Melanoma risk in skin of colour patients with a history of a keratinocyte carcinoma

This manuscript uses individual-level data from 5 million Medicare beneficiaries to investigate the risks of melanoma in skin of color patients with a history of keratinocyte carcinoma. Despite worse melanoma outcomes, skin of color patients are often excluded from skin cancer literature. We found that skin of color patients with a history of keratinocyte carcinoma are at a significantly increased risk of melanoma, though their absolute risk is low.

Skin Cancers in Medicare Beneficiaries With Actinic Keratoses

Importance

Actinic keratoses (AK) are common premalignant skin lesions with a small risk of progressing to cutaneous squamous cell carcinoma (SCC). There is some evidence that patients with AKs also have increased risks of other skin cancers beyond SCC. However, the absolute risks of skin cancer in patients with AKs are unknown.

Objective

To calculate the absolute and relative risks of future skin cancer in Medicare beneficiaries with AKs.

Design, Setting, and Participants

This retrospective cohort study was performed using a deidentified, random sample of 4 999 999 fee-for-service Medicare beneficiaries from 2009 through 2018. Patients with treated AKs were included, and patients with seborrheic keratoses (SKs) were included as a comparator group. All patients were required to have at least 1 year between data set entry and first AK or SK. Patients with a history of skin cancer were excluded. Data were analyzed from September 2022 to March 2023.

Main Outcomes and Measures

Outcomes were first surgically treated skin cancer, including keratinocyte carcinoma (including SCC and basal cell carcinoma [BCC]) and melanoma. The absolute risks of skin cancer in patients with AKs were evaluated. Skin cancer risks in patients with AKs were compared with patients with SKs using adjusted competing risks regression.

Results

A total of 555 945 patients with AKs (mean [SD] age, 74.0 [7.4] years; 55.4% female) and 481 024 patients with SKs (mean [SD] age, 73.3 [7.3] years; 72.4% female) were included. The absolute risk of skin cancer after a first AK was 6.3% (95% CI, 6.3%-6.4%) at 1 year, 18.4% (95% CI, 18.3%-18.5%) at 3 years, and 28.5% (95% CI, 28.4%-28.7%) at 5 years. Patients with AKs had increased risk of skin cancer compared with patients with SKs (any skin cancer: adjusted hazard ratio [aHR], 2.17; 95% CI, 2.15-2.19; keratinocyte carcinoma: aHR, 2.20; 95% CI, 2.18-2.22; SCC: aHR, 2.63; 95% CI, 2.59-2.66; BCC: aHR, 1.85; 95% CI, 1.82-1.87; and melanoma: aHR, 1.67; 95% CI, 1.60-1.73).

Conclusions and Relevance

In this cohort study, older patients with AKs had substantial absolute risks, as well as elevated relative risks, of skin cancer. AKs may be clinical markers of UV exposure and increased skin cancer risk, including SCC, BCC, and melanoma. However, guidelines are lacking for follow-up skin cancer surveillance in patients with AKs. Efforts to develop evidence-based recommendations for skin cancer surveillance in patients with AKs are paramount.

Trends Over Time in Medicare for Advanced Practice Clinicians in Dermatology, 2013-2020

Importance

The number of advanced practice clinicians (APCs, including nurse practitioners and physician assistants) in the US is increasing. The effect this has on dermatology is unclear.

Objective

To develop a method to identify APCs practicing dermatology in claims data and to evaluate the contribution of dermatology APCs to the dermatology workforce and how this has changed over time.

Design, Setting, and Participants

This retrospective cohort study used the Medicare Provider Utilization and Payment Data Public Use files (2013 to 2020). As APCs are not listed by specialty, a method to identify APCs practicing dermatology was developed and validated using common dermatology procedural codes. The data were analyzed from November 2022 to April 2023.

Main Outcomes and Measures

The proportion of clinicians and office visits by dermatology APCs and physician dermatologists were evaluated using Mann-Kendall tests. Joinpoint analysis was also used to compare the average annual percentage change of dermatology procedures and clinicians in rural-urban areas between dermatology APCs and physician dermatologists.

