:Journal of Neuroscience Methods
Author(s): Zhiqun Wu, Makoto Nakamura, Joachim K. Krauss, Kerstin Schwabe, Nadine John
BackgroundAlthough tumor resection is among the most important prognostic factors, high grade gliomas regrow in most cases. Also, resection of glial tumors in eloquent brain regions is not or only partially possible. Despite these severe restraints, however, only a few in-vivo models have been established to investigate tumor recurrence and local treatment. Here we characterize the intracranial BT4Ca rat glioma as a model for these aspects.New MethodBT4Ca cells were stereotaxically implanted into the frontal cortex of BDIX rats. Rats were than allocated to (1) a control group, which received no further treatment; (2) a catheter group, where a catheter was implanted for repeated microinjection of vehicle every 3rd day as catheter-control; (3) a resection group, where the tumor was microsurgically removed eight days after cell injection. Postoperatively, survival time, weight and general health condition were scored and the tumor size was histologically assessed.ResultsInjection of BT4Ca cells induced fast-growing tumors with a mean survival time of 16 days in the control and catheter groups. Resection significantly prolonged survival time whereby the tumor regrew in all rats. Tumor size was similar between all groups.Comparison with Existing Method(s)We here present a robust and reliable intracranial rat glioma model, which is suitable to simulate tumor recurrence after surgical resection and local treatment. Importantly, this model does not require advanced imaging or elaborate surgical techniques.ConclusionsThe intracranial BT4Ca glioma model appears to be a feasible tool to investigate tumor recurrence after resection and to test local treatment.



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Physical activity and telomere length in American Indians: the Strong Heart Study

Abstract

Telomere length, a marker of biological aging, has been associated with many chronic diseases, but its relations with physical activity remains unclear. The purpose of this study was to examine the association of objectively measured ambulatory activity with leukocyte telomere length (LTL), a marker of biological aging, among American Indians. This cross-sectional study included 2312 AI participants from the Strong Heart Family Study. Steps per day were measured using Accusplit AE120 pedometers. Quantitative PCR was used to measure LTL. Generalized estimating equations were used to examine the associations of steps per day with LTL. The median steps per day over a 1 week period was 5118 steps (interquartile range = 3163–7576 steps). Compared to participants in the lowest quartile of steps per day, participants in the upper three quartiles of steps per day had longer LTL: beta ± SE = 0.0195 ± 0.0144, 0.0273 ± 0.0139, and 0.0375 ± 0.0143 T/S ratio units longer (p trend = 0.010) after adjustment for potential confounders. These data suggest that ambulatory activity is associated with LTL. Further studies are needed to determine the mechanism by which ambulatory activity influences LTL.

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Risk of pharmacokinetic interactions between antiepileptic and other drugs in older persons and factors associated with risk

Summary

Objective

To determine the frequency of older Americans with epilepsy receiving concomitant prescriptions for antiepileptic drugs (AEDs) and non-epilepsy drugs (NEDs) which could result in significant pharmacokinetic (PK) interaction, and to assess the contributions of racial/ethnic, socioeconomic, and demographic factors.

Methods

Retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries ≥67 years old in 2009 augmented for minority representation. Prevalent cases had ≥1 ICD-9 345.x or ≥2 ICD-9 780.3x, and ≥1 AED. Among them, incident cases had no seizure/epilepsy claim codes nor AEDs in preceding 365 days. Drug claims for AEDs, and for the 50 most common NEDs within +/− 60 days of the index epilepsy date were tabulated. Interacting pairs of AEDs/NEDs were identified by literature review. Logistic regression models were used to examine factors affecting the likelihood of interaction risk.

Results

Interacting drug pairs affecting NED efficacy were found in 24.5% of incident, 39% of prevalent cases. Combinations affecting AED efficacy were found in 20.4% of incident, 29.3% of prevalent cases. Factors predicting higher interaction risk included having ≥ 1 comorbidity, being eligible for Part D low Income Subsidy, and not living in the northeastern US. Protective factors were Asian race/ethnicity, and treatment by a neurologist.

Significance

A substantial portion of older epilepsy patients received NED-AED combinations that could cause important PK interactions. The lower frequency among incident vs. prevalent cases may reflect changes in prescribing practices. Avoidance of interacting AEDs is feasible for most persons because of the availability of newer drugs.

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The perception of anticipatory labial coarticulation by blind listeners in noise: A comparison with sighted listeners in audio-only, visual-only and audiovisual conditions

Publication date: March 2018
Source:Journal of Phonetics, Volume 67
Author(s): Véronique Delvaux, Kathy Huet, Myriam Piccaluga, Bernard Harmegnies
This study investigates the time course of the perception of the /i-y/ contrast by French-speaking blind listeners using a gating paradigm. The performances of the blind listeners in discrimination and identification are compared with the range of performances exhibited by sighted perceivers when stimuli are presented auditorily, visually and audiovisually, whether in acoustically non degraded or in noisy conditions. Results provide evidence in favor of partial compensation for visual deprivation in speech perception. Blind listeners outperformed sighted participants in discriminating between auditorily-presented gated stimuli, particularly in noisy conditions. But this small advantage allowed them to compensate only partially for their inability to exploit visual information in order to process coarticulated speech as quickly and efficiently as sighted controls.



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FDA Approves Test of New Drug to Protect Hearing

The first clinical trial of a new drug designed to protect humans' hearing will involve a compound developed at the University of Washington (UW).

The U.S. Food and Drug Administration has approved ORC-13661 as an investigational drug to protect people from the hearing-damaging side effects of aminoglycosides, a class of antibiotics used to combat serious infections.  The FDA approval clears the way for a Phase I trial of volunteers to confirm whether the drug, which demonstrated significant protective ability in animal models, is safe for humans.

ORC-13661 represents more than a decade of work by two UW scientists: Edwin Rubel, a professor of hearing sciences in the departments of otolaryngology-head and neck surgery and physiology & biophysics, and David Raible, a professor of biological structure in the School of Medicine.

"Our collaboration started in 2001; it was a novel idea and we got funded," Rubel said. "The goal was to discover how the receptor cells in the inner ear die. Why do some people start to lose their hearing at age 40 and others have good hearing at age 80?"

Their study of zebrafish was pivotal to understanding the mechanisms that affect hearing in humans. Fish have external hair cells akin to the receptor-cell structures in humans' cochleas, which turn sound waves into electrical impulses for the brain to interpret.

"With the hair cells on the outside of their bodies, we could observe them very readily for genetic and molecular studies," Rubel said.

Human receptor cells can be damaged as a secondary effect of antibiotics called aminoglycosides, which doctors employ against severe infections in cases of cystic fibrosis, immune suppression, and premature newborns, among other conditions. These powerul antibiotics – for example, gentamicin and streptomycin – can kill the receptor cells in the cochlea and balance organs, causing permanent hearing loss and unsteadiness for patients.

Over 16 years, Rubel and Raible confirmed that the fishes' hair cells are similar genetically and in other ways to hearing receptor cells in humans and other mammals.

In concert with Julian Simon, a medicinal chemist based at the Fred Hutchinson Cancer Research Center, and others, they tested the ability of more than 10,000 molecules to protect the zebrafishes' hair cells from the toxic effects of these antibiotics.

"We did a phenotypic screen," said Raible. "It's a different approach from many drug screens that target a specific receptor or protein known to be important, and then design a molecule to fit the active site of the protein. Instead, we screened libraries of chemicals to find ones that stopped zebrafish hair cells from dying, and used the one that worked best. But we can't say we know exactly why it works."

Their breakthrough results, published last month, involved a change that amplified the effectiveness of a promising compound from earlier studies. The drug demonstrated outstanding safety and 100-percent protection of hair cells in zebrafish and rats in vivo. This spurred the FDA's action.

In 2013 Raible and Rubel co-founded a company, Oricula Therapeutics, which exclusively licenses patents for ORC-13661 held by the University of Washington and Fred Hutch.  Oricula made the application to the FDA and will pursue funding for the Phase I trial of the drug's safety in humans, Rubel said. If that were to succeed, the next step would be testing the drug's effectiveness among patients who must take aminoglycosides to stave off life-threatening infections.

