BACKGROUND: Changes in the dimensions of the cervical neural foramina (CNF) are considered to be a key factor in nerve root compression and development of cervical radiculopathy. However, to what extent foraminal geometry differs between patients who underwent anterior cervical discectomy and fusion (ACDF) and those who underwent total disc arthroplasty with an artificial disc (AD) during physiological motion is largely unknown.
PURPOSE: The objective of this study is to compare compare CNF dimensions during physiological neck motion between ACDF and AD.
STUDY DESIGN/SETTING: This is a retrospective comparative analysis of prospectively collected, consecutive, non-randomized series of patients at a single institution.
PATIENT SAMPLE: A total of 16 single-level C5-6 ACDF (4M, 12F; 28-71 years) and 7 single-level C5-6 cervical arthroplasty patients (3M, 4F; 38-57 years), at least 12 months after surgery (23.6 ± 6.8 months) were included.
OUTCOME MEASURES: Patient demographics, pre-operative MRI based measurements of cervical spine degeneration and 2-year post-operative measurements of dynamic foraminal geometry.
METHODS: Biplane x-ray images were acquired during axial neck rotation and neck extension. A CT scan was also acquired from C3 to the first thoracic vertebrae. The subaxial cervical vertebrae (C3 to C7) were reconstructed into 3D bone models for use with model-based tracking. Foraminal height (FH) was calculated as the 3D distance between the superior point of the inferior pedicle and the inferior point of the superior pedicle using custom software. Foraminal width (FW) was similarly calculated as the 3D distance between the anterolateral aspect of the superior vertebral body inferior notch, and the posterolateral aspect of the inferior vertebral body superior notch. Dynamic foraminal dimensions were quantified as the minimum (FH.Min, FW.Min), the range (FH.Range, FW.Range) and the median (FH.Med, FW.Med) of each trial and then averaged over trials. Mixed model ANOVA framework was used to examine the differences between ACDF and AD groups. The initial severity of disc degeneration as determined from pre-operative MRI images was introduced as covariates in the models. There were no study-specific biases related to conflicts of interest.
RESULTS: At the operated level (C5-6), FH.Med and FH.Range were smaller in ACDF than in AD during axial rotation and neck extension (p<0.003 to p<0.05). At the superior adjacent level (C4-5), no significant difference was found. At the inferior adjacent level (C6-7), FW.Range was greater in ACDF than in AD during axial rotation and extension (p<0.05). At the nonadjacent level (C3-4), FW.Range was greater in ACDF than in AD during extension (p<0.008).
CONCLUSIONS: This study demonstrated decreases in foraminal dimensions and their range for ACDF compared to AD at the operated level. In contrast, it demonstrated increases in the range of foraminal dimensions during motion for ACDF compared to AD at the nonoperated segments. Together, these data support the notion that increased mobility at the nonoperated segments after ACDF may contribute to a greater risk for adjacent segment degeneration. Due to the significant presence of Range variables in the findings, the current data also indicate that a dynamic evaluation is likely more appropriate for evaluation of the differences in foramina between ACDF and AD than a static evaluation.
BACKGROUND: An obstructive neck lesion presents an airway challenge for any emergency physician. Retrograde intubation is an infrequently used airway alternative that can be employed in the difficult airway algorithm that requires little training and is less invasive than surgical cricothyrotomy.
CASE REPORT: We report a case of a 31-year-old male patient who presented with respiratory distress progressing to respiratory failure from upper airway obstruction. The patient had significant tracheal thickening at the level of the thyroid gland based on a computed tomography report from 3 weeks prior to his presentation. Awake upright fiberoptic intubation and subsequent percutaneous cricothyrotomy were unsuccessful secondary to obstructive neck mass. We performed a retrograde intubation via tracheal approach and secured the airway via manipulation of a small-diameter endotracheal tube over the guidewire using visualization with video laryngoscopy. This case describes a combination of difficult airway techniques utilizing retrograde intubation with a Glidescope (Verathon Inc., Bothell, WA) as a rescue maneuver for a difficult airway secondary to a tracheal obstruction and supraglottic and subglottic stenosis. Follow-up confirmed the patient's diagnosis as granulomatosis with polyangiitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of supraglottic and subglottic narrowing or mass lesions, retrograde intubation can be a life-saving technique that is an important consideration in the difficult airway algorithm. This technique may be combined with other difficult airway techniques and is especially relevant and potentially life-saving for patients in whom an open cricothyrotomy is undesirable, such as patients with a potentially vascular neck mass, subglottic stenosis, localized neck trauma, or morbid obesity.