Results

The method to identify APCs practicing dermatology had 96% positive predictive value, 100% negative predictive value, 100% sensitivity, and 100% specificity. Between 2013 and 2020, 8444 dermatology APCs and 14 402 physician dermatologists were identified. They provided 109 366 704 office visits in Medicare. The percentage of dermatology clinicians who were APCs increased over time, from 27.7% in 2013 to 37.0% in 2020 (P = .002). The proportion of dermatologic office visits provided by APCs also increased over time, from 15.5% in 2013 to 27.4% in 2020 (P = .002). For all procedure categories, the average annual percentage change was positive for dermatology APCs (range, 10.05%-12.65%) and was higher than that of physician dermatologists. For all rural-urban designations, the average annual percentage change was positive for dermatology APCs (range, 2.03%-8.69%) and was higher than metropolitan, micropolitan, and small-town areas from that of physician dermatologists.

Conclusions and Relevance

In this retrospective cohort study, there was a temporal increase in the amount of dermatologic care provided by APCs in Medicare. These findings demonstrate changes in the dermatology workforce and may have implications for dermatology as a specialty.

The Role of Biologic Mesh and Fundoplication in the Surgical Management of Hiatal Hernias: A Multicenter Evaluation

INTRODUCTION

Hiatal hernia repair is associated with substantial recurrence of both hiatal hernia and symptoms of gastroesophageal reflux (GER). While small randomized controlled trials demonstrate limited differences in outcomes with use of mesh or fundoplication type, uncertainty remains.

METHODS

A multicenter, retrospective review of patients undergoing surgical treatment of hiatal hernias between 2015 and 2020 was performed. Patients with mesh and with suture-only repair were compared, and partial versus complete fundoplication was compared. Primary outcomes were hernia recurrence and occurrence of postoperative GER symptoms and dysphagia. Multivariable regression was performed to assess the effect of each intervention on clinical outcomes.

RESULTS

A total of 453 patients from four sites were followed for a median (IQR) of 17 (13) months. On multivariate analysis, mesh had no impact on hernia recurrence (odds ratio 0.993, 95% CI: 0.53-1.87, p = 0.982), and fundoplication type did not impact recurrence of postoperative GER symptoms (complete: odds ratio 0.607, 95% CI: 0.33-1.12, p = 0.112) or dysphagia (complete: odds ratio 1.17, 95% CI: 0.56-2.43, p = 0.677).

CONCLUSION

During hiatal hernia repair, mesh and fundoplication type do not appear to have substantial impact on GER symptoms, dysphagia, or hernia recurrence. This multicenter study provides real-world evidence to support the findings of small RCTs.

Atypical Pediatric Presentation of Pilomatricoma

Pilomatricomas are uncommon, benign tumors of the hair follicle, which are often misdiagnosed upon initial inspection. Here we describe the case of a 4-year-old boy who presented with a persistent draining tumor on the left side of his neck for approximately two years. The tumor was originally misdiagnosed as scrofuloderma but, eventually, our patient's pilomatricoma was identified with biopsy and successfully treated with elliptical excision. We discuss the importance of considering pilomatricoma in the differential diagnosis.

Systematic Review of Treatment of Patients with Achalasia: Heller Myotomy, Pneumatic Dilation, and Peroral Endoscopic Myotomy

BACKGROUND

The aim of this systematic review is to assess all comparative randomized controlled trials evaluating Heller myotomy, pneumatic dilation, and peroral endoscopic myotomy.

STUDY DESIGN

Achalasia is an esophageal motility disorder associated with degeneration of the myenteric plexus; it causes significant symptoms and impacts patient quality of life (QOL). The optimal treatment for patients with achalasia and the impact of these interventions on QOL remain unclear. PubMed, Embase, Scopus, and Cochrane were searched from inception to April 2020. Randomized controlled trials that compared the 3 interventions were included. Primary outcome was QOL at 12 to 36 months after the operation. Secondary outcomes included reintervention, dysphagia, leak/perforation, and GERD recurrence.