Both scientists reflected on the infusion of $34,000 that got them going back in 2001. The money came from the UW's Royalty Research Fund, a mechanism in which UW's royalty and licensing fee income is selectively reinvested in promising new research.

"It's such a cool thing that the university uses royalties to seed new ideas that might one day reinfuse the fund," Raible said. "The people who came up with the fund should know that it does make a difference in these ventures."

This news original appeared in the UW Medicine Newsroom.

Published: 2/6/2018 1:09:00 PM

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Editorial Board

Publication date: February 2018
Source:Pathology - Research and Practice, Volume 214, Issue 2





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Editorial Board

Publication date: January 2018
Source:Pathology - Research and Practice, Volume 214, Issue 1





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Modified biweekly cisplatin, docetaxel plus cetuximab (TPEx) as first-line treatment for patients with recurrent/metastatic head and neck cancer

Abstract

Three weekly high-dose chemotherapy regimens in combination with weekly cetuximab are the treatment of choice for patients with recurrent/metastatic (R/M) head and neck squamous cell carcinoma (SCCHN), although the majority of patients suffer from severe side effects. Thus, we investigated the efficacy and safety of an alternative, more convenient and less toxic biweekly modified cisplatin, docetaxel plus cetuximab (TPEx) regimen in this retrospective analysis. Thirty-eight patients receiving off-protocol cisplatin (50 mg/m²) in combination with docetaxel (50 mg/m²) plus cetuximab (500 mg/m²) every other week were included. Data collection included baseline demographic, response rate (ORR) and toxicity data as well as disease control rate, overall survival (OS) and progression-free survival (PFS). The median age was 60 years, and the majority of patients suffered from oral cavity carcinomas (44.7%) followed by oropharyngeal (28.9%) and laryngeal (17.9%) carcinomas. The ORR was 50%, and four (10.5%) patients achieved a complete response, while 15 (39.5%) patients had a partial response. The OS and PFS were 10.8 months (95% CI 6.7–14.2) and 6.3 months (95% CI 5.7–6.8), respectively. The one-year survival rate was 44.7%. The therapy was well tolerated, and the most common grade 3/4 adverse events were myelosuppression (13.2%), hypomagnesaemia (23.7%) and acne-like rash (13.1%). In conclusion, modified biweekly TPEx is of comparable efficacy with conventional TPEx and represents a well-tolerated regimen in R/M SCCHN patients. Further evaluation of this protocol in prospective clinical trials is warranted.

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Memory decline from hippocampal electrodes? Let's not forget statistics and study design

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Epilepsia – February 2018 – Announcements

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Response: Memory decline from hippocampal electrodes? Let's not forget statistics and study design

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Issue Information–ISSN page

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Trends of incidence, mortality, and survival of multiple myeloma in Switzerland between 1994 and 2013

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Martin Andres, Anita Feller, Volker Arndt
BackgroundTreatment of multiple myeloma has changed considerably over the last two decades with remarkable reduction in mortality rates in clinical trials and in population-based studies. Since health care systems and patient management differ between countries, population-based data from cancer registries with high coverage may provide further insight into real-life achievements and unmet needs. We report on the first population-based nation-wide study of incidence, mortality and survival of multiple myeloma in Switzerland covering the era of autologous stem cell transplantation and the first proteasome inhibitors and immunomodulatory drugs.MethodsWe performed a retrospective registry study with data from the National Institute for Cancer Epidemiology and Registration (NICER) database in Switzerland from 1994 to 2013.ResultsWe identified 5770 patients with multiple myeloma. Incidence has increased from 419 new cases per year in 1994–1998 to 557 new cases per year in 2009–2013 while the age-adjusted incidence rate remained stable at 4.7–5.0 per 100′000 person-years. Five- and 10-year relative survival increased from 32.6% (95%CI 29.3–36.0) and 17.8% (95%CI 14.9–21.0) in 1994–1998 to 46.4% (95%CI 43.3–49.3) and 25.0% (95%CI 21.9–28.3) in 2009–2013.ConclusionThe increase in incidence can be attributed to demographic changes. There is a trend to longer relative survival in all age groups with substantial increase in myeloma patients aged less than 75 years and only minimal changes in older persons.



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Esophageal cancer male to female incidence ratios in Africa: A systematic review and meta-analysis of geographic, time and age trends

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Daniel R.S. Middleton, Liacine Bouaoun, Rachel Hanisch, Freddie Bray, Charles Dzamalala, Steady Chasimpha, Diana Menya, Charles Gombé Mbalawa, Guy N'Da, Mathewos A. Woldegeorgis, Ramou Njie, Moussa Koulibaly, Nathan Buziba, Josefo Ferro, Hassan Nouhou, Femi Ogunbiyi, Henry R. Wabinga, Eric Chokunonga, Margaret Z. Borok, Anne R. Korir, Amos O. Mwasamwaja, Blandina T. Mmbaga, Joachim Schüz, Valerie A. McCormack
Esophageal squamous cell carcinoma (ESCC) remains the predominant histological subtype of esophageal cancer (EC) in many transitioning countries, with an enigmatic and geographically distinct etiology, and consistently elevated incidence rates in many Eastern and Southern African countries. To gain epidemiological insights into ESCC patterns across the continent, we conducted a systematic review and meta-analysis of male-to-female (M:F) sex ratios of EC age-standardised (world) incidence rates in Africa according to geography, time and age at diagnosis. Data from 197 populations in 36 countries were included in the analysis, based on data from cancer registries included in IARC's Cancer Incidence in Five Continents, Cancer in Africa and Cancer in Sub-Saharan Africa reports, alongside a systematic search of peer-reviewed literature. A consistent male excess in incidence rates overall (1.7; 95% CI: 1.4, 2.0), and in the high-risk Eastern (1.6; 95% CI: 1.4, 1.8) and Southern (1.8; 95% CI: 1.5, 2.0) African regions was observed. Within the latter two regions, there was a male excess evident in 30–39 year olds that was not observed in low-risk regions. Despite possible referral biases affecting the interpretability of the M:F ratios in place and time, the high degree of heterogeneity in ESCC incidence implies a large fraction of the disease is preventable, and directs research enquiries to elucidate early-age exposures among young men in Africa.



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Development and validation of a prognostic index for survival in non-small cell lung cancer: Results from a Tunisian cohort study

Publication date: April 2018
Source:Cancer Epidemiology, Volume 53
Author(s): Ghassen Soussi, Nissaf Ben Alaya, Nawel Chaouch, Hajer Racil
IntroductionDespite the continuous efforts made with the TNM system, the issue of heterogeneity of prognosis within the stages of non-small cell lung cancer (NSCLC) could not be resolved. Our aim was to identify prognostic factors and develop an index to predict NSCLC survival with greater accuracy.MethodsWe conducted a survival study over 5 years on patients with NSCLC. Kaplan–Meier analysis followed by Cox regression modelling were used. Prognostic indices were derived, using either an additive or a multiplicative pattern, and were compared by their receiver operating characteristics (ROC) curves. We then proceeded to a risk stratification and validation of the index on the derivation cohort.ResultsTwo hundred and sixty-two NSCLC patients were included. Two models were constructed, using the following nine variables as prognostic factors: age, performance status, haemoglobin level, leucocyte count, calcium, lactate dehydrogenase, alkaline phosphatase levels, histological type and TNM stage. Four prognostic indices were derived, and the best one was picked and validated on a population of five risk groups. The higher the risk group, the shorter the survival.ConclusionsThis novel and simple prognostic tool could predict survival more accurately in patients with NSCLC.



