Increasing FLAIR signal intensity in the postoperative cavity predicts progression in gross-total resected high-grade gliomas

Abstract

To evaluate the prognostic value of fluid-attenuated inversion recovery (FLAIR) signal intensity of postoperative cavity on progression free survival (PFS) and overall survival (OS) in patients with high-grade gliomas (HGG). This study retrospectively enrolled 45 consecutive HGG patients. These patients had chemoradiotherapy after gross-total resection of tumors. Quantitative analysis of the FLAIR signal intensity in postoperative cavity and background was made. We evaluated the threshold value, accuracy, sensitivity, specificity, and survival state with this technique. The patients who progressed and patients who did not progress were 33 and 12 cases separately. The ratio of postoperative cavity and background (C–B) on FLAIR sequence in patients who progressed was higher than that of patients who did not progress (P = 0.014). The PFS of the patients who progressed was shorter than that of patients who did not progress (P = 0.008). The area under ROC curve, threshold, sensitivity, specificity of C–B ratio for predicting tumor progression were 0.875, 62.3, 69.7, 0.84, and 0.50% respectively. The PFS of lower signal group was much longer than that of higher signal group (P = 0.004). The OS of the patients with higher signal was shorter than that of patients with lower signal (P = 0.034). The increase of gray value of FLAIR in postoperative cavity may be used as an imaging marker for predicting tumor progression.

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Spatial orientation of the adult cochlea: rotation, tilt, and angle theta 3

Abstract

Objective

Quantitative description in adult crania of (1) angular orientation of the basal turn of the cochlea relative to the sagittal (termed "rotation") and Frankfort horizontal (termed "tilt") planes, and angle theta 3 [angular relationship of the line defined by the cochlea's spiral center and cochlear (round) window, to the cochlear window]; (2) orientation of the cochlea relative to the plane defined by the horizontal and vertical portions of the facial nerve; (3) orientation of the basal turn of the cochlea relative to the plane of the posterior semicircular canal; and (4) the association of these orientations with the extent of mastoid pneumatization.

Methods

Postmortem material analysis. From 41 bequeathed anatomical ear-normal cadaveric cranial, high-resolution CT scans were performed of the five crania with the largest and the five with the smallest mastoids. Eleven points in three-dimensional Cartesian space were appointed and studied with the software program FIJI.

Results

The median angle values (and ranges) for right ears were: "rotation" 52° (range 47–61); and, "tilt" 84° (79–89). The planes of the cochlear basal turn and facial nerve approximated superimposition: median 15° (2–19). Angle theta 3 for right ears was median 40° (28–44). Bilateral symmetry was found for the relationships between the planes. However, no association of any planar relationship with mastoid pneumatization was suggested.

Conclusion

Considering the range of angles found in clinically normal adult specimens, spatial orientation of the cochlea may explain some of the difficulties in implantation.

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Have Laryngologists Found One More Disease to Treat With a Flexible Laryngoscope and a Needle?—Reply

In Reply We thank Dr Bradley for his commentary regarding our recently published article, "Serial In-Office Intralesional Steroid Injections in Airway Stenosis." We agree with his comment highlighting how advances in one discipline can forward another, and that the treatment of scarring has been well studied. Applying proven treatments for scarring in other locations of the body is prudent, and we foresee the application of a number of newer treatments for scarring (ie, flourourocil) in airway stenosis. We acknowledge the lack of a true control group in this particular study. In addition, we appreciate that it is not clear how many total injections are required to effect positive changes for any given patient. With future evaluation of a larger cohort, we anticipate elucidating this more clearly and will likely be able to target different etiologic subgroups more specifically. Recognizing that intralesional steroid injections for airway stenosis will not be a panacea, patients with different etiologies of subglottic stenosis will need to be treated slightly differently, tailoring treatment to the patient's disease. We use intralesional steroid injections largely in 3 different ways. The first is as an adjuvant after an endoscopic procedure; this is done for patients in all etiologic subgroups. For patients in the traumatic subgroup for whom intralesional steroid injection is effective (ie, without significant cartilage collapse), ongoing intervention may not be required because they do not have a relapsing disorder. On the other hand, patients with inflammatory causes of stenosis, who have a high chance of recurrence, can benefit from adjuvant injections after surgery as well as maintenance injections for early recurrence. Recent reports aimed at identifying the etiology of idiopathic subglottic stenosis (iSGS), have suggested a local, inflammatory, immune response. The early stage of recurrence in both iSGS and rheumatologic-types of stenosis is granulation and erythema in the subglottis, followed by healing with fibrosis. Intervention with intralesional steroid injections (or potentially another immune modulator) at this early stage may alter wound healing, avoid scar formation, and therefore circumvent the need for surgical intervention. Several studies have shown efficacy, safety, and tolerance in patients with iSGS in addition to reducing the need for surgical treatment. Last, as previously observed, we have seen steroid injections dissolve scar tissue that has already formed, therefore obviating the need for surgical intervention in some patients when presenting without critical stenosis. Investigating alternative treatments for scarring is relevant in subglottic stenosis, but we also suggest exploring ways to pharmacologically modulate the inflammatory phase of the disease.