RESULTS

Nine publications of 6 studies were included. Of the 9 publications, there was no significant difference in QOL at 12 to 36 months except for one study in which QOL was significantly higher in patients who underwent Heller myotomy as opposed to pneumatic dilation at 3 years; however, at 5 years there was no difference. Pneumatic dilation was associated with the highest rates of dysphagia recurrence and reintervention, but peroral endoscopic myotomy had the lowest.

CONCLUSIONS

The treatment of achalasia should be chosen in accordance with patient goals. After any of the 3 interventions, QOL appears to be similar. However, peroral endoscopic myotomy may be associated with the lowest rates of perforation/leak, dysphagia, and reintervention and may be the lowest risk option. However, there are barriers to widespread use due to challenges in training and adoption.

Evaluation of ICARUS Guidelines and Recommendations Not Supported by Randomized Controlled Trials

BACKGROUND

The ICARUS guidelines are a systematic review and Delphi process that provide recommendations in the treatment and management of patients with gastroesophageal reflux disease (GERD). Many of the recommendations were supported by randomized trials; some were not. This study assesses guidelines with limited evidence and weak endorsement.

METHODS

Four ICARUS guidelines were chosen: the role of fundoplication for patients with BMI > 35, regurgitation, chest pain, and extra-esophageal symptoms. A multicenter database of patients undergoing fundoplication surgery for GERD between 2015 and 2020 was used. Outcomes assessed were anatomic failure and symptom recurrence. Multivariable regression was performed.

RESULTS

Five institutions performed a fundoplication on 461 patients for GERD with a median of follow-up of 14.7 months (IQR 14.2). On multivariate analysis, patients with the chosen pre-operative comorbidities achieved comparable post-operative benefits. Patients with a BMI > 35 were not more likely to experience anatomic failure. Patients with pre-operative regurgitation had similar symptom recurrence rates to those without. Patients with non-cardiac chest pain had comparable rates of symptom recurrence to those without. Reporting a pre-operative chronic cough attributable to reflux was not associated with higher rates of post-operative symptom recurrence.

DISCUSSION

Among the ICARUS guidelines and recommendations, a small proportion was lacking evidence at low risk for bias and endorsement. The results of this multicenter study evaluated outcomes of patients with various pre-operative conditions: BMI > 35, chest pain attributable to reflux, extra-esophageal symptoms attributable to reflux, and regurgitation. Our findings endorse patients with these characteristics as candidates for anti-reflux surgery.

The Food and Drug Administration's (FDA's) 510(k) Process: A Systematic Review of 1000 Cases

BACKGROUND

The vast majority of devices cleared by the Food and Drug Administration (FDA) are through the 510(k) process, which allows medical devices to be quickly introduced into the market. The FDA 510(k) process is designed to minimize the burden and expense of bringing new devices to market; however, as a result, the FDA may be limited in its ability to establish the safety of these devices.

METHODS

The FDA 510(k) online archives were searched for devices cleared from 2013 to 2014. One thousand devices were randomly selected. PubMed was searched for each device to identify publications about the devices. The primary outcome was the percentage of devices cleared through the 510(k) process with no published research. Secondary outcomes included: conflict of interest (COI) of authors and outcomes of published studies on the devices.

RESULTS

A total of 6152 devices were cleared through the 510(k) process in 2013-2014. Of the 1000 randomly selected devices, 17.8% had published research. There were 375 manuscripts, of which 47 (12.5%) were randomized controlled trials. One-fourth (25.1%) of studies had a clearly identifiable COI, while COI was unclear for half (49.9%).

CONCLUSION AND RELEVANCE

There is limited evidence examining the safety and effectiveness of devices cleared via the 510(k) process. Thousands of devices are cleared through the FDA's 510(k) process each year with limited or no evidence publicly available. This has led to the market being introduced to potentially costly, nonbeneficial, or harmful devices. Devices, like prescription drugs, should undergo a more rigorous clearance process.

Safety and Feasibility of Performing Antireflux Procedures at a Safety Net Hospital

INTRODUCTION

One-half of Americans have limited access to health care; these patients often receive care through safety net hospitals, which are associated with worse medical outcomes. This study aims to compare the outcomes of patients who received foregut surgery at a safety net hospital to those at a private or university hospital. We hypothesized that patients treated at the safety net hospital will have a greater rate of radiographic recurrence and reoperations.