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Upper Lid Thick Skin Blepharoplasty

Facial plast Surg 2018; 34: 043-049
DOI: 10.1055/s-0037-1615824

While many of the basic tenants of upper lid blepharoplasty remain constant regardless of skin type, the thick-skinned eyelid patient requires special consideration. The brow may be naturally lower in the thick-skinned patient. These patients are more prone to having the brow pulled downward while attempting to remove redundant skin. There may also be more fat in the medial and central compartments. There may be fat in a lateral compartment overlying the lacrimal gland. Patient's expectations for a deep lid sulcus and complete excision of redundant skin may not be possible. They are more prone to an observable scar, a small dog ear at the lateral wound edge, and prolonged postoperative lid edema. Patients with lifelong upper lid fullness must get some input from significant others because their upper face aesthetic will change. In these patients, the eyelid surgery is not a rejuvenation, but a creation.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Integrated Management of the Thick-Skinned Rhinoplasty Patient

Facial plast Surg 2018; 34: 003-008
DOI: 10.1055/s-0037-1617445

Patients with thick skin are a challenge in facial plastic surgery. Rhinoplasty is still the most frequently performed facial plastic procedure worldwide and it becomes very difficult to obtain optimal consistent results in these patients. A systematic presurgical skin evaluation is performed dividing skin into type I–III depending on the elasticity, oiliness, presence of skin alterations, size of skin pores, and laxity. Depending on the skin type, presurgical, surgical, and postsurgical management of the epidermis and dermis is defined. Preconditioning and treating thick skin can improve postsurgical results and reduce postsurgical unwanted results.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Indications and Use of Isotretinoin in Facial Plastic Surgery

Facial plast Surg 2018; 34: 075-081
DOI: 10.1055/s-0037-1617446

Isotretinoin is a first generation retinoid with pleiotropic effects on keratinocyte differentiation, proliferation, and activity of sebaceous glands. For years, there has been intense debate on whether the use of isotretinoin combined with cosmetic or surgical procedures is safe and potentially more efficient than either therapy alone. Due to delays in wound healing and keloid formation, conservative recommendations were not to combine isotretinoin with any plastic surgery or local treatment at 6 to 12 months after discontinuation of the drug. However, there is increasing evidence that a combination approach is not only safe, but may also provide excellent cosmetic outcomes in acne scars, sebaceous gland hyperplasia, and thick-skinned patients undergoing facial plastic surgery. In particular, low-dose regimens of isotretinoin may offer advantages over standard dosage treatments because of better tolerability and safety in long-term use adjunct with surgical interventions. In this article, the authors aim to summarize the current evidence on the use of isotretinoin in facial plastic surgery and to share their experience from selected patients.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
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Use of 5-Fluorouracil for Management of the Thick-Skinned Nose

Facial plast Surg 2018; 34: 009-013
DOI: 10.1055/s-0037-1617420

Patients with a thick nasal skin and soft tissue envelope can have unpredictable results and irregular scarring after rhinoplasty surgery. These patients typically have sebaceous tissue over the nasal tip and are particularly susceptible to soft tissue polly beak formation and excess scar tissue in the radix, tip, and septum. Targeted injections of 5-fluorouracil alone or mixed with low concentrations of steroid can be useful to prevent and treat excess postoperative scar tissue deposition. Ideally, four to six injections are performed every 1 to 4 weeks beginning 1 week postoperatively. The injections are most beneficial when performed within the first 3 months after surgery. Even a single injection may improve outcomes with minimal side effects.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Reducing Periorbital Edema and Ecchymosis after Rhinoplasty: Literature Review and Personal Approach

Facial plast Surg 2018; 34: 014-021
DOI: 10.1055/s-0037-1617444

Postoperative periorbital edema and ecchymosis are most bothersome to rhinoplasty patients. The degree of swelling and bruising is influenced by several factors, and numerous prophylactic and therapeutic measures have been described in the literature. This article reviews the current literature and concludes with the author's suggestions on how to best minimize postoperative periorbital edema and ecchymosis.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Managing the Thick Skin in Facial Plastic Surgery

Facial plast Surg 2018; 34: 001-002
DOI: 10.1055/s-0037-1617447

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Full text

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Managing the Lower Eyelid Complex in the Thick-Skinned Patient

Facial plast Surg 2018; 34: 050-058
DOI: 10.1055/s-0037-1617419

Thick skin presents a unique set of challenges within the realm of facial plastic surgery, and addressing the lower lid complex is no exception. There are several procedures for addressing the lower lids, the first and foremost being lower lid blepharoplasty. However, the remaining procedures combined with surgical techniques have exclusive implications in thick skin. Understanding the anatomy and various techniques that can be applied to thick skin can help achieve aesthetically more pleasing results in comparison to those of thin skin. As will be discussed in this article, patients with skin color of Fitzpatrick's grade III or higher have several characteristics associated with their skin, including thicker dermis as well as different patterns of aging, which have implications for addressing the lower lid complex. The senior author has extensive experience performing lower lid procedures and seeks to impart how best to understand and adapt for these differences to allow for the best aesthetic result.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Surgical Tips for the Management of the Wide Nasal Base

Facial plast Surg 2018; 34: 029-035
DOI: 10.1055/s-0037-1621714

Alar base reduction (ABR) was first described by Weir in 1892, but continues to be a controversial topic in rhinoplasty in terms of optimal techniques. The authors describe the techniques for ABR including internal, external and combined ABR, flare excisions, and alar hooding reductions. The techniques described have resulted in consistent outcomes with acceptable scarring and high patient satisfaction.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Cool Atmospheric Plasma (J-Plasma) and New Options for Facial Contouring and Skin Rejuvenation of the Heavy Face and Neck

Facial plast Surg 2018; 34: 066-074
DOI: 10.1055/s-0037-1621713

Treating patients with heavy or thick features comes with challenges not present in those patients lacking these physical characteristics. The authors report our experience with cool atmospheric plasma for facial contouring and skin rejuvenation of the heavy face and neck including rhinophyma. Cool atmospheric plasma is generated by running helium gas over radiofrequency energy. The resulting plasma is a fourth state of matter and has enhanced clinical effects for ablation and thinning of skin and soft tissues as well of contouring and tightening of deeper soft tissues and fascia. Cool helium plasma has been a very effective tool for skin rejuvenation and skin tightening as well as using it as a tool for nonexcisional microinvasive face and neck rejuvenation. Future research may indicate that it can help treat primary or recurrent superficial cutaneous malignancies.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Management of the Heavy Brows: Long-Term Surgical Options

Facial plast Surg 2018; 34: 036-042
DOI: 10.1055/s-0037-1617422

One of the first signs of aging belongs to the upper third of the face. With the aging process, mestizo facial features become more prominent. The thicker skin-soft tissue envelope (S-STE) has a tendency to sag more, hooding of the eyelids tends to be more pronounced, and there is a tendency for eyebrows to droop, specifically the tail of the brows, because of the loss of support. A "tired" or "sad" look implies that the complex eyebrow-upper eyelid is showing one or more of these signs. Different surgical as well as non-surgical techniques have been described to treat this area, every one of them aiming at making the patient look rested and natural. The objective of this study is to describe a technique for endoscopic brow lifting, consisting on minimal incisions, a biplanar dissection, and a different fixation technique designed for helping reshape the brow. This particular surgical technique has shown the advantage of being minimally invasive and effective. Careful analysis of the patient should be made to decide both the technique and the changes desired by the patient and the surgeon. The authors believe the technique described is another option for approaching and fixating the heavy eyebrows in mestizo patients.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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International consensus (ICON) on treatment of sudden sensorineural hearing loss.

Related Articles

International consensus (ICON) on treatment of sudden sensorineural hearing loss.

