Endoscopic Transcanal Myringoplasty for Anterior Perforations of the Tympanic Membrane.

Endoscopic Transcanal Myringoplasty for Anterior Perforations of the Tympanic Membrane.:

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Endoscopic Transcanal Myringoplasty for Anterior Perforations of the Tympanic Membrane.

JAMA Otolaryngol Head Neck Surg. 2016 Nov 01;142(11):1088-1093

Authors: Tseng CC, Lai MT, Wu CC, Yuan SP, Ding YF

Abstract

Importance: Repairing anterior perforations of the tympanic membrane has been challenging for otolaryngologists. Therefore, devising a simple and effective technique for performing the repair is crucial.

Objective: To assess the results of endoscopic transcanal myringoplasty for repairing anterior perforations of the tympanic membrane.

Design, Setting, and Participants: This medical record review included 59 patients who underwent endoscopic transcanal myringoplasty from January 1, 2013, to June 1, 2015, at PoJen General Hospital, Taipei, Taiwan. Patients with ossicular chain disease and cholesteatoma or inadequate follow-up were excluded. Patients were followed up for 6 months, and final follow-up was completed on January 1, 2016.

Main Outcomes and Measures: The main outcome was the rate of overall graft success after endoscopic transcanal myringoplasty. Secondary outcomes included hearing results and prognostic factors.

Results: The study sample included the medical records of 59 patients (30 men [51%]; 29 women [49%]; mean [SD] age, 49.5 [13.1] years) who underwent endoscopic transcanal myringoplasty. Overall, 55 patients (93%) had a successful graft at 6 postoperative months. The mean (SD) preoperative and postoperative air-bone gaps were 15.9 (9.4) and 5.4 (7.0) dB, respectively, revealing a significant mean (SD) improvement of 10.3 (7.6) dB (Cohen d, 1.27; 95% CI, 0.90-1.63; P < .001, paired t test) in the gap. The postoperative air-bone gap in 46 patients (78%) was less than 10 dB; in 12 patients (20%), 10 to 20 dB; and in 1 patient (2%), more than 20 dB. Postoperative otorrhea significantly affected the graft success rate (odds ratio, 52.00; 95% CI, 4.08-662.55; P < .01, χ2 test). The visualization of the perforation margin (complete or partial) was not significantly associated with the graft success rate. However, partial visualization of the perforation margin significantly prolonged the mean (SD) operative time (complete vs partial, 59.2 [13.7] vs 68.1 [14.1] minutes; Cohen d, 0.64; 95% CI, 0.12-1.18; P = .02, t test).

Conclusions and Relevance: The rate of graft success and hearing outcomes for endoscopic transcanal myringoplasty are comparable with those of microscopic myringoplasty for repairing anterior perforations of the tympanic membrane. However, the present technique is simpler because postauricular incision, canalplasty, and general anesthesia are not required. Thus, endoscopic transcanal myringoplasty should be considered for repairing anterior perforations of the tympanic membrane.

PMID: 27540858 [PubMed - indexed for MEDLINE]

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A comparison of speech intonation production and perception abilities of Farsi speaking cochlear implanted and normal hearing children

A comparison of speech intonation production and perception abilities of Farsi speaking cochlear implanted and normal hearing children: Cochlear implant prosthesis facilitates spoken language development and speech comprehension in children with severe-profound hearing loss. However, this prosthesis is limited in encoding information about fundamental frequency and pitch that are essentially for recognition of speech prosody. The purpose of the present study is to investigate the perception and production of intonation in cochlear implant children and comparison with normal hearing children.

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“On-command” dissolvable tympanostomy tube in the chinchilla model: A proof of concept

"On-command" dissolvable tympanostomy tube in the chinchilla model: A proof of concept: To prove the concept that a dissolvable "on-command" tympanostomy tube placed into the tympanic membrane of a chinchilla can dissolve when a benign solution is applied and result in a well healed tympanic membrane without histologic evidence of injury.

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Fluid-Structure Finite-Element Modelling and Clinical Measurement of the Wideband Acoustic Input Admittance of the Newborn Ear Canal and Middle Ear

Fluid-Structure Finite-Element Modelling and Clinical Measurement of the Wideband Acoustic Input Admittance of the Newborn Ear Canal and Middle Ear: AbstractThe anatomical differences between the newborn ear and the adult one result in different input admittance responses in newborns than those in adults. Taking into account fluid-structure interactions, we have developed a finite-element model to investigate the wideband admittance responses of the ear canal and middle ear in newborns for frequencies up to 10  kHz. We have also performed admittance measurements on a group of 23 infants with ages between 14 and 28 days, for frequencies from 250 to 8000 Hz with 1/12-octave resolution. Sensitivity analyses of the model were performed to investigate the contributions of the ear canal and middle ear to the overall admittance responses, as well as the effects of the material parameters, measurement location and geometrical variability. T...