METHODS

A retrospective study was conducted on patients who underwent hiatal hernia repair or fundoplication for gastroesophageal reflux disease at an affiliated safety net, private, or university hospital from June 2015 to May 2020. The primary outcome was radiographic recurrence. The secondary outcomes included reoperation and symptom recurrence. Analysis was performed using analysis of variance, chi-square, and logistic regression.

RESULTS

A total of 499 patients were identified: 157 at a safety net hospital, 233 at a private hospital, and 119 at a university hospital. The median (interquartile range) follow-up was 16 (13) mo. The safety net hospital treated more Hispanics, females, and patients with comorbidities. Large hiatal hernias were more common at the safety net and private hospitals. Robotic surgery was more frequently at the university hospital. There was no difference in radiographic recurrence (13.4% versus 19.7% versus 17.6%; P = 0.269), reoperation (3.8% versus 7.2% versus 6.7%; P = 0.389), or postoperative dysphagia (15.3% versus 12.6% versus 15.1%; P = 0.696). On logistic regression, there were no differences in outcomes among institutions.

CONCLUSIONS

This study suggests that despite the challenges faced at safety net hospitals, it could be feasible to safely perform minimally invasive foregut surgery with similar outcomes to private and university hospitals.

Review of SAGES GERD guidelines and recommendations

BACKGROUND

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed evidence-based guidelines for the management of patients with gastroesophageal reflux disease (GERD). The aim of this study is to evaluate guidelines lacking agreement among experts (grades B-D) or lacking support from randomized controlled trials (levels II-III).

METHODS

Six guidelines were chosen for evaluation. A retrospective review of a multicenter database of patients undergoing fundoplication surgery for treatment of GERD between 2015 and 2020 was performed. Patients that underwent a concurrent gastrectomy or were diagnosed with pre-operative achalasia were excluded. Demographics, pre-operative, intra-operative, and post-operative variables were collected. Post-operative outcomes were evaluated based on selected SAGES guidelines. Outcomes were assessed using multivariable regression or stratified analysis for each guideline.

RESULTS

A total of 444 patients from four institutions underwent surgery for the management of GERD with a median (interquartile range) follow-up of 16 (13) months. Guidelines supported by our data were (1) robotic repair has similar short-term outcomes to laparoscopic repair, (2) outcomes in older patients are similar to outcomes of younger patients undergoing antireflux surgery, and (3) following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from pre-operative values. Guidelines that were not supported were (1) mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation, (2) a bougie has been found to be effective, and (3) the long-term effectiveness of fundoplication in obese individuals (BMI > 30) has been questioned due to higher failure rates.

CONCLUSION

Many SAGES GERD guidelines not receiving Grade A or Level I recommendation are supported by large, multicenter database findings. However, further studies at low risk for bias are needed to further refine these guidelines.

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis

IMPORTANCE

In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs.

OBJECTIVE

To assess the use and safety of outpatient management of acute appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020.

EXPOSURES

Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively.

MAIN OUTCOMES AND MEASURES

Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared.

RESULTS

Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores.

CONCLUSIONS AND RELEVANCE

These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02800785.

1-GHz dual-comb spectrometer with high mutual coherence for fast and broadband measurements

Dual-frequency comb spectroscopy permits broadband precision spectroscopy with high acquisition rate. The combs' repetition rates as well as the mutual coherence between the combs are key to fast and broadband measurements. Here, we demonstrate a 1-GHz high-repetition-rate dual-comb system with high mutual coherence (sub-Hz heterodyne beatnotes) based on mature, digitally controlled, low-noise erbium-doped mode-locked lasers. Two spectroscopy experiments are performed with acquisition parameters not attainable in a 100-MHz system: detection of water vapor absorption around 1375 nm, illustrating the potential for fast and ambiguity-free broadband operation, as well as acquisition of narrow gas absorption features across a spectral span of 0.6 THz (600 comb lines) in only 5 μs.

Patient quality of life before and after ventral hernia repair

BACKGROUND

Recurrence is often reported as the primary outcome among studies of patients with hernias; however, there is growing interest in patient quality of life. The relationship between quality of life and recurrence is poorly understood. This study evaluates this relationship.