Anti-Obesity and Weight Loss (1) Pathologic Constriction (3), Respiratory Failure (1), Airway Obstruction (1), more mentions
OBJECTIVES: Pleomorphic adenomas and Warthin tumors are the most common salivary gland tumors. It is important to differentiate between them because at least a partial parotidectomy is necessary for pleomorphic adenomas, whereas enucleation is sufficient for Warthin tumors. This study aimed to evaluate the usefulness of vascular pattern analysis using microvascular sonography to differentiate between the tumors.
METHODS: Sixty-two patients with pathologically proven pleomorphic adenomas (n = 38) and Warthin tumors (n = 24) were included. For all tumors, grayscale, power Doppler, and microvascular sonographic examinations were performed. Differences in vascular patterns (vascular distribution and internal vascularity) on power Doppler and microvascular sonography as well as grayscale sonographic features (size, shape, border, echogenicity, heterogeneity, and cystic change) between pleomorphic adenomas and Warthin tumors were evaluated. A comparison of diagnostic performances of grayscale sonography with power Doppler sonography and grayscale sonography with microvascular sonography was performed. The level of interobserver agreement between 2 reviewers in diagnosing tumors was evaluated.
RESULTS: No grayscale sonographic features showed a significant difference between the tumors. Vascular distributions and internal vascularity on power Doppler sonography (P = .01 and .002) and microvascular sonography (both P < .001) were all significantly different. The diagnostic accuracy of grayscale sonography with microvascular sonography (79.0%) was higher than that of grayscale sonography with power Doppler sonography (72.6%). This difference was significant according to the McNemar test (P = .004). Interobserver agreement was excellent in diagnosing tumors on both grayscale sonography with power Doppler sonography (κ = 0.83) and grayscale sonography with microvascular sonography (κ = 0.94).
CONCLUSIONS: Vascular pattern analysis using microvascular sonography with other sonographic features is helpful for differentiating between pleomorphic adenomas and Warthin tumors.
Adenolymphoma (7), Pleomorphic Adenoma (7), Neoplasms (7), more mentions
AIMS: Tumour-associated macrophages (TAMs) and regulatory T cells (Tregs) form a special niche supporting tumour progression, and both correlate with worse survival in head and neck cancers. However, the prognostic role of TAM and Tregs in nasopharyngeal carcinoma (NPC) is still unknown. Therefore, we determined differences in TAMs and Tregs in different NPC subtypes, and their prognostic significance.
METHODS: Tissue of 91 NPCs was assessed for TAMs and Tregs by determination of CD68, CD163, CD206 and FOXP3 expression in the tumour microenvironment. Clinicopathological correlations were assessed using Pearson X(2) test, Fisher's exact test, analysis of variance and Mann-Whitney U test. Survival was analysed using Kaplan-Meier curves and Cox regression.
RESULTS: CD68 and FOXP3 counts were higher in Epstein-Barr virus (EBV)-positive NPC, while CD68-/FOXP3-, CD163+/FOXP3- and CD206+/FOXP3- infiltrates were more common in EBV-negative NPC. In the whole NPC group, CD68-/FOXP3- correlated with worse overall survival (OS), and after multivariate analysis high FOXP3 count showed better OS (HR 0.352, 95% CI 0.128 to 0.968). No difference in M2 counts existed between EBV-positive and negative NPC.
CONCLUSIONS: FOXP3, a Treg marker, seems to be an independent prognostic factor for better OS in the whole NPC group. Therefore, immune-based therapies targeting Tregs should be carefully evaluated. M2 spectrum macrophages are probably more prominent in EBV-negative NPC with also functional differences compared with EBV-positive NPC.