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Passive Transcutaneous Bone Conduction Hearing Implants: A Systematic Review.

Passive Transcutaneous Bone Conduction Hearing Implants: A Systematic Review.: Objective: To systematically review the literature on currently available passive transcutaneous bone conduction hearing implants (pTCBI) with regard to complications, audiological outcomes, and quality-of-life scores.

Data Sources: MEDLINE, EMBASE, Scopus, and Cochrane Library.

Study Selection: All identified English-language articles reporting on the implantation of currently available pTCBI's and their complications. Both pediatric and adult patients were included. No limitation was placed on study design or level of evidence.

Data Extraction: Complications, audiological outcomes including mean pure-tone average gain and mean speech reception threshold gain, and quality-of-life outcomes.

Data Synthesis: Twenty-six articles were included in the review. Four hundred eighty-two pTCBIs have been reported in the literature. Major complications including skin breakdown, wound dehiscence, hematoma, seroma, and inability to use the device occurred in 5.2% of patients. Minor complications including pain and self-resolving erythema at the implant site occurred in 13.1% of the patients. The weighted mean pure-tone average gain of the two included devices was 28.4 +/- 2.1 dB and the mean speech reception threshold gain was 32.9 +/- 3.9 dB. Favorable quality-of-life scores have been demonstrated with pTCBIs.

Conclusion: pTCBIs are a viable alternative to percutaneous devices in a carefully selected group of patients. These devices have demonstrated good audiological outcomes, low morbidity, and high patient satisfaction.

Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Response to therapy of papillary thyroid cancer of known BRAF status

Response to therapy of papillary thyroid cancer of known BRAF status:

Abstract

Context

A dynamic risk stratification with modified initial estimated risk based on response to therapy and disease course is one of the crucial changes adopted recently by the American Thyroid Association (ATA). This approach focuses on an individualized risk-adapted approach to the management of differentiated thyroid cancer. The BRAF V600E mutation is the most common genetic alteration in papillary thyroid cancer (PTC). However, the prognostic value of this mutation remains unclear.

Objective

The aim of this study was to examine the relation between the BRAF V600E status in PTC and all ATA response to therapy categories, as well as the recurrence and persistence of both biochemical and structural disease.

Participants

Unselected PTC cases with known BRAF status diagnosed from 2000–2013 and actively monitored at one institution (n=723) were reviewed retrospectively.

Main Outcome Measures

The association between the BRAF V600E mutation and clinicopathological characteristics, ATA 2015 response-to-therapy category, recurrence after a period of no evidence of disease (NED), and persistent biochemical or structural disease were analyzed.

Results

BRAF V600E was found in 65.7% (475/723) of PTC cases. Although BRAF mutation status correlated significantly with certain clinicopathological prognostic factors, there was no correlation with any of the response to therapy categories. Recurrences and persistent biochemical or structural disease were not associated with BRAF status.

Conclusions

Our data are consistent with those of other studies reporting a positive relation between BRAF V600E mutation and poor prognostic factors in PTC, however, the BRAF status did not significantly correlate with a response to therapy.

This article is protected by copyright. All rights reserved.

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The Effect of Routine Radiological Reporting of Thyroid Incidentalomas on Rates of Thyroid Needle Biopsy, Thyroid Surgery and Detection of Thyroid Malignancy

The Effect of Routine Radiological Reporting of Thyroid Incidentalomas on Rates of Thyroid Needle Biopsy, Thyroid Surgery and Detection of Thyroid Malignancy:

Abstract

Objective

This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate.

Context

Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed.

Design

Data were collected retrospectively during a two year period, including 12 months before and 12 months after the change in reporting policy and categorised according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion.

Patients

All patients undergoing ultrasound guided fine-needle aspiration cytology (FNAC) or core biopsy were included.

Measurements

The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention.

Results

There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET) detected cancer, 2/4 of the non-PET detected malignancies were <1.5cm.

Conclusion

This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.

This article is protected by copyright. All rights reserved.

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Cutaneous Indeterminate Cell Histiocytosis of Donor Origin After Allogeneic Hematopoietic Stem-Cell Transplantation.