Eur Ann Otorhinolaryngol Head Neck Dis. 2018 Jan 29;:

Authors: Marx M, Younes E, Chandrasekhar SS, Ito J, Plontke S, O'Leary S, Sterkers O

Abstract
Sudden sensorineural hearing loss (SSNHL) is a common and alarming symptom that often prompts an urgent visit to an ENT specialist. Treatment of SSNHL remains one of the most problematic issues for contemporary otorhinolaryngology: although many meta-analyses and national guidelines have been issued, management is not standardized in terms of medical treatment, and duration and route of administration. We present several methodological suggestions for the study of treatments for SSNHL. These were developed from the existing level of evidence of the main treatments used in SSNHL by experts who convened at the IFOS 2017 ENT World Congress in Paris, France. All panelists agreed that one of the main limitations present in studies on SSNHL is related to the wide heterogeneity, which characterizes both the initial hearing deficit and the amount of hearing recovery. Although evidence of the efficacy of systemic steroids cannot be considered as strong enough to recommend their use, it is still the most widespread primary therapy and can be considered as the current standard of care. Therefore, systemic steroids stand as an adequate control for any innovative treatment. To reduce the number of subjects we suggest that the inclusion criteria should be restricted to moderate to profound levels of hearing loss. The efficacy of trans-tympanic steroids as a salvage therapy was suggested in several reports on small populations and needs to be confirmed with larger randomized controlled trials.

PMID: 29396226 [PubMed - as supplied by publisher]

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Can Improved Cardiovascular Health Enhance Auditory Function?

No abstract available

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Tinnitus, Hyperacusis, and the Autonomic Nervous System

No abstract available

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On the Heels of the World Health Assembly 2017 Resolution

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Auditory Processing Assessment Model for Older Patients

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Improving the Quality of Life of Tinnitus Patients

No abstract available

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Going for Gold: Inspiration from Athletes with Hearing Loss

No abstract available

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Considerations for Culturally Sensitive Hearing Care

No abstract available

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Updates on Unilateral Hearing Loss

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Hearing Loss in Children with Down Syndrome

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Symptom: Ear Canal Mass

No abstract available

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10 Facts (and a Question) About NIHL and Medical-legal Evaluation

No abstract available

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Manufacturers News

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3D quantitative comparative analysis of long bone diaphysis variations in microanatomy and cross-sectional geometry

Abstract

Long bone inner structure and cross-sectional geometry display a strong functional signal, leading to convergences, and are widely analyzed in comparative anatomy at small and large taxonomic scales. Long bone microanatomical studies have essentially been conducted on transverse sections but also on a few longitudinal ones. Recent studies highlighted the interest in analyzing variations of the inner structure along the diaphysis using a qualitative as well as a quantitative approach. With the development of microtomography, it has become possible to study three-dimensional (3D) bone microanatomy and, in more detail, the form–function relationships of these features. This study focused on the selection of quantitative parameters to describe in detail the cross-sectional shape changes and distribution of the osseous tissue along the diaphysis. Two-dimensional (2D) virtual transverse sections were also performed in the two usual reference planes and results were compared with those obtained based on the whole diaphysis analysis. The sample consisted in 14 humeri and 14 femora of various mammalian taxa that are essentially terrestrial. Comparative quantitative analyses between different datasets made it possible to highlight the parameters that are strongly impacted by size and phylogeny and the redundant ones, and thus to estimate their relevance for use in form-function analyses. The analysis illustrated that results based on 2D transverse sections are similar for both sectional planes; thus if a strong bias exists when mixing sections from the two reference planes in the same analysis, it would not problematic to use either one plane or the other in comparative studies. However, this may no longer hold for taxa showing a much stronger variation in bone microstructure along the diaphysis. Finally, the analysis demonstrated the significant contribution of the parameters describing variations along the diaphysis, and thus the interest in performing 3D analyses; this should be even more fruitful for heterogeneous diaphyses. In addition, covariation analyses showed that there is a strong interest in removing the size effect to access the differences in the microstructure of the humerus and femur. This methodological study provides a reference for future quantitative analyses on long bone inner structure and should make it possible, through a detailed knowledge of each descriptive parameter, to better interpret results from the multivariate analyses associated with these studies. This will have direct implications for studies in vertebrate anatomy, but also in paleontology and anthropology.

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ASBA campaign for “Dental Sleep Medicine Expert to the Medical Review Board” appointment

WASHINGTON, D.C. – The long push to get federal certainty in the diagnosis and treatment of obstructive sleep apnea in transportation workers came a step closer last week. In a meeting with the staff of Rep. Anna Eshoo, Dr. Elliott J. Alpher asked for support in the efforts to get a dental sleep medicine expert appointed to the Federal Motor Carriers Safety Administration's Medical Review Board.

 

 

FMCSA-Medical Review Board

This five-member panel of physicians sets the health and safety guidelines for truckers. The MRC also sets training standards for more than 5,000 certified medical examiners who perform physicals on truckers. Yet no member of the MRC has been trained in the diagnosis and treatment of sleep apnea.

Rep. Eshoo has long been a supporter of federal regulatory authority over the diagnosis and treatment of obstructive sleep apnea among transportation workers. In 2016, she hosted an educational session for members of Congress on the devastating effects of obstructive sleep apnea.

According to statistics from the ASBA, obstructive sleep disorders affect over 25 million Americans, and that number is on the rise. Current FMSCA Medical Review Board guidelines base a diagnosis on three criteria, while the American Sleep and Breathing Academy standard includes 14 scientific and medical points, including intraoral exams and measurements and allows for a home sleep study.

Source: ASBA.net

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Brainstem Injury in Pediatric Patients With Posterior Fossa Tumors Treated With Proton Beam Therapy and Associated Dosimetric Factors

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Michelle S. Gentile, Beow Y. Yeap, Harald Paganetti, Claire P. Goebel, Dillon E. Gaudet, Sara L. Gallotto, Elizabeth A. Weyman, Michael L. Morgan, Shannon M. MacDonald, Drosoula Giantsoudi, Judith Adams, Nancy J. Tarbell, Hanne Kooy, Torunn I. Yock
PurposeProton radiation therapy is commonly used in young children with brain tumors for its potential to reduce late effects. However, some proton series report higher rates of brainstem injury (0%-16%) than most photon series (2.2%-8.6%). We report the incidence of brainstem injury and a risk factor analysis in pediatric patients with posterior fossa primary tumors treated with proton radiation therapy at our institution.Methods and MaterialsThe study included 216 consecutive patients treated between 2000 and 2015. Dosimetry was available for all but 4 patients. Grade 2 to 5 late brainstem toxicity was assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0.ResultsThe histologies include medulloblastoma (n=154, 71.3%), ependymoma (n=56, 25.9%), and atypical teratoid rhabdoid tumor (n=6, 2.8%). The median age at irradiation was 6.6 years (range, 0.5-23.1 years); median dose, 54 gray relative biological effectiveness (Gy RBE) (range, 46.8-59.4 Gy RBE); and median follow-up period, 4.2 years (range, 0.1-15.3 years) among 198 survivors. Of the patients, 83.3% received chemotherapy; 70.4% achieved gross total resection. The crude rate of injury was 2.3% in all patients, 1.9% in those with medulloblastoma, 3.6% in those with ependymoma, and 0% in those with atypical teratoid rhabdoid tumor. The 5-year cumulative incidence of injury was 2.0% (95% confidence interval, 0.7%-4.8%). The median brainstem dose (minimum dose received by 50% of brainstem) in the whole cohort was 53.6 Gy RBE (range, 16.5-56.8 Gy RBE); maximum point dose within the brainstem (Dmax), 55.2 Gy RBE (range, 48.4-60.5 Gy RBE); and mean dose, 50.4 Gy RBE (range, 21.1-56.7 Gy RBE). In the 5 patients with injury, the median minimum dose received by 50% of the brainstem was 54.6 Gy RBE (range, 50.2-55.1 Gy RBE); Dmax, 56.2 Gy RBE (range, 55.0-57.1 Gy RBE); mean dose, 51.3 Gy RBE (range, 45.4-54.4 Gy RBE); and median volume of the brainstem receiving ≥55 Gy RBE (V55), 27.4% (range, 0%-59.4%). Of the 5 patients with injury, 4 had a brainstem Dmax in the highest quartile (≥55.8 Gy RBE, P = .016) and a V55 in the highest tertile (>6.0%) of the cohort distribution (P = .047). Of the 5 patients with injury, 3 were aged >6 years (age range, 4.1-22.8 years), and 4 of 5 patients received chemotherapy and achieved gross total resection.ConclusionsThe incidence of injury in pediatric patients with posterior fossa tumors is consistent with previous reports in the photon setting. Our data suggest that when Dmax and V55 are kept <55.8 Gy RBE and ≤6.0%, respectively, the 5-year rate of radiation brainstem injury would be <2%.