Oncology (2) Carcinoma (2), Head and Neck Neoplasms (1), more mentions
The medial longitudinal fasciculus (MLF) is the final common pathway for all conjugate adducting horizontal eye movements, as well as for the vertical-torsional vestibulo-ocular reflex (VOR). MLF lesion causes adduction paresis of ipsilesional (adducting) eye with dissociated nystagmus of contralesional (abducting) eye-the well-known clinical syndrome of internuclear ophthalmoplegia (INO). We measured the VOR stimulation and also any catch-up saccades, from individual semicircular canal (SCC) evoked by the head impulse test (HIT), using head and binocular 3-dimensional scleral search coils in 27 multiple sclerosis (MS) patients, 8 with unilateral, 19 with bilateral INO. In unilateral INO, VOR gain (normal >0.90) from ipsilesional lateral SCC stimulation was 0.48 for the adducting eye and 0.81 for the abducting eye; 0.61 from contralesional anterior SCC stimulation and only 0.29 from contralesional posterior SCC stimulation. In bilateral INO, there were VOR gain deficits from all six SCCs: lateral SCC gains were asymmetrically reduced to 0.45 in the adducting eye and 0.66 in the abducting eye; anterior SCC gain was 0.48 and posterior SCC gain was only 0.19. Horizontal VOR versional dysconjugacy between adducting and abducting eyes at 0.66 was less severe than horizontal catch-up saccade versional dysconjugacy (0.44); normal >0.80. Unexpected partial preservation of horizontal VOR with greater catch-up saccade impairment from the adducting than abducting eye suggests that the ascending tract of Deiters (ATD), an extra-MLF pathway, also mediates the horizontal VOR, but not adducting horizontal saccades. Vertical VOR deficits will produce vertical oscillopsia with any vertical head movement and measurement of the vertical VOR could help with the diagnosis and quantitative evaluation of MLF lesions in suspected MS. Horizontal VOR deficits and catch-up saccade versional dysconjugacy in INO will cause gaze instability and horizontal oscillopsia during active horizontal head movements.
Immune System Diseases (2) Multiple Sclerosis (4), Internuclear Ophthalmoplegia (2), Paresis (1), more mentions
OBJECTIVES: We aimed to determine the most efficient quantitative parameters to establish a contrast-enhanced ultrasound (US) assessment system for distinguishing between benign and malignant thyroid nodules.
METHODS: A total of 167 patients with thyroid solitary nodules had the diagnosis confirmed by surgery or fine-needle aspiration. Quantitative contrast-enhanced US indicators (time to peak, time from peak to one-half, ascend slope, descend slope, peak intensity, and area under the curve [AUC]) were gathered in nodule and perinodule areas. Univariate and multivariate logistic regression analyses were performed. Receiver operating characteristic curves were generated. Sensitivities, specificities, and positive and negative predictive values were calculated to identify the best cutoff value.
RESULTS: The univariate logistic regression model showed that the peak intensity, ascend slope, descend slope, and AUC were significant indicators for discriminating benign from malignant nodules under contrast-enhanced US (P < .0001). For thyroid nodules, low peak intensity, ascend slope, and AUC and high descend slope values were significant indicators of malignancy. However, in perinodule areas, high peak intensity, ascend slope, and AUC and low descend slope values were significantly associated with malignancies. The cutoff values for the nodule peak intensity, ascend slope, descend slope, and AUC were 20.75, 0.91, -0.2, and 1818.23, respectively. The cutoff values for the ratios of the nodule versus perinodule peak intensity, ascend slope, descend slope, and AUC were 0.90, 0.95, 0.96, and 0.96. The nodule-to-perinodule peak intensity ratio showed the best diagnostic efficiency, with 80.41% sensitivity and 80.00% specificity.
CONCLUSIONS: Quantitative contrast-enhanced US indicators help discriminate benign from malignant thyroid nodules. The nodule-to-perinodule peak intensity ratio showed the best diagnostic efficiency.
BACKGROUND: A recent large United Kingdom (UK) clinical trial demonstrated that positron-emission tomography-computed tomography (PET-CT)-guided administration of neck dissection (ND) in patients with advanced head and neck cancer after primary chemo-radiotherapy treatment produces similar survival outcomes to planned ND (standard care) and is cost-effective over a short-term horizon. Further assessment of long-term outcomes is required to inform a robust adoption decision. Here we present results of a lifetime cost-effectiveness analysis of PET-CT-guided management from a UK secondary care perspective.
METHODS: Initial 6-month cost and health outcomes were derived from trial data; subsequent incidence of recurrence and mortality was simulated using a de novo Markov model. Health benefit was measured in quality-adjusted life years (QALYs) and costs reported in 2015 British pounds. Model parameters were derived from trial data and published literature. Sensitivity analyses were conducted to assess the impact of uncertainty and broader National Health Service (NHS) and personal social services (PSS) costs on the results.