Cutaneous Indeterminate Cell Histiocytosis of Donor Origin After Allogeneic Hematopoietic Stem-Cell Transplantation.: Allogeneic hematopoietic stem-cell transplantation and solid-organ transplantation are associated with an increased risk of secondary neoplasms. Indeterminate cell histiocytosis (ICH) is a rare disease composed of so-called indeterminate cells, an alleged cutaneous dendritic cell subset displaying histological and some ultrastructural and immunophenotypic features of Langerhans cells but lacking Birbeck granules. We report a case of cutaneous ICH occurring after allogeneic hematopoietic stem-cell transplantation for a myelodysplastic syndrome in a 56-year-old man. Microsatellite analysis demonstrated that the neoplastic cells were derived from the donor's hematopoietic system. This case broadens the spectrum of complications after stem-cell transplantation and demonstrates that cutaneous ICH in the setting of myelodysplastic syndromes may have a nonrelated origin to dysplastic myeloid cells.

Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study

Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study: BACKGROUND: Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management.

METHODS: We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery.

RESULTS: A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%–2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF was independently associated with an increased length of hospital stay by 6.0 days (95% confidence interval, 3.5–8.5 days) and vascular complications (eg, stroke or congestive heart failure). The usage of an oral anticoagulant at the time of hospital discharge among patients with new AF and a CHADS2 score of 0, 1, 2, 3, and ≥4 was 6.9%, 10.2%, 23.0%, 9.4%, and 33.3%, respectively. Two independent predictors of patients developing new clinically important AF were identified (ie, age and surgery). The prediction rule included the following factors and assigned weights: age ≥85 years (4 points), age 75 to 84 years (3 points), age 65 to 74 years (2 points), intrathoracic surgery (3 points), major vascular surgery (2 points), and intra-abdominal surgery (1 point). The incidence of new AF based on scores of 0 to 1, 2, 3 to 4, and 5 to 6 was 0.5%, 1.0%, 3.1%, and 5.3%, respectively.

CONCLUSIONS: Age and surgery are independent predictors of new clinically important AF in the perioperative setting. A minority of patients developing new clinically important AF with high CHADS2 scores are discharged on an oral anticoagulant. There is a need to develop effective and safe interventions to prevent this outcome and to optimize the management of this event when it occurs.

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Role of glutathione in the regulation of epigenetic mechanisms in disease

Publication date: November 2017
Source:Free Radical Biology and Medicine, Volume 112
Author(s): José Luis García-Giménez, Carlos Romá-Mateo, Gisselle Pérez-Machado, Lorena Peiró-Chova, Federico V. Pallardó
Epigenetics is a rapidly growing field that studies gene expression modifications not involving changes in the DNA sequence. Histone H3, one of the basic proteins in the nucleosomes that make up chromatin, is S-glutathionylated in mammalian cells and tissues, making Gamma-L-glutamyl-L-cysteinylglycine, glutathione (GSH), a physiological antioxidant and second messenger in cells, a new post-translational modifier of the histone code that alters the structure of the nucleosome. However, the role of GSH in the epigenetic mechanisms likely goes beyond a mere structural function. Evidence supports the hypothesis that there is a link between GSH metabolism and the control of epigenetic mechanisms at different levels (i.e., substrate availability, enzymatic activity for DNA methylation, changes in the expression of microRNAs, and participation in the histone code). However, little is known about the molecular pathways by which GSH can control epigenetic events. Studying mutations in enzymes involved in GSH metabolism and the alterations of the levels of cofactors affecting epigenetic mechanisms appears challenging. However, the number of diseases induced by aberrant epigenetic regulation is growing, so elucidating the intricate network between GSH metabolism, oxidative stress and epigenetics could shed light on how their deregulation contributes to the development of neurodegeneration, cancer, metabolic pathologies and many other types of diseases.

Graphical abstract

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Little Black Boxes: Noncardiac Implantable Electronic Medical Devices and Their Anesthetic and Surgical Implications

Little Black Boxes: Noncardiac Implantable Electronic Medical Devices and Their Anesthetic and Surgical Implications: Implanted electronic medical devices. or stimulators such as pacemakers and nerve stimulators have grown enormously in diversity and complexity over recent decades. The function and potential interaction of these devices with the perioperative environment is of increasing concern for anesthesiologists and surgeons. Because of the innate electromagnetic environment of the hospital (operating room, gastrointestinal procedure suite, and imaging suite), implanted device malfunction, reprogramming, or destruction may occur and cause physical harm (including nerve injury, blindness, deafness, burn, stroke, paralysis, or coma) to the patient. It is critical for the anesthesiologist and surgeon to be aware of the function and interaction of implanted devices, both with other implanted devices and procedures (such as magnetic resonance imaging and cardioversion) in the hospital environment. Because of these interactions, it is imperative that proper device function is assessed when the surgical procedure is complete. This review article will discuss these important issues for 12 different types of "little black boxes," or noncardiac implantable electronic medical devices.