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Extending the Ear-Kidney Association to Presbycusis

Understanding the causes of presbycusis is a major goal of health research because it is such a common human condition. The ear-kidney association has been known at least since the early 20th century, when the Alport and branchio-oto-renal syndromes were described. It was also noted that the cochlea and kidney share the presence of pericytes and podocytes in the glomeruli and inner ear, indicating similarities in microcirculation. The ear and kidney have in common some forms of organ-specific toxic effects (eg, due to treatment with aminoglycosides or cisplatin), and both organs are actively engaged in ion transport functions to maintain homeostasis. On the other hand, there has been little evidence that the ear-kidney association might be important in presbycusis.

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Hearing Aid Use and Health Care Costs Among Older Adults

A number of studies have attempted to quantify the cost of hearing loss, including ones using the same data source but an earlier time. A systematic review that summarized many of these findings documented the financial results of hearing loss, but also highlighted the variability across studies and lack of standardization of how hearing loss is defined when using large data sets. Fewer data are available, however, on whether the use of hearing aids (HAs) mitigates, attenuates, or contributes to these costs. Given the lack of data, the increasing numbers of older adults who might benefit from the use of HAs and the current lack of health care coverage for hearing health care, Mahmoudi et al is exploring an important topic in this issue of JAMA Otolaryngology–Head and Neck Surgery. Elucidating the outcomes of HA use on health care costs could provide valuable data for those designing health care policy. The findings are interesting, yet raise a number of issues that could inform data interpretation as well as highlight additional research priorities.

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Have Laryngologists Found One More Disease to Treat With a Flexible Laryngoscope and a Needle?

To the Editor "Learning and innovation go hand in hand. The arrogance of success is to think that what you did yesterday will be sufficient for tomorrow."—William Pollard

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Cystatin C and 20-Year Incidence of Hearing Impairment

This longitudinal, population-based study uses data from the Epidemiology of Hearing Loss Study to investigate the association between cystatin C, both as an independent biomarker and as a marker of kidney function, and the 20-year incidence of hearing impairment in a cohort of middle-aged and older adults.

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Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss

This population-based cohort study of older adults with hearing loss evaluates the association of hearing aid use and health care use and cost.

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Effect of Perioperative Gabapentin Use in Patients Undergoing Head and Neck Mucosal Surgery

This randomized clinical trial investigates the effect of perioperative gabapentin treatment vs placebo on postsurgical pain in patients undergoing head and neck mucosal surgery.

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Spatial orientation of the adult cochlea: rotation, tilt, and angle theta 3

Abstract

Objective

Quantitative description in adult crania of (1) angular orientation of the basal turn of the cochlea relative to the sagittal (termed "rotation") and Frankfort horizontal (termed "tilt") planes, and angle theta 3 [angular relationship of the line defined by the cochlea's spiral center and cochlear (round) window, to the cochlear window]; (2) orientation of the cochlea relative to the plane defined by the horizontal and vertical portions of the facial nerve; (3) orientation of the basal turn of the cochlea relative to the plane of the posterior semicircular canal; and (4) the association of these orientations with the extent of mastoid pneumatization.

Methods

Postmortem material analysis. From 41 bequeathed anatomical ear-normal cadaveric cranial, high-resolution CT scans were performed of the five crania with the largest and the five with the smallest mastoids. Eleven points in three-dimensional Cartesian space were appointed and studied with the software program FIJI.

Results

The median angle values (and ranges) for right ears were: "rotation" 52° (range 47–61); and, "tilt" 84° (79–89). The planes of the cochlear basal turn and facial nerve approximated superimposition: median 15° (2–19). Angle theta 3 for right ears was median 40° (28–44). Bilateral symmetry was found for the relationships between the planes. However, no association of any planar relationship with mastoid pneumatization was suggested.

Conclusion

Considering the range of angles found in clinically normal adult specimens, spatial orientation of the cochlea may explain some of the difficulties in implantation.