RESULTS: PET-CT management produced an average per-person lifetime cost saving of £1485 and an additional 0.13 QALYs. At a £20,000 willingness-to-pay per additional QALY threshold, there was a 75% probability that PET-CT was cost-effective, and the results remained cost-effective over the majority of sensitivity analyses. When adopting a broader NHS and PSS perspective, PET-CT management produced an average saving of £700 and had an 81% probability of being cost-effective.
CONCLUSIONS: This analysis indicates that PET-CT-guided management is cost-effective in the long-term and supports the case for wide-scale adoption.
CONTEXT: Approximately 1.8-3.6 million annual traumatic brain injuries occur in the United States. An evidence-based treatment for concussions that is reliable and effective has not been available.
OBJECTIVE: The objective of this study is to test whether head-eye vestibular motion (HEVM) therapy is associated with decreased symptoms and increased function in postconcussive syndrome (PCS) patients that have been severely impaired for greater than 6 months after a mild traumatic brain injury.
DESIGN: Retrospective clinical chart review.
SETTING AND PARTICIPANTS: Tertiary Specialist Brain Rehabilitation Center.
INTERVENTIONS: All subjects underwent comprehensive neurological examinations including measurement of eye and head movement. The seven modules of the C3 Logix Comprehensive Concussion Management System were used for pre- and postmeasurements of outcome of HEVM therapy.
MATERIALS AND METHODS: We utilized an objective validated measurement of physical and mental health characteristics of our patients before and after a 1-week HEVM rehabilitation program. We included only PCS patients that were disabled from work or school for a period of time exceeding 6 months after suffering a sports concussion. These subjects all were enrolled in a 5-day HEVM rehabilitation program at our Institutional Brain Center with pre- and post-C3 Logix testing outcomes.
RESULTS: There were statistical and substantive significant decreases in PCS symptom severity after treatment and statistical and substantive significant increases in standardized assessment of concussion scores. The outcomes were associated with positive changes in mental and physical health issues. This is a retrospective review and no control group has been included in this study. These are major limitations with retrospective reviews and further investigations with prospective designs including a randomized controlled study are necessary to further our understanding.
CONCLUSION: Head-eye vestibular motion therapy of 5 days duration is associated with statistical and substantive significant decreases of symptom severity associated with chronic PCS.
OBJECTIVES: Plain radiography has been widely used in dentistry. Because of the variability of the quality of equipment, radiographic technique, accuracy of interpretation, and radiation risk to the patients, the field is ripe for the introduction of other newer diagnostic modalities. In this report, we demonstrate the utility of ultrasonography in the diagnostic workup of cystic or cystlike lesions of the jaw.
METHODS: We used a transfacial ultrasonographic scanning approach to examine 32 patients with clinical or radiographic presentation of a jaw cyst. Computed tomography and histopathologic analysis were used as the reference standards to confirm the findings.
RESULTS: Ultrasonography could establish the presence or absence of a lesion, erosion of the buccal cortical plate, and identification of associated soft tissue involvement in all cases (sensitivity and specificity, 100% and 100%, respectively; area under the receiver operating characteristic curve, 1.0; P < .001).
CONCLUSIONS: Our observations revealed the usefulness of ultrasonography and demonstrated its potential value when introduced as a routine office-based imaging method for dentistry.
Mammals as a rule have seven cervical vertebrae, a number that remains remarkably constant. Changes of this number are associated with major congenital abnormalities (pleiotropic effects) that are, at least in humans, strongly selected against. Recently, it was found that Late Pleistocene mammoths (Mammuthus primigenius) from the North Sea have an unusually high incidence of abnormal cervical vertebral numbers, approximately ten times higher than that of extant elephants. Abnormal numbers were due to the presence of large cervical ribs on the seventh vertebra, indicating a homeotic change from a cervical rib-less vertebra into a thoracic rib-bearing vertebra. The high incidence of cervical ribs indicates a vulnerable condition and is thought to be due to inbreeding and adverse conditions that may have impacted early pregnancies in declining populations. In this study we investigated the incidence of cervical ribs in another extinct Late Pleistocene megaherbivore from the North Sea and the Netherlands, the woolly rhinoceros (Coelodonta antiquitatis). We show that the incidence of abnormal cervical vertebral numbers in the woolly rhinoceros is unusually high for mammals (15,6%, n = 32) and much higher than in extant Rhinoceratidae (0%, n = 56). This indicates that woolly rhinoceros lived under vulnerable conditions, just like woolly mammoths. The vulnerable condition may well have contributed to their eventual extinction.