METHODS

A secondary analysis of 3 prospective clinical trials was performed. The modified Activities Assessment Scale, a validated, abdominal wall-specific quality of life tool was used (1 = poor quality of life and 100 = perfect quality of life). Patients with and without a hernia recurrence were compared. Baseline quality of life, follow-up quality of life, and change in quality of life were measured. The relationship between quality of life and clinical outcomes was examined.

RESULTS

A total of 238 patients were followed for median (range) 30 (14-44) months, of whom 31 (13.0%) had a clinical recurrence, whereas 207 (87.0%) had no clinical recurrence. Patients with recurrence were more likely to have a lower mean baseline quality of life (14 vs 26; P = .035), follow-up quality of life (42 vs 82; P < .001), and change in quality of life (19 vs 33; P < .018). The majority of patients with or without recurrence still experienced an improvement in quality of life (68% vs 79%; P = .142).

CONCLUSION

Patients with lower baseline quality of life are likely to experience a recurrence following repair; however, most still report substantial improvements in quality of life. Assessing follow-up quality of life without accounting for baseline quality of life is incomplete; follow-up quality of life should be assessed with appropriate adjustment for baseline quality of life.

On the fate of oxygenated organic molecules in atmospheric aerosol particles

Highly oxygenated organic molecules (HOMs) are formed from the oxidation of biogenic and anthropogenic gases and affect Earth's climate and air quality by their key role in particle formation and growth. While the formation of these molecules in the gas phase has been extensively studied, the complexity of organic aerosol (OA) and lack of suitable measurement techniques have hindered the investigation of their fate post-condensation, although further reactions have been proposed. We report here novel real-time measurements of these species in the particle phase, achieved using our recently developed extractive electrospray ionization time-of-flight mass spectrometer (EESI-TOF). Our results reveal that condensed-phase reactions rapidly alter OA composition and the contribution of HOMs to the particle mass. In consequence, the atmospheric fate of HOMs cannot be described solely in terms of volatility, but particle-phase reactions must be considered to describe HOM effects on the overall particle life cycle and global carbon budget.

Molecular Composition and Volatility of Organic Aerosol in the Southeastern U.S.: Implications for IEPOX Derived SOA

We present measurements as part of the Southern Oxidant and Aerosol Study (SOAS) during which atmospheric aerosol particles were comprehensively characterized. We present results utilizing a Filter Inlet for Gases and AEROsol coupled to a chemical ionization mass spectrometer (CIMS). We focus on the volatility and composition of isoprene derived organic aerosol tracers and of the bulk organic aerosol. By utilizing the online volatility and molecular composition information provided by the FIGAERO-CIMS, we show that the vast majority of commonly reported molecular tracers of isoprene epoxydiol (IEPOX) derived secondary organic aerosol (SOA) is derived from thermal decomposition of accretion products or other low volatility organics having effective saturation vapor concentrations <10(-3) μg m(-3). In addition, while accounting for up to 30% of total submicrometer organic aerosol mass, the IEPOX-derived SOA has a higher volatility than the remaining bulk. That IEPOX-SOA, and more generally bulk organic aerosol in the Southeastern U.S. is comprised of effectively nonvolatile material has important implications for modeling SOA derived from isoprene, and for mechanistic interpretations of molecular tracer measurements. Our results show that partitioning theory performs well for 2-methyltetrols, once accretion product decomposition is taken into account. No significant partitioning delays due to aerosol phase or viscosity are observed, and no partitioning to particle-phase water or other unexplained mechanisms are needed to explain our results.

Midinfrared frequency comb from self-stable degenerate GaAs optical parametric oscillator

We pump a degenerate frequency-divide-by-two optical parametric oscillator (OPO) based on orientation-patterned GaAs with a stable Tm frequency comb at 2 micrometer wavelength and measure the OPO comb offset frequency and linewidth. We show frequency division by two with sub-Hz relative linewidth of the comb teeth. The OPO thermally self-stabilizes and oscillates for nearly an hour without any active control.