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In Reply to Daisne et al

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Jean-Emmanuel Bibault, Philippe Giraud, Magali Morelle, Lionel Perrier, Marius Huguet




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Stereotactic Radiosurgery for Resected Brain Metastases: New Evidence Supports a Practice Shift, but Questions Remain

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Giuseppe Minniti, Scott G. Soltys, Lia M. Halasz, John C. Breneman, Michael Chan, Nadia N. Laack, John P. Kirkpatrick




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Enhancing Radiation Therapy Through Cherenkov Light-Activated Phototherapy

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Suk W. Yoon, Vadim Tsvankin, Zachary Shrock, Boyu Meng, Xiaofeng Zhang, Mark Dewhirst, Peter Fecci, Justus Adamson, Mark Oldham
PurposeThis work investigates a new approach to enhance radiotherapy through a photo therapeutic agent activated by Cherenkov light produced from the megavoltage photon beam. The process is termed Radiotherapy Enhanced with Cherenkov photo-Activation (RECA). RECA is compatible with various photo-therapeutics, but here we focus on use with psoralen, an ultraviolet activated therapeutic with extensive history of application in superficial and extracorporeal settings. RECA has potential to extend the scope of psoralen treatments beyond superficial to deep seated lesions.Methods and MaterialsIn vitro studies in B16 melanoma and 4T1 murine breast cancer cells were performed to investigate the potential of RT plus RECA versus RT alone for increasing cytotoxicity (local control) and increasing surface expression of major histocompatibility complex I (MHC I). The latter represents potential for immune response amplification (increased antigen presentation), which has been observed in other psoralen therapies. Cytotoxicity assays included luminescence and clonogenics. The MHC I assays were performed using flow cytometry. In addition, Cherenkov light intensity measurements were performed to investigate the possibility of increasing the Cherenkov light intensity per unit dose from clinical megavoltage beams, to maximize psoralen activation.ResultsLuminescence assays showed that RECA treatment (2 Gy at 6 MV) increased cytotoxicity by up to 20% and 9.5% for 4T1 and B16 cells, respectively, compared with radiation and psoralen alone (ie, Cherenkov light was blocked). Similarly, flow cytometry revealed median MHC I expression was significantly higher in RECA-treated cells, compared with those receiving radiation and psoralen alone (approximately 450% and 250% at 3 Gy and 6 Gy, respectively, P << .0001). Clonogenic assays of B16 cells at doses of 6 Gy and 12 Gy showed decreases in tumor cell viability of 7% (P = .017) and 36% (P = .006), respectively, when Cherenkov was present.ConclusionThis work demonstrates for the first time the potential for photo-activation of psoralen directly in situ, from Cherenkov light generated by a clinical megavoltage treatment beam.



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Radiation Oncology in Egypt: A Model for Africa

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Mohamed S. Zaghloul, Mai K. Bishr




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Secondary Acute Leukemia in Sarcoma Patients: A Population-Based Study

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Nina N. Sanford, Allison M. Martin, Andrew M. Brunner, Gregory M. Cote, Edwin Choy, Thomas F. DeLaney, Ayal A. Aizer, Yen-Lin Chen
PurposeTo compare rates of secondary acute leukemia between sarcoma patients and the general population, using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) registry, and to examine whether various patient, tumor, and treatment factors were associated with development of a secondary acute leukemia.Methods and MaterialsPatients with a primary diagnosis of connective tissue malignancy between 1973 and 2008 in the SEER database were included. Multivariable competing risk analysis was used to determine risk factors associated with subsequent development of acute leukemia. Using observed-to-expected ratios, we compared incidence rates of secondary acute leukemia between sarcoma patients and the general population.ResultsA total of 72,945 patients were identified, with median follow-up of 131 months. On multivariable competing risk analysis, factors associated with increased risk of secondary acute leukemia included receipt of radiation therapy (hazard ratio [HR] 1.67, P=.02), distant disease (HR 2.67, P=.004), male gender (HR 1.53, P=.03), year of diagnosis (HR 0.98, P=.049), and Ewing sarcoma histology (HR 9.95, P < .0001) and osteosarcoma histology (HR 5.06, P=.0001). The observed-to-expected ratio for development of a secondary acute leukemia was 3.67 (95% confidence interval [CI] 1.95-6.28), 3.41 (95% CI 2.73-4.20), and 1.6 (95% CI 1.38-8.19) for acute lymphocytic leukemia, acute myeloid leukemia, and acute monocytic leukemia, respectively. The 10-year cumulative incidence of secondary acute leukemia for patients who did and did receive radiation therapy was 0.3% versus 0.1% (P=.02).ConclusionsPatients treated for sarcoma, in particular those with Ewing sarcoma and osteosarcoma histology, seem to have a higher incidence of secondary acute leukemia as compared with the general population. Treatment factors including radiation therapy and chemotherapy seem to play a role in this increased risk, although the absolute incidence nevertheless remains very small.



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Seymour H. Levitt, MD, 1928-2017

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Luther W. Brady




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In Reply to McClelland et al

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Nina N. Sanford, Helen A. Shih




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Involved-Site Radiation to Maximize Control

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Parag Sanghvi




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Watch and Wait, Salvage Later

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Avyakta Kallam, James O. Armitage




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Curative Radiation Therapy at Time of Progression Under Active Surveillance Compared With Up-front Radical Radiation Therapy for Prostate Cancer

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Alejandro Berlin, Ardalan E. Ahmad, Melvin L.K. Chua, Fabio Y. Moraes, Haiyan Jiang, Maria Komisarenko, Narhari Trimilshina, Hamid Raziee, Ali Hosni, Jure Murgic, Peter Chung, Robert G. Bristow, Antonio Finelli
PurposeTo describe and compare outcomes in men with initially presumed indolent prostate cancer receiving definitive radiation therapy after active surveillance (AS) versus those in a risk-matched cohort undergoing up-front radiation therapy.Methods and MaterialsMen prospectively enrolled in an AS program between 1992 and 2014 and subsequently undergoing curative radiation therapy (ie, image guided radiation therapy [IGRT] or low-dose-rate brachytherapy [LDR-BT]) were identified. Biochemical relapse–free rate (bRFR), metastasis-free rate (mFR), and overall survival (OS) were compared against a cohort of men treated up front, matched by age, clinical prognostic indices (risk group, prostate-specific antigen, cT category, Gleason score, percentage of involved biopsy cores), and radiation therapy modality.ResultsOf 1070 patients in the AS registry, 200 underwent definitive radiation therapy (143 IGRT and 57 LDR-BT) after a median of 32.9 (interquartile range [IQR] 20.6-59.8) months on surveillance. Main reasons for treatment were grade and volume upgrading (57.5% and 26%, respectively). Median follow-up after radiation therapy was 4.9 (IQR 3.1-7.5) years. At 5 years the bRFR, mFR, and OS were, respectively, 97%, 99%, and 98.5%. No patient died of prostate cancer. Adequate risk-matching was confirmed in an independent cohort comprising 359 patients receiving up-front IGRT (71%) or LDR-BT (29%) and followed for a median of 9 (IQR 3.1-7.5) years. There was no difference in the disease-specific outcomes (bRFR, mFR) between the 2 cohorts (Gray's P value of .257 and .934, respectively). In multivariate analyses, timing of radical radiation therapy (deferred vs up-front) was not correlated to biochemical relapse or metastases occurrence.ConclusionsCurative-intent radiation therapy (ie, dose-escalated IGRT or LDR-BT) after a period of AS renders excellent oncologic outcomes at 5 years. Deferring radical therapy after a period of AS does not seem to result in inferior oncologic outcomes compared with patients with similar risk characteristics undergoing up-front treatment.