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Giant Thebesian Valve Appearing As a Right Atrial Mass

Giant Thebesian Valve Appearing As a Right Atrial Mass: INTRACARDIAC MASSES are usually non-neoplastic and include infections, thrombi, and structural abnormalities. Neoplastic masses of the heart are rare and often are benign like myxomas, fibromas, lipomas, angiomas, and papillary fibroelastomas. They are seen more commonly in the right atrium.1 Malignant tumors of the heart can be primary or metastatic from the lungs, breast, or other tissues. The presenting symptoms from the cardiac masses are quite variable and depend on the size and location of the mass.

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Acute Type-B Aortic Dissection in Pregnancy: Therapeutic Challenges in a Multidisciplinary Setting

Acute Type-B Aortic Dissection in Pregnancy: Therapeutic Challenges in a Multidisciplinary Setting: ALTHOUGH ACUTE AORTIC dissection during pregnancy is a rare occurrence, it remains important because it is frequently a cardiovascular emergency that can be lethal for both the mother and the fetus. Clinical data from the International Registry of Acute Aortic Dissection have suggested that the risk of acute aortic dissection during pregnancy is about 0.2%.1 Despite this low prevalence, it should be noted that 50% of aortic dissections in women younger than 40 years occur in the setting of pregnancy.

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Hemoptysis in a Patient With Persistent Left Upper Lobe Consolidation

Hemoptysis in a Patient With Persistent Left Upper Lobe Consolidation: A 35-YEAR-OLD man (weight 67 kg, height 169.9 cm), with a history of cough, dyspnea on exertion, and hemoptysis of 90 days' duration, presented to the authors' institution for further evaluation. Eight months before his presentation, he underwent radiofrequency catheter ablation for paroxysmal atrial fibrillation. About 5 months after the procedure, he was admitted to the hospital in respiratory distress with dyspnea and hemoptysis. Thoracic computed tomography showed left upper lobe consolidation (Fig 1).

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Preoperative fasting in children

Preoperative fasting in children: 1A012A033J03


Key points

Prolonged preoperative fasting times for healthy elective cases have been extrapolated from the aspiration risk of 'full-stomach' emergency cases.

Gastric emptying is regulated by hormonal, neuronal, and metabolic feedback.

Residual gastric volume is a poor surrogate for the risk of aspiration, and there appears to be no causal link or critical volume threshold.

Perioperative pulmonary aspiration in children is rare. The incidence is 0.07–0.1% and the consequences of clear fluid aspiration are not catastrophic.



Newer liberal paediatric fasting regimens for elective cases seem to confer no increase in aspiration risk compared with more conservative regimens.

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Muscle Tissue Saturation Compared With Muscle Tissue Perfusion During Low Blood Flows: An Experimental Study

Muscle Tissue Saturation Compared With Muscle Tissue Perfusion During Low Blood Flows: An Experimental Study: To investigate whether changes in muscle tissue perfusion measured with positron emission tomography would be reflected by parallel changes in muscle tissue oxygen saturation (StO2) measured using near-infrared spectroscopy during high and low blood flow levels achieved using cardiopulmonary bypass (CPB) in an animal model.

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Maintenance of Drug-Eluting Stent Patency Through Use of a Cangrelor Infusion in the Clinical Setting of Massive Pulmonary Hemorrhage and Venoarterial Extracorporeal Membrane Oxygenation

Maintenance of Drug-Eluting Stent Patency Through Use of a Cangrelor Infusion in the Clinical Setting of Massive Pulmonary Hemorrhage and Venoarterial Extracorporeal Membrane Oxygenation: THE USE OF an ultrashort-acting parenteral P2Y12 inhibitor, cangrelor, for the maintenance of fresh drug-eluting stent (DES) patency in a patient with concurrent pulmonary hemorrhage and cardiogenic shock requiring central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is described. The current standard of care for use of antiplatelet agents after percutaneous coronary intervention (PCI) with DES placement in acute coronary syndrome includes indefinite use of aspirin and 12 months of P2Y12 inhibitor to avoid in-stent thrombosis.

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Remote Ischemic Preconditioning in Cardiac Surgery: Is There a Proven Clinical Benefit?