BACKGROUND AND PURPOSE: We aimed to evaluate the relationship between brainstem necrosis and dose-volume histograms in patients with head and neck tumors after carbon-ion radiotherapy.
MATERIAL AND METHODS: We evaluated 85 patients with head and neck tumors who underwent carbon-ion radiotherapy and were followed-up for ≥12months. Brainstem necrosis was evaluated using the Common Terminology Criteria for Adverse Events (version 4.0).
RESULTS: The median follow-up was 24months, and four patients developed grade 1 brainstem necrosis, with 2-year and 3-year cumulative rates of 2.8% and 6.5%, respectively. Receiver operating characteristic curve analysis revealed the following significant cut-off values: a maximum brainstem dose of 48Gy (relative biological effectiveness [RBE]), D1cm(3) of 27Gy (RBE), V40Gy (RBE) of 0.1cm(3), V30Gy (RBE) of 0.7cm(3), and V20Gy (RBE) of 1.4cm(3). Multivariate analysis revealed that V30Gy (RBE) was most significantly associated with brainstem necrosis. The 2-year cumulative rates were 33% and 0% for V30Gy (RBE) of ≥0.7cm(3) and <0.7cm(3), respectively (p<0.001).
CONCLUSIONS: The present study indicated that the dose constraints might help minimize brainstem necrosis after carbon-ion radiotherapy.
Necrosis (7), Neoplasms (4), Squamous Cell Carcinoma (1), more mentions
OBJECTIVE: Head and neck ultrasonography (HNUS) increasingly is used as a point-of-care diagnostic tool by otolaryngologists. However, ultrasonography (US) is a very operator-dependent image modality. Hence, this study aimed to explore the diagnostic accuracy of surgeon-performed HNUS and to establish validity evidence for an objective structured assessment of ultrasound skills (OSAUS) used for competency-based assessment.
STUDY DESIGN: A prospective experimental study.
METHODS: Six otolaryngologists and 11 US novices were included in a standardized test setup for which they had to perform focused HNUS of eight patients suspected for different head and neck lesions. Their diagnostic accuracy was calculated based on the US reports, and two blinded raters assessed the video-recorded US performance using the OSAUS scale.
RESULTS: The otolaryngologists obtained a high diagnostic accuracy on 88% (range 63%-100%) compared to the US novices on 38% (range 0-63%); P < 0.001. The OSAUS score demonstrated good inter-case reliability (0.85) and inter-rater reliability (0.76), and significant discrimination between otolaryngologist and US novices; P < 0.001. A strong correlation between the OSAUS score and the diagnostic accuracy was found (Spearman's ?, 0.85; P < P 0.001), and a pass/fail score was established at 2.8.
CONCLUSION: Strong validity evidence supported the use of the OSAUS scale to assess HNUS competence with good reliability, significant discrimination between US competence levels, and a strong correlation of assessment score to diagnostic accuracy. An OSAUS pass/fail score was established and could be used for competence-based assessment in surgeon-performed HNUS.
LEVEL OF EVIDENCE: NA. Laryngoscope, 2017.
INTRODUCTION: Verrucous carcinoma (VC) is a rare, variant of squamous cell carcinoma with benign cytohistopathologic features and a generally favorable prognosis. Epidemiologic and clinical outcomes data are lacking as a result of limited cases of sinonasal VC.
OBJECTIVE: To describe the incidence and determinants of survival of patients with verrucous carcinoma of the sinonasal tract between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database.
METHODS: The SEER registry was utilized to calculate survival trends for patients with verrucous carcinoma of the sinonasal tract between 1973 and 2014. Patient data then was analyzed with respect to age, sex, race, and treatment modalities (surgery and radiation therapy). Overall survival (OS) and disease-specific survival (DSS) were calculated.
RESULTS: A total of 86 cases of VC of the sinonasal tract were identified. The cohort was comprised of 69.8% males. The mean age at diagnosis was 67.4 years. The nasal cavity was the most common primary site (51.2%), followed by the maxillary sinus (40.7%) and nasopharynx (5.8%). The median OS was 97.6 months. 89.5% of cases underwent surgery and 20.9% received both surgery and radiation therapy. Overall survival at 2, 5, and 10 years was 73%, 59%, and 36%, respectively. On multivariate analysis, advanced age (P < 0.05) and primary site (P < 0.05) were associated with worse OS and DSS, respectively. Primary nasopharyngeal tumor site was associated with reduced DSS (P < 0.05). Surgery improved OS (P < 0.001) and DSS (P < 0.001).