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Observe, and Keep Chemotherapy Up the Sleeve

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Carol Marquez




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Normal Tissue Complication Probability Modeling of Pulmonary Toxicity After Stereotactic and Hypofractionated Radiation Therapy for Central Lung Tumors

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): H. Tekatli, M. Duijm, E. Oomen-de Hoop, W. Verbakel, W. Schillemans, B.J. Slotman, J.J. Nuyttens, S. Senan
PurposeTo evaluate clinical pulmonary and radiographic bronchial toxicity after stereotactic ablative radiation therapy and hypofractionated radiation therapy for central lung tumors, and perform normal tissue complication probability modeling and multivariable analyses to identify predictors for toxicity.Methods and MaterialsA pooled analysis was performed of patients with a central lung tumor treated using ≤12 fractions at 2 centers between 2006 and 2015. Airways were manually contoured on planning computed tomography scans, and doses were recalculated to an equivalent dose of 2 Gy per fraction with an α/β ratio of 3. Grade ≥3 (≥G3) clinical pulmonary toxicity was evaluated by 2 or more physicians. Radiographic toxicity was defined as a stenosis or an occlusion with or without atelectasis using follow-up computed tomography scans. Logistic regression analyses were used for statistical analyses.ResultsA total of 585 bronchial structures were studied in 195 patients who were mainly treated using 5 or 8 fractions (60%). Median patient survival was 27.9 months (95% confidence interval 22.3-33.6 months). Clinical ≥G3 toxicity was observed in 24 patients (12%) and radiographic bronchial toxicity in 55 patients (28%), both mainly manifesting ≤12 months after treatment. All analyzed dosimetric parameters correlated with clinical and lobar bronchial radiographic toxicity, with V130Gy,EQD having the highest odds ratio. Normal tissue complication probability modeling showed a volume dependency for the development of both clinical and radiographic toxicity. On multivariate analyses, significant predictors for ≥G3 toxicity were a planning target volume overlapping the trachea or main stem bronchus (P = .005), chronic obstructive pulmonary disease (P = .034), and the total V130Gy,EQD (P = .012). Radiographic bronchial toxicity did not significantly correlate with clinical toxicity (P = .663).ConclusionsWe identified patient and dosimetric factors associated with clinical and radiographic toxicity after high-dose radiation therapy for central lung tumors. Additional data from prospective studies are needed to validate these findings.



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Development of a Radiation Oncology Resident Continuity Clinic to Improve Clinical Competency and Patient Compliance

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Stella K. Yoo, Shelly X. Bian, Eugene Lin, Sukhjeet S. Batth, Lydia W. Ng, Jacob Andrade, Patrick A. Williams, Anthony H. Pham, Omar M. Ragab, Naomi R. Schechter, Eric L. Chang, Richard L.S. Jennelle




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Complex DNA Damage Induced by High Linear Energy Transfer Alpha-Particles and Protons Triggers a Specific Cellular DNA Damage Response

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Rachel J. Carter, Catherine M. Nickson, James M. Thompson, Andrzej Kacperek, Mark A. Hill, Jason L. Parsons
PurposeTo investigate the precise mechanism of recognition and processing of ionizing radiation (IR)-induced complex DNA damage (CDD), where two or more DNA lesions are in close proximity, in cellular DNA which is packaged with histones to form chromatin.Methods and MaterialsHeLa and oropharyngeal squamous cell carcinoma (UMSCC74A and UMSCC6) cells were irradiated with high linear energy transfer (LET) α-particles or protons, versus low-LET protons and X rays. At various time points after irradiation, site-specific histone post-translational modifications were analyzed by quantitative Western blotting; DNA damage and repair were measured by different versions of the comet assay; and cell survival was determined using clonogenic assays.ResultsSite-specific histone post-translational modifications after low- and high-LET radiation, particularly proton irradiation, were screened, aiming to identify those responsive to CDD. We demonstrate that histone H2B ubiquitylated on lysine 120 (H2Bub) is specifically induced several hours after irradiation in response to high-LET α-particles and protons but not by low-LET protons or X rays/γ-radiation. This is associated with increased levels of CDD, which contributes to decreased cell survival. We further discovered that modulation of H2Bub is under the control of two E3 ubiquitin ligases, MSL2 and RNF20/RNF40 complex, whose depletion leads to defective processing and further persistence of CDD, and to additional decreased cell survival after irradiation.ConclusionThis study demonstrates that the signaling and repair of CDD, particularly induced by high-LET IR is co-ordinated through the specific induction of H2Bub catalyzed by MSL2 and RNF20/40, a mechanism that contributes significantly to cell survival after irradiation.



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Utilizing 10-Year Results From the American Board of Radiology Clinical Examination to Identify Areas for Programmatic Improvement

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Robert B. Den, Marlene Folino, Adam P. Dicker




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In Reply to Leddy

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Nishant K. Shah, Brad Zehr, Ankit Agarwal, Apar Gupta, Ariel E. Hirsch




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In Reply to Overgaard et al

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): William A. Stokes, Sana D. Karam




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Radiation Safety for Pregnant Workers at a Proton Facility

Publication date: 1 March 2018
Source:International Journal of Radiation Oncology*Biology*Physics, Volume 100, Issue 3
Author(s): Genevieve Maquilan, Marc R. Bussière, Joseph McCormack, Tara Medich, Andrzej Niemierko, Helen A. Shih
PurposeTo quantify radiation exposure of radiation therapy technologists (RTTs) in a proton treatment facility in comparison with a photon therapy facility, to inform and establish these specialized occupational safety guidelines.Methods and MaterialsTwo groups of RTTs, consisting of 12 full-time passive scattering proton RTTs and 18 full-time conventional photon RTTs, wore an additional dosimetry badge at the waist for a period of 14 weeks. The 2 groups of RTTs were given identical instructions on the proper use of the badges. To compare exposures between passive scatter and scanning beam systems, exposure rates from activated equipment in both systems were measured.ResultsOver the 14-week period, the mean and standard deviation background-corrected dose for the passively scattered proton RTTs was 39.9 ± 5.4 mrem. The mean and standard deviation background-corrected dose for the conventional photon RTTs was similar at 39.9 ± 9.0 mrem (P = .6). Exposure rates were lower in equipment activated in a scanning beam system in comparison with those from a passive scatter system.ConclusionsRadiation dose to passively scattered proton and photon radiation therapy technologists was similar when measured with a dosimeter worn at the waist over a period of 14 weeks. On the basis of these data, the departmental policy permits pregnant radiation workers to work in proton treatment areas, and the policy for pregnant workers does not differ between proton and photon radiation workers or between passive scatter and scanning beam systems. All employees are encouraged to limit time near and proximity to activated equipment.



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Full Endoscopic Interlaminar Approach for Nerve Root Decompression of Sacral Metastatic Tumor

Publication date: April 2018
Source:World Neurosurgery, Volume 112
Author(s): Sheng-Hua Tsai, Hsuan-Han Wu, Chun-Yuan Cheng, Chien-Min Chen
BackgroundEndoscopic surgery has been successfully applied in treatment of degenerative spinal disease, but few studies have assessed its use in treating sacral metastasis. We report a successful full endoscopic interlaminar approach for sacral nerve root decompression of a sacral metastatic tumor.Case DescriptionAn 80-year-old man with a history of hepatocellular carcinoma presented with buttock pain with radiation to the right lower leg for 1 week. There was also decreased muscle power of the right lower extremity. Lumbosacral magnetic resonance imaging revealed metastasis of the sacral spine and right iliac bone with S1 exiting nerve root compression. S1 nerve root decompression via a full endoscopic interlaminar approach under local anesthesia was performed. Under fluorescence guidance, a working sleeve with a beveled opening was placed in the interlaminar space of L5-S1. We entered the sacral canal and identified the S1 exiting nerve root. A laminotomy was performed from the internal edge of the right sacral laminae toward the lateral recess. During decompression of the nerve root, buttock and leg pain improved gradually. There was almost complete resolution of leg pain after surgery, and the patient recovered the ability to walk. Visual analog scale score for pain decreased from 8 to 2 after 3 months of follow-up.ConclusionsFor patients with sacral metastasis without spinal instability or difficulty lying in prone position under local anesthesia, the full endoscopic interlaminar approach for nerve root decompression of sacral metastasis may be a suitable method.