The measurement invariance of schizotypy in Europe

The short version of the Oxford-Liverpool Inventory of Feelings and Experiences (sO-LIFE) is a widely used measure assessing schizotypy. There is limited information, however, on how sO-LIFE scores compare across different countries. The main goal of the present study is to test the measurement invariance of the sO-LIFE scores in a large sample of non-clinical adolescents and young adults from four European countries (UK, Switzerland, Italy, and Spain). The scores were obtained from validated versions of the sO-LIFE in their respective languages. The sample comprised 4190 participants (M=20.87 years; SD=3.71 years). The study of the internal structure, using confirmatory factor analysis, revealed that both three (i.e., positive schizotypy, cognitive disorganisation, and introvertive anhedonia) and four-factor (i.e., positive schizotypy, cognitive disorganisation, introvertive anhedonia, and impulsive nonconformity) models fitted the data moderately well. Multi-group confirmatory factor analysis showed that the three-factor model had partial strong measurement invariance across countries. Eight items were non-invariant across samples. Significant statistical differences in the mean scores of the s-OLIFE were found by country. Reliability scores, estimated with Ordinal alpha ranged from 0.75 to 0.87. Using the Item Response Theory framework, the sO-LIFE provides more accuracy information at the medium and high end of the latent trait. The current results show further evidence in support of the psychometric proprieties of the sO-LIFE, provide new information about the cross-cultural equivalence of schizotypy and support the use of this measure to screen for psychotic-like features and liability to psychosis in general population samples from different European countries.

Ultra-low noise all polarization-maintaining Er fiber-based optical frequency combs facilitated with a graphene modulator

High bandwidth carrier phase and repetition rate control are critical for the construction of low phase noise optical frequency combs. Here we demonstrate the use of a graphene modulator for the former and a bulk electro-optic modulator for the latter enabling record low phase noise operation of an Er fiber frequency comb. For applications that do not require carrier phase control, we show that the form factor of a fiber comb can be reduced by adapting a graphene modulator for rapid repetition rate control. Moreover, the whole system demonstration is performed with all-polarization maintaining Er fiber frequency combs, highly suitable for applications in the field.

Association between adaptive behaviour and age in adults with Down syndrome without dementia: examining the range and severity of adaptive behaviour problems

BACKGROUND

Studies on adaptive behaviour and ageing in adults with Down syndrome (DS) (without dementia) have typically analysed age-related change in terms of the total item scores on questionnaires. This research extends the literature by investigating whether the age-related changes in adaptive abilities could be differentially attributed to changes in the number or severity (intensity) of behavioural questionnaire items endorsed.

METHODS

The Adaptive Behaviour Assessment System-II Adult (ABAS-II Adult) was completed by parents and caregivers of 53 adults with DS aged between 16 and 56 years. Twenty adults with DS and their parents/caregivers were a part of a longitudinal study, which provided two time points of data. In addition 33 adults with DS and their parents/caregivers from a cross-sectional study were included. Random effects regression analyses were used to examine the patterns in item scores associated with ageing.

RESULTS

Increasing age was found to be significantly associated with lower adaptive behaviour abilities for all the adaptive behaviour composite scores, expect for the practical composite. These associations were entirely related to fewer ABAS-II Adult items being selected as present for the older participants, as opposed to the scores being attributable to lower item severity.

CONCLUSIONS

This study provides evidence for a differential pattern of age-related change for various adaptive behaviour skills in terms of range, but not severity. Possible reasons for this pattern will be discussed. Overall, these findings suggest that adults with DS may benefit from additional support in terms of their social and conceptual abilities as they age.

Biochemical mechanisms of pallidal deep brain stimulation in X-linked dystonia parkinsonism

OBJECTIVE

Invasive techniques such as in-vivo microdialysis provide the opportunity to directly assess neurotransmitter levels in subcortical brain areas.

METHODS

Five male Filipino patients (mean age 42.4, range 34-52 years) with severe X-linked dystonia-parkinsonism underwent bilateral implantation of deep brain leads into the internal part of the globus pallidus (GPi). Intraoperative microdialysis and measurement of gamma aminobutyric acid and glutamate was performed in the GPi in three patients and globus pallidus externus (GPe) in two patients at baseline for 25/30 min and during 25/30 min of high-frequency GPi stimulation.