CONCLUSION: Verrucous carcinoma of the sinonasal tract is associated with a generally favorable prognosis. Age, primary site, and surgical therapy are independent predictors of OS and DSS, respectively. We present the first population-based analysis of sinonasal VC, thus clarifying the prognosis and reinforcing the management of this malignancy.
LEVEL OF EVIDENCE: 4. Laryngoscope, 2017.
BACKGROUND: This study assesses the value of the video head impulse test (vHIT) for early diagnosis of vestibular neuritis (VN) among acute vertigo.
METHODS: Thirty-three cases of vestibular neuritis (VN), 96 patients with other acute vertigo (AV), and 50 cases of normal controls used vHIT to quantitatively test a pair of horizontal vestibulo-ocular reflection (VOR) gains, two pairs of vertical VOR gains, and the corresponding three pairs of VOR gain asymmetry. The peculiarity of VOR gains in VN and the differences between VN and other AV, normal controls by vHIT, were collected and analyzed.
RESULTS: There were statistically significant differences in the three pairs of VOR gains asymmetry between VN and other AV, and normal controls (P<0.01). The sensitivity was 87.9% and specificity was 94.3% in differentiating VN from normal and other acute vertigo by vHIT.
CONCLUSIONS: This study shows vHIT has advantages in the diagnosis of VN in acute vertigo with good sensitivity and specificity and indicates a widespread clinical application.
AIMS: Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.
PATIENTS AND METHODS: Between 2002 and 2014, 77 RHAs were implanted in 54 men and 23 women with either acute injuries (54) or with traumatic sequelae (23) of a fracture of the radial head. Four designs of RHA were used, including the Guepar (Small Bone Innovations (SBi)/Stryker; 36), Evolutive (Aston Medical; 24), rHead RECON (SBi/Stryker; ten) or rHead STANDARD (SBi/Stryker; 7) prostheses. The mean follow-up was 74.0 months (standard deviation (sd) 38.6; 24 to 141). The indication for further surgery, range of movement, mean Mayo Elbow Performance (MEP) score, quick Disabilities of the Arm, Shoulder and Hand (quickDASH) score, osteolysis and positioning of the implant were also assessed according to the design, and acute or delayed use.
RESULTS: The mean MEP and quickDASH scores were 90.2 (sd 14; 45 to 100), and 14.0 points (sd 12; 1.2 to 52.5), respectively. There were no significant differences between RHA performed in acute or delayed fashion. There were 30 re-operations (19 with, and 11 without removal of the implant) during the first three post-operative years. Painful loosening was the primary indication for removal in 14 patients. Short-stemmed prostheses (16 mm to 22 mm in length) were also associated with an increased risk of painful loosening (odds ratio 3.54 (1.02 to 12.2), p = 0.045). Radiocapitellar instability was the primary indication for re-operation with retention of the implant (5). The overall survival of the RHA, free from re-operation, was 60.8% (sd 5.7%) at ten years.
CONCLUSION: Bipolar and press-fit RHA gives unsatisfactory mid-term outcomes in the treatment of acute fractures of the radial head or their sequelae. The outcome may vary according to the design of the implant. The rate of re-operation during the first three years is predictive of the long-term survival in tight-fitting RHAs. Cite this article: Bone Joint J 2017;99-B1197-1203.
OBJECTIVES: Structural changes and metabolic stress have been reported on diffusion-weighted magnetic resonance imaging in the cornu ammonis 1 area of the hippocampus in patients with transient global amnesia (TGA), but a consensus on pathogenesis is still lacking. The aim of our study was to perform a comprehensive ultrasound analysis of the cerebrovascular circulation in our population of patients with TGA.
METHODS: One hundred patients with TGA and 50 age- and sex-matched control participants underwent ultrasound examinations of the cervicocranial circulation.