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Mentoring: Giving Forward While Giving Back

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Manual Versus Automated Narrative Analysis of Agrammatic Production Patterns: The Northwestern Narrative Language Analysis and Computerized Language Analysis

Purpose

The purpose of this study is to compare the outcomes of the manually coded Northwestern Narrative Language Analysis (NNLA) system, which was developed for characterizing agrammatic production patterns, and the automated Computerized Language Analysis (CLAN) system, which has recently been adopted to analyze speech samples of individuals with aphasia (a) for reliability purposes to ascertain whether they yield similar results and (b) to evaluate CLAN for its ability to automatically identify language variables important for detailing agrammatic production patterns.

Method

The same set of Cinderella narrative samples from 8 participants with a clinical diagnosis of agrammatic aphasia and 10 cognitively healthy control participants were transcribed and coded using NNLA and CLAN. Both coding systems were utilized to quantify and characterize speech production patterns across several microsyntactic levels: utterance, sentence, lexical, morphological, and verb argument structure levels. Agreement between the 2 coding systems was computed for variables coded by both.

Results

Comparison of the 2 systems revealed high agreement for most, but not all, lexical-level and morphological-level variables. However, NNLA elucidated utterance-level, sentence-level, and verb argument structure–level impairments, important for assessment and treatment of agrammatism, which are not automatically coded by CLAN.

Conclusions

CLAN automatically and reliably codes most lexical and morphological variables but does not automatically quantify variables important for detailing production deficits in agrammatic aphasia, although conventions for manually coding some of these variables in Codes for the Human Analysis of Transcripts are possible. Suggestions for combining automated programs and manual coding to capture these variables or revising CLAN to automate coding of these variables are discussed.

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Utterance Duration as It Relates to Communicative Variables in Infant Vocal Development

Purpose

We aimed to provide novel information on utterance duration as it relates to vocal type, facial affect, gaze direction, and age in the prelinguistic/early linguistic infant.

Method

Infant utterances were analyzed from longitudinal recordings of 15 infants at 8, 10, 12, 14, and 16 months of age. Utterance durations were measured and coded for vocal type (i.e., squeal, growl, raspberry, vowel, cry, laugh), facial affect (i.e., positive, negative, neutral), and gaze direction (i.e., to person, to mirror, or not directed).

Results

Of the 18,236 utterances analyzed, durations were typically shortest at 14 months of age and longest at 16 months of age. Statistically significant changes were observed in utterance durations across age for all variables of interest.

Conclusion

Despite variation in duration of infant utterances, developmental patterns were observed. For these infants, utterance durations appear to become more consolidated later in development, after the 1st year of life. Indeed, 12 months is often noted as the typical age of onset for 1st words and might possibly be a point in time when utterance durations begin to show patterns across communicative variables.

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Cognitive Profiles of Finnish Preschool Children With Expressive and Receptive Language Impairment

Purpose

The aim of this study was to compare the verbal and nonverbal cognitive profiles of children with specific language impairment (SLI) with problems predominantly in expressive (SLI-E) or receptive (SLI-R) language skills. These diagnostic subgroups have not been compared before in psychological studies.

Method

Participants were preschool-age Finnish-speaking children with SLI diagnosed by a multidisciplinary team. Cognitive profile differences between the diagnostic subgroups and the relationship between verbal and nonverbal reasoning skills were evaluated.

Results

Performance was worse for the SLI-R subgroup than for the SLI-E subgroup not only in verbal reasoning and short-term memory but also in nonverbal reasoning, and several nonverbal subtests correlated significantly with the composite verbal index. However, weaknesses and strengths in the cognitive profiles of the subgroups were parallel.

Conclusions

Poor verbal comprehension and reasoning skills seem to be associated with lower nonverbal performance in children with SLI. Performance index (Performance Intelligence Quotient) may not always represent the intact nonverbal capacity assumed in SLI diagnostics, and a broader assessment is recommended when a child fails any of the compulsory Performance Intelligence Quotient subtests. Differences between the SLI subgroups appear quantitative rather than qualitative, in line with the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) classification (American Psychiatric Association, 2013).

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Contemporary Management of Mandibular Fracture Nonunion – A Retrospective Review and Treatment Algorithm

Publication date: Available online 6 February 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Benjamin T. Ostrander, Howard D. Wang, Alessandro Cusano, Paul N. Manson, Arthur J. Nam, Amir H. Dorafshar
PurposeNonunion is an uncommon complication after mandible fractures. The purpose of this investigation was to compare outcomes of patients with mandibular fracture nonunion who were treated with a single-stage versus two-stage approach, and propose a pragmatic treatment algorithm for surgical management based on preoperative characteristics.MethodsInvestigators conducted a retrospective study consisting of patients who presented to two Level-1 trauma centers for the management of mandibular fracture nonunion over a 10-year period. The primary predictor variable was one-stage versus two-stage treatment. Outcomes were examined to propose a treatment algorithm.ResultsEighteen patients were included into the study. The sample's mean age was 44.0 ± 19.3 years, and most were male (88.9%). Mandibular angle and body accounted for 77.8% of cases. A single-stage approach was used in 13 patients (72.2%). Bone grafts or vascularized bone flaps were required in 13 patients (72.2%). Patients who required two-stage treatments had intraoral soft tissue defects. Mean length of follow-up was 13.3 ± 20.4 months. All patients achieved bony union, with complications occurring in 5 patients (27.8%). Our 10-year experience was used to formulate a treatment algorithm based on bony defect size and soft tissue status, which can be used to inform optimal surgical management.ConclusionsNonunion of mandibular fractures is an infrequent and complex condition requiring careful and deliberate surgical management. A single-stage approach is appropriate in most cases and does not negatively affect outcomes. Bony defect size and soft tissue status are essential parameters for determining approach and timing of reconstruction.



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Straticyte demonstrates prognostic value over oral epithelial dysplasia grade for oral potentially malignant lesion assessment

Publication date: February 2018
Source:Oral Oncology, Volume 77
Author(s): Jason T.K. Hwang, Ying R. Gu, Benjamin J. Dickson, Mi Shen, Ranju Ralhan, Paul G. Walfish, David Mock, Kenneth P.H. Pritzker




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Editorial Board/Aims & Scope

Publication date: February 2018
Source:Oral Oncology, Volume 77





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Complications After Vulvar and Perineal Reconstruction With a Lotus Petal Flap

Background Lotus petal flaps are often used to reconstruct defects in the vulvoperineal area. Wound complications occur more often after surgery in the vulvoperineal area than in other areas of the body. Postoperative complications have a great impact on patients' well-being, length of hospital stay, care needed, and return to participation in daily life. Therefore, it is important to determine which patients are more prone to develop complications. Methods All lotus petal flap reconstructions in our center between January 2004 and August 2014 were retrospectively reviewed. Complications were categorized by the Clavien-Dindo classification. Results Ninety-three patients with 137 flaps were reviewed. The complication rates did not differ significantly between the reconstruction areas. In 30.1% of subjects, no complications were reported. A total of 51.7% of the subjects experienced Clavien-Dindo grade I or II complications, which required no or minor intervention. In 18.3% of subjects, intervention was required under general anesthesia (Clavien-Dindo grade IIIb complications), usually for debridement (64.7%). Donor site morbidity occurred in 14.0% of the subjects. The age group younger than 60 years showed a significantly higher rate of complications compared with the group older than 60 years (P = 0.015; odds ratio, 0.235; 95% confidence interval, 0.073–0.754). Conclusions This is the largest study to date on the complications of the lotus petal flap reconstruction. Complication rates did not differ between vulvar, perineal, and vulvoperineal reconstruction. Young patients seem to have a higher risk of developing complications.