RESULTS

While the gamma-aminobutyric acid concentration increased in the GPi during high frequency stimulation (231 ± 102% in comparison to baseline values), a decrease was observed in the GPe (22 ± 10%). Extracellular glutamate levels largely remained unchanged.

CONCLUSIONS

Pallidal microdialysis is a promising intraoperative monitoring tool to better understand pathophysiological implications in movement disorders and therapeutic mechanisms of high frequency stimulation. The increased inhibitory tone of GPi neurons and the subsequent thalamic inhibition could be one of the key mechanisms of GPi deep brain stimulation in dystonia. Such a mechanism may explain how competing (dystonic) movements can be suppressed in GPi/thalamic circuits in favour of desired motor programs.

Orbital tumors: operative and therapeutic strategies

The term "orbital tumors" includes diverse benign or malignant space-occupying lesions of the orbit, often leading to dystopia of the eyeball, motility disturbances, diplopia, visual field defects, and sometimes a complete loss of vision. Removing these tumors in a limited surgical field is challenging. Therefore, the preservation of function is a primary concern. We retrospectively reviewed 671 patients with orbital tumors from October 1999 to June 2014. Diagnosis on referral, presenting symptoms, radiological records, histology of the primary tumor or orbital metastasis, and treatment choice were analyzed. Among the 671 orbital tumors, 40% were accessed anteriorly, 36% via an orbitotomy with temporary osteotomy, and 23.9% underwent an orbital exenteration. As an illustration of the operative strategies with subsequent reconstructions, a distinction was made among the main indication groups: (1) function-preserving therapy for retrobulbar tumors, (2) malignant tumors of the conjunctiva and the eyelids, (3) exenteration of the orbit and subsequent reconstruction, and (4) operative and therapeutic strategy for orbital metastases. Adequate preoperative use of modern imaging techniques and thorough planning of the operation are crucial. Accurate histopathological diagnosis is crucial for planning appropriate therapeutic and surgical interventions. New innovative treatment concepts and surgical techniques arise from the close cooperation of related disciplines such as ophthalmology and neurosurgery. Although an orbital exenteration in patients with eyelid and conjunctival carcinomas can now often be avoided, eye-preserving treatment for locally advanced carcinomas of the conjunctiva and eyelid must be attempted. For extensive orbital malignancies, orbital exenteration is curative. In this context, primary closure of the orbit can improve the patient's quality of life and avoid subsequent complications. Concerning orbital metastasis, early diagnosis can preserve function and fulfil the esthetic demands of the patients. In palliative tumor disease, operative procedures such as orbital decompression or tumor debulking can reduce patient complaints and contribute to improved quality of life.

Tracheal intubation in patients with odentogenous abscesses and reduced mouth opening

BACKGROUND

Odentogenous abscesses with involvement of the facial or cervical spaces can be life-threatening and often have to be drained under general anaesthesia. Trismus and swelling can make intubation with a Macintosh laryngoscope difficult or even impossible. However, indirect laryngoscopy has been successful when conventional direct laryngoscopy has failed. Therefore, we evaluated the efficacy of the Glidescope laryngoscope in patients with odentogenous abscesses and the improvement in mouth opening after neuromuscular block.

METHODS

After approval of the ethics committee, 100 patients with odentogenous abscesses were randomized to undergo tracheal intubation with the Glidescope or Macintosh laryngoscope. Success rate, visualization of the glottis, intubation duration, and need for supporting manoeuvres were evaluated.

RESULTS

Intubation with the Glidescope was always successful, while conventional intubation failed in 17 out of 50 patients (P<0.0001). In all patients in whom conventional tracheal intubation failed, a subsequent attempt with the Glidescope was successful. The view at the glottis (according to Cormack and Lehane; P<0.0001), intubation duration [34 s (CI 27-41) vs 67 s (CI 52-82), mean (95% confidence interval); P=0.0001], and need for supporting manoeuvres (P<0.0001) were significantly different. The inter-incisor distance improved overall with induction of anaesthesia from 2.0 cm (CI 1.8-2.2) to 2.6 cm (CI 2.3-2.9; P<0.0001) and was correlated with the duration of symptoms.