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Volunteering Could Equal Better Well Being

Whether you are feeling excited to get more involved, or glad that your volunteering time has concluded with this year's convention there is mounting evidence to support that the simple act of volunteering may positively impact your well-being.  A 2016 longitudinal study found that participants who regularly partook in volunteer activities experienced greater mental well-being ratings using the General Health Questionnaire.

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Preoperative Photographing and Morphing for Predictable Profiles in Rhinoplasty

This Surgical Pearl discusses preoperative photographing and morphing for predictable profiles in rhinoplasty.

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A Closer Look at the Analgesic Regimen After Rhinoplasty—Reply

In Reply We thank Kendall and Castro-Alves for taking the time to read and critically analyze our article. Their commentary was very insightful and thought provoking. First, to directly answer their inquiries, we did not use a consistent standardized intraoperative or perioperative pain regimen, although that would have been desirable. In large medical center and academic medical center hospitals, and especially now with large anesthesia groups, the ability to have the same anesthesia team even throughout a single case is difficult because different anesthesiologists and certified registered nurse anesthetists continually come in and out of the operating room to spell one another for breaks and leave at shift changes so that the person who started the anesthesia portion is often not the same as who ends the case and extubates the patient. We agree that pain management should be discussed and coordinated with the anesthesiology team, and this should be a proactive venture that is highly dependent on the ability of local anesthesia to quell the need for intravenous medications during the case.

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A Closer Look at the Analgesic Regimen After Rhinoplasty

To the Editor We read with great interest the article of Patel and colleagues in a recent issue of the JAMA Facial Plastic Surgery. The authors performed a retrospective study of 62 patients who underwent rhinoplasty, and they proposed a multifaceted pain control program to manage postoperative pain and ascertain the balance between controlling pain and avoiding overprescribing narcotics. The authors should be commended for performing a study in an important topic (eg, opioid consumption) in patients undergoing outpatient surgery. The current emphasis on the need to improve postoperative pain using multimodal analgesic strategies makes the topic very relevant in perioperative medicine.

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A 3-Dimensional–Printed Short-Segment Template Prototype for Mandibular Fracture Repair

This feasibility study explores the potential application of a 3-dimensional–printed short-segment mandibular template in the management of complex mandibular fractures.

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Intracranial meningioma with carcinoma tumor-to-tumor metastasis: two case reports

CNS Oncology, Ahead of Print.


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Reply: Postoperative Patient- and Parent-Reported Outcomes for Children with Congenital Hand Differences A Systematic Review

No abstract available

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Discussion: Evaluating the July Phenomenon in Plastic Surgery A National Surgical Quality Improvement Program Analysis

No abstract available

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Aseptic Freeze-Dried versus Sterile Wet-Packaged Human Cadaveric Acellular Dermal Matrix in Immediate Tissue Expander Breast Reconstruction: A Propensity Score Analysis

Background: Although multiple acellular dermal matrix sources exist, it is unclear how its processing impacts complication rates. The authors compared complications between two preparations of human cadaveric acellular dermal matrix (freeze dried and ready-to-use) in immediate tissue expander breast reconstruction to analyze the effect of processing on complications. Methods: The authors retrospectively reviewed all alloplastic breast reconstructions with freeze-dried or ready-to-use human acellular dermal matrices between 2006 and 2016. The primary outcome measure was surgical-site occurrence defined as seroma, skin dehiscence, surgical-site infection, or reconstruction failure. The two groups were compared before and after propensity score matching. Results: The authors included 988 reconstructions (freeze-dried, 53.8 percent; ready-to-use, 46.2 percent). Analysis of 384 propensity score–matched pairs demonstrated a slightly higher rate of surgical-site occurrence (21.4 percent versus 16.7 percent; p = 0.10) and surgical-site infection (9.6 percent versus 7.8 percent; p = 0.13) in the freeze-dried group than in the ready-to-use group, but the difference was not significant. However, failure was significantly higher for the freeze-dried versus ready-to-use group (7.8 percent versus 4.4 percent; p = 0.050). Conclusions: This is the largest study comparing the outcomes of alloplastic breast reconstruction using human acellular dermal matrix materials prepared by different methods. The authors demonstrated higher early complications with aseptic, freeze-dried matrix than with sterile ready-to-use matrix; reconstructive failure was the only outcome to achieve statistical significance. The authors conclude that acellular dermal matrix preparation has an independent impact on patient outcomes in their comparison of one company's product. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery

Background: Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery. Methods: Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated. Results: Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted. Conclusions: The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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