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Fingertip Replantation Without and With Palmar Venous Anastomosis: Analysis of the Survival Rates and Vein Distribution

No abstract available

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Insurance Appeals for Pediatric Reconstructive Surgery: A Micro Cost Analysis and How-to Guide

Background When insurance coverage for pediatric reconstructive procedures is denied, a stressful and time-consuming appeals process ensues. This article discusses the results of a micro cost analysis performed to better understand the time and monetary burden that the insurance process places on our clinic and families. We also advise plastic surgeons on how to appeal insurance denials for necessary reconstructive procedures. Methods Our micro cost analysis focused on patients with congenital breast anomalies who were denied insurance coverage during the preservice insurance authorization process. We surveyed staff and family members to determine the steps involved in the insurance process and how long each person spent on each step. We combined this with average compensation data to calculate cost. Results For the 5 patients included in our analysis, the insurance process took an average of 7.4 hours of institutional time and cost $521.43 per patient. All patients were denied coverage during prior authorization and required a peer-to-peer, and all denials occurred because surgery was deemed cosmetic or not medically necessary. Conclusions This analysis estimated the time and monetary cost of the insurance process in our department. Access to care was limited by prior authorization and the opinion of medical directors that these procedures are unnecessary or cosmetic. We encourage plastic surgeons to continue to perform patient-centered outcomes research in their practice to build on literature that proves the functional and psychosocial benefits of reconstructive procedures.

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Botulinum Toxin Therapy: Is Syringe Type Related to Cost-Effectiveness?

Introduction Clostridium botulinum toxin is effective through cleaving presynaptic proteins at the neuromuscular junction, which prevents the release of acetylcholine and inhibits muscle contraction. Several serotypes of botulinum toxin (BT) exist; however, only 2 types have been approved by the US Food and Drug Administration for commercial and medical use, A and B. Both types of BT must be administered intramuscularly with a syringe, but the type of syringe is the injector's preference. Which syringe type is most efficient in minimizing product waste and most cost-effective for the patient and provider? Methods We performed a single-center, open-label, analytical study using BT therapy and 2 types of syringes for analytics of cost-effectiveness. OnabotulinumtoxinA was the neuromodulator used in this report. Vials (100 U) of BT A were each reconstituted with 2.5 mL of 0.9% sodium chloride, for a final concentration of 4 U/0.1 mL. High-dead-space syringes are compared with low-dead-space syringes: 1-mL tuberculin (TB) luer slip syringe with detachable 25-gauge needle and 1-mL ultrafine insulin syringe with an attached 31-gauge needle, respectively. After each syringe was evacuated, the TB syringe was noted to contain 0.05 mL of the remaining product in the hub. Results Providers are discarding approximately 2 U of BT per TB syringe product injection. If the physician uses 30 syringes per day, 3 days a week, for 1 year, it equals to a lost revenue of approximately $155,500 per year. To individualize the cost-effective analysis, average quantity of syringes used per patient and overall patient volume must be considered, with corresponding adjustment of cost and units discarded. Discussion The American Society of Plastic Surgeons reported that the use of neuromodulators has increased by approximately 797% from 2000 to 2016. During that period, the price of neuromodulators has also increased by approximately 85%. Considering these statistics, the type of syringe used for BT neuromodular injection is a thought-provoking concept but surrounded by a paucity of data. Overall, our data suggest that the use of ultrafine insulin syringes for injection of BT reduces product waste and is cost-effective for the patient and the provider.

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Course Review: Plastic Surgery for Surgical Trainees

Early in their careers, trainees contemplating a career in plastic surgery may have limited specialty experience. Courses can provide valuable insight into specialty training and help develop necessary basic skills. However, this is not without a significant financial burden. Plastic Surgery for Surgical Trainees is a 1-day course that only costs £50 GBP (US $65). Accredited by the Royal College of Surgeons, this course held in Bristol, United Kingdom, offers an inexpensive practical introduction toward plastic surgical techniques for trainees interested in plastic surgery and those in other surgical specialties. In this review, we provide an evaluation of the course.

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Characterizing Breast Deformities After Massive Weight Loss: Utilizing the Pittsburgh Rating Scale to Examine Factors Affecting Severity Score and Surgical Decision Making in a Retrospective Series

Background and Objectives Massive weight loss (MWL) can result in variable contour deformities of the breasts. The Pittsburgh Rating Scale (PRS) was designed to describe the multitude of deformities after MWL and recommends operations to consider for surgical improvement. We present the first comprehensive description of breast deformities in a large sample of MWL patients, examine factors affecting the severity of deformities, and report the correlation between PRS score and surgical decision making. Methods A retrospective review of all MWL patients presenting for breast surgery at our institution's Life After Weight Loss program from 2004 to 2015 was performed. Information including demographics, body mass indices (BMIs), method of weight loss, and type of surgical intervention was collected. Preoperative breast photographs were blinded and scored according to the PRS. Results A total of 204 MWL patients were identified; 26% (53) scored 1, 34% (69) scored 2, and 40% (82) scored 3 on the PRS. Greater deformities were seen after weight loss from bariatric surgery versus diet and exercise alone (P = 0.031), in mastopexy versus augmentation/mastopexy (P = 0.001), and in breast reduction versus augmentation/mastopexy patients (P > 0.0001). Patients who underwent reduction mammaplasty had the greatest maximum BMI compared with other procedures (P = 0.016). The PRS scores were positively correlated to maximum BMI (P

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Mixed Versus Pure Variants of Desmoplastic Melanoma: The Cleveland Clinic Experience

Background Desmoplastic melanoma (DM) is a subvariant of spindle cell melanoma, accounting for less than 4% of all cutaneous melanomas. It occurs later in life and is associated with chronic sun exposure. Desmoplastic melanoma prognosis is considered more favorable than other variants, with lower rates of metastasis and higher survival. Recently, DM has been further subclassified into pure and mixed, calling into question surgical management and patient outcomes as well as viability of current nationwide databases without this distinction. Methods We identified all patients with a histopathologic diagnosis of DM from the Cleveland Clinic electronic melanoma database (n = 58) from 1997 to 2013. Clinical and histopathologic data were collected. Comparison in clinical variables was performed between patients who had pure (n = 15) and mixed (n = 43) variants of DM. Results There were no differences in age, sex, location of lesion, Breslow depth, ulceration, or regression. Patients with mixed DM were more likely to have lymphovascular invasion (P = 0.03) compared with pure DM. There was no difference in performance of sentinel lymph node biopsy (P = 0.25) or sentinel lymph node positivity (P = 0.31) between the 2 groups. Recurrence was present in 13.3% of pure and 30.2% of mixed patients. Overall, Kaplan-Meier 3-year survival was 75% for pure and 80% for mixed DM (P = 0.53). Conclusions Pure and mixed DMs seem to have similar clinical characteristics and outcomes. This indicates that analysis of national datasets without this subclassification remains viable.

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Surgeon-Controlled Comparison of Direct-to-Implant and 2-Stage Tissue Expander–Implant Immediate Breast Reconstruction Outcomes

Background Current literature comparing outcomes of immediate breast reconstruction using direct-to-implant (DTI) single-stage and 2-stage tissue expanders (TEs) is conflicting. This study compared overall outcomes and determined predictive patient factors associated with higher complication rates. Methods After institutional review board approval, a retrospective cohort study of consecutive patients who underwent immediate breast reconstruction from 2010 to 2014 at a single hospital was performed. Demographic data and complications were recorded and compared using univariate analysis. Infection was defined as any patient receiving antibiotics beyond the expected postoperative course or restarting antibiotics for a suspected infection. Results Seventy-nine breasts (50 patients) underwent immediate breast reconstruction using tissue expansion, and 117 breasts (69 patients) underwent immediate breast reconstruction using the DTI technique. Overall complications, infection rate, and rate of aesthetic revisions were higher in the TE group compared with the DTI group. There was no difference in rates of seroma, hematoma, and mastectomy skin flap necrosis between the 2 groups. Infectious complications were significantly higher in patients with body mass index of greater than 30 who underwent TE-based reconstruction than those who underwent DTI-based reconstruction. Conclusions Single-stage DTI immediate breast reconstruction has less overall complications than 2-stage TE-based immediate reconstruction. Direct-to-implant immediate breast reconstruction may provide favorable outcomes in patients with body mass index of greater than 30.

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