Remote Ischemic Preconditioning in Cardiac Surgery: Is There a Proven Clinical Benefit?: PROTECTING THE MYOCARDIUM from ischemic injury during aortic cross-clamping and from reperfusion injury following release of the aortic cross-clamp is one of the most important goals of cardioplegia in cardiac surgery. Inadequate protection may manifest as either arrhythmias or myocardial stunning upon termination of cardiopulmonary bypass. It also may lead to more permanent complications including renal failure and increased short- and long-term mortality. Unfortunately there still are limited ways to provide perioperative myocardial protection.

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Health Economic Analysis of Allergen Immunotherapy (AIT) for the Management of Allergic Rhinitis, Asthma, Food Allergy and Venom Allergy: A Systematic Overview

Health Economic Analysis of Allergen Immunotherapy (AIT) for the Management of Allergic Rhinitis, Asthma, Food Allergy and Venom Allergy: A Systematic Overview:

Abstract

Background

The European Academy of Allergy and Clinical Immunology (EAACI) is developing guidelines for allergen immunotherapy (AIT) for the management of allergic rhinitis, allergic asthma, IgE-mediated food allergy and venom allergy. To inform the development of clinical recommendations, we undertook systematic reviews to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT for these conditions. This paper focusses on synthesizing data and gaps in the evidence on the cost-effectiveness of AIT for these conditions.

Methods

We produced summaries of evidence in each domain and then synthesized findings on health economic data identified from four recent systematic reviews on allergic rhinitis, asthma, food allergy and venom allergy, respectively. The quality of these studies were independently assessed using the Critical Appraisal Skills Programme (CASP) tool for health economic evaluations.

Results

23 studies satisfied our inclusion criteria. Of these, 19 studies investigated the cost-effectiveness of AIT in allergic rhinitis, of which seven were based on data from randomized controlled trials with economic evaluations conducted from a health system perspective. This body of evidence suggested that sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) would be considered cost-effective using the (English) National Institute for Health and Clinical Excellence (NICE) cost-effectiveness threshold of £20,000/quality adjusted life year (QALY). However, the quality of the studies and the general lack of attention to characterizing uncertainty and handling missing data should be taken into account when interpreting these results. For asthma, there were three eligible studies, all of which had significant methodological limitations; these suggested that SLIT, when used in patients with both asthma and allergic rhinitis, may be cost-effective with an incremental cost-effectiveness ratio (ICER) of £10,726 per QALY. We found one economic modelling study for venom allergy which, despite being based largely on expert opinion and plausible assumptions, suggested that AIT for bee and wasp venom allergy is only likely to be cost-effective for very high risk groups who may be exposed to multiple exposures to venom/year (e.g., bee keepers). We found no eligible studies investigating the cost-effectiveness of AIT for food allergy.

Conclusions

Overall the evidence to support the cost-effectiveness of AIT is limited and of low methodological quality, but suggests that AIT may be cost-effective for people with allergic rhinitis with or without asthma and in high risk subgroups for venom allergy. We were unable to draw any conclusions on the cost-effectiveness of AIT for food allergy.

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Long term effects: Galectin-1 and specific immunotherapy for allergic responses in the intestine

Long term effects: Galectin-1 and specific immunotherapy for allergic responses in the intestine:

Abstract

Background and aims

Mast cell activation interferes with the effects of allergen-specific immunotherapy (SIT). Galectin-1 (Gal-1) is capable of regulating immune cells' functions. This study tests the hypothesis that administration of Gal-1 promotes and prolongs the efficacy of SIT via suppressing mast cell activation.

Methods

An intestinal allergy mouse model was developed. The co-administration of SIT and Gal-1 on suppression of the allergic responses, prevention of mast cell activation, and generation of antigen-specific regulatory T cells (Treg) in the intestine were observed in sensitized mice.

Results

The coadministration of Gal-1 and SIT markedly suppressed the allergic responses in the mouse intestine vs. the use of either SIT alone or Gal-1 alone. The Gal-1 binds to the IgE/FcɛRI complexes on the surface of mast cells to prevent mast cell activation during SIT. Gal-1 promoted the SIT-generated allergen-specific Tregs in the intestine of sensitized mice. Coadministration of Gal-1 and SIT significantly enhanced the efficacy of immunotherapy in suppressing allergic responses in the intestine, which lasted for at least for 12 months.

Conclusions

Long term effects of specific immunotherapy on intestinal allergy can be achieved with Gal-1/SIT therapy by inhibiting mast cell activation and facilitating Treg development.

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