RESULTS: The most significant risk factor for TGA was arterial hypertension (P < .01). There were no significant atherosclerotic lesions on the large arteries of the neck (mean internal carotid artery stenosis ± SD, 28.7% ± 11.7%) or on the large intracerebral arteries (good structural and hemodynamic status; P > .05). Rarely detected microembolic signals or a right-left cardiopulmonary shunt excluded an emboligenic mechanism of TGA (P > .05). The internal jugular vein valves were incompetent in 54% of patients with TGA, and this condition was associated with an increased risk of TGA (odds ratio, 4.16; 95% confidence interval, 1.91-9.04). The mean values of the breath holding index and pulsatility index, as parameters of small-vessel function, were within normal ranges and without differences between the TGA and control groups (P > .05).
CONCLUSIONS: Our ultrasound examination did not detect significant structural atherosclerotic changes of cervicocranial arteries, and an emboligenic mechanism was excluded. Only a significant rise of blood pressure in TGA and significant valvular insufficiency of the internal jugular vein were established. New research should clarify whether these simultaneous functional circulatory changes have relevance for metabolic stress in the cornu ammonis of the hippocampus.
Cardiovascular Diseases (1) Transient Global Amnesia (12), Hypertension (1), more mentions
OBJECTIVES: Unplanned 30-day readmission rate following hospital discharge is an important metric of healthcare quality. This study sought to characterize the rate, risk factors, and common causes of readmission in head and neck cancer patients following free or pedicled flap reconstruction.
STUDY DESIGN: Retrospective cohort study.
METHODS: Charts were reviewed of all patients who underwent free or pedicled flap reconstruction following resection of head and neck cancer at the Massachusetts Eye and Ear Infirmary 2009 to 2014. Readmission risk factors were evaluated by univariate and multivariate analysis.
RESULTS: Of 682 patients with free (76%) or pedicled flap reconstruction, 135 patients (19.8%) were readmitted. Factors not associated with readmission included age, gender, American Society of Anesthesiologists status, operative time, prior radiation therapy, primary cancer site, and free (vs. pedicled) flap type. Significant readmission risk factors included surgical site infections (SSI) (45.2% vs. 9.9%), use of hardware (18.5% vs. 11.3%), and clean-contaminated or contaminated surgery (15.2% vs. clean 8.2%). Surgical site infections (P < 0.001) and use of hardware (P = 0.03) remained predictive of readmission on multiple regression analysis. Primary reasons for readmission included wound complications (61.5%) and supportive care (15.6%). The median time to readmission was 8 days, and 41% of readmissions occurred within 1 week. Seventy percent of readmissions occurred within 2 weeks, including 77% of readmissions for SSIs and 86% for supportive care.
CONCLUSION: Readmissions occurred in nearly one-fifth of patients following flap surgery. SSIs and use of hardware were risk factors, whereas wound complications were the most common cause of readmission.
LEVEL OF EVIDENCE: 4. Laryngoscope, 2017.
Oncology (5) Infections (3), Head and Neck Neoplasms (2), Neoplasms (1), more mentions
BACKGROUND: In situ screw fixation remains the most common treatment for minimally displaced femoral neck fractures (FNFs). Total hip arthroplasty (THA) can be used as a salvage procedure, but the results of conversion THA in this population have not been evaluated. The goals of this study were to evaluate (1) unique complications associated with conversion THA, (2) implant survivorship free of revision and reoperation, (3) radiographic results, and (4) clinical outcomes in patients undergoing conversion THA after in situ fixation of nondisplaced FNFs.
METHODS: Between 2000 and 2014, 62 consecutive patients >65 years of age who underwent THA after in situ fixation of minimally displaced FNFs were identified. Indications were osteonecrosis (44%), post-traumatic/degenerative arthritis (35%), and nonunion (21%). Mean age was 78 years, and 73% patients were women. Mean follow-up was 5.5 years.
RESULTS: One patient was revised for aseptic femoral loosening at 11 years. One patient underwent debridement and modular component exchange at 10 years for acute hematogenous periprosthetic joint infection. Two patients underwent acute reoperation without component exchange (one superficial wound infection, one hematoma evacuation). Survivorship free of reoperation for any indication was 97% at 5 years. No patients with surviving implants had radiographic evidence of loosening at 5 years. Harris hip scores improved from 35-85 (P < .01) after THA.
CONCLUSION: Conversion THA was associated with clinical improvement, a low rate of complications, and excellent implant durability. Risks of loosening, dislocation, and periprosthetic fracture can be minimized with appropriate operative strategies and perioperative management.
Muscular and Skeletal Diseases (1) Hematoma (1), Wound Infections (1), Infections (1), more mentions