CONCLUSIONS

In patients with odentogenous abscesses, the use of a Glidescope laryngoscope was associated with significantly faster tracheal intubation, with a better view, fewer supporting manoeuvres, and a higher success rate than with a conventional laryngoscope. Improvement of the inter-incisor distance after induction of anaesthesia correlated with the duration of symptoms.

Carrier envelope offset frequency of a doubly resonant, nondegenerate, mid-infrared GaAs optical parametric oscillator

We measure the carrier envelope offset (CEO) frequency of the mid-infrared frequency comb (wavelength tunable between 3 and 6 μm) from a doubly resonant nondegenerate synchronously pumped optical parametric oscillator (SPOPO) as a function of the CEO frequency of the Tm-fiber pump laser. We show that the CEO frequency of the SPOPO signal wave is a linear function of the CEO frequency of the pump laser, with a slope determined by the signal to pump center-frequency ratio.

Nasotracheal intubation with three indirect laryngoscopes assisted by standard or modified Magill forceps

We assessed the effect of modifying standard Magill forceps on the laryngeal introduction of an Eschmann stylet during nasotracheal intubations with three indirect laryngoscopes (Airtraq™, C-MAC(®) or GlideScope(®)) in patients with predicted difficult intubation. We allocated 50 participants to each laryngoscope. The stylet was advanced by one forceps followed by the other (standard or modified), with each sequence allocated to 25/50 for each laryngoscope. There were no differences in rates of failed tracheal intubation with the allocated laryngoscopes: 6/50, 5/50 and 5/50, respectively. An Eschmann stylet was advanced into the trachea less often with the standard forceps (65% vs 93%, p < 0.0001). Mean (SD) time for stylet advancement was longer with the standard forceps, 38 (30) vs 19 (19) s, p < 0.0001. In conclusion, the modified Magill forceps facilitated nasotracheal intubation, independent of the type of indirect laryngoscope.

Frequency comb stabilization with bandwidth beyond the limit of gain lifetime by an intracavity graphene electro-optic modulator

Intracavity loss modulation enables offset-frequency control with bandwidths beyond what is possible by pump power modulation. To demonstrate this new method, we use a subwavelength thick graphene electro-optic modulator to stabilize the offset frequency in a Tm:fiber frequency comb at 1.95 μm wavelength. Record-low residual phase noise of 144 mrads was achieved with this new locking scheme.

Widely tunable midinfrared difference frequency generation in orientation-patterned GaAs pumped with a femtosecond Tm-fiber system

We demonstrate a midinfrared source tunable from 6.7 to 12.7 μm via difference frequency generation (DFG) in orientation-patterned GaAs, with 1.3 mW average output power. The input pulses are generated via Raman self-frequency shift of a femtosecond Tm-doped-fiber laser system in a fluoride fiber. We numerically model the DFG process and show good agreement between simulations and experiments. We use this numerical model to show an improved design using longer pump pulses.

Biomass burning contributions to urban aerosols in a coastal Mediterranean city

Mean annual biomass burning contributions to the bulk particulate matter (PM(X)) load were quantified in a southern-European urban environment (Barcelona, Spain) with special attention to typical Mediterranean winter and summer conditions. In spite of the complexity of the local air pollution cocktail and the expected low contribution of biomass burning emissions to PM levels in Southern Europe, the impact of these emissions was detected at an urban background site by means of tracers such as levoglucosan, K(+) and organic carbon (OC). The significant correlation between levoglucosan and OC (r(2)=0.77) and K(+) (r(2)=0.65), as well as a marked day/night variability of the levoglucosan levels and levoglucosan/OC ratios was indicative of the contribution from regional scale biomass burning emissions during night-time transported by land breezes. In addition, on specific days (21-22 March), the contribution from long-range transported biomass burning aerosols was detected. Quantification of the contribution of biomass burning aerosols to PM levels on an annual basis was possible by means of the Multilinear Engine (ME). Biomass burning emissions accounted for 3% of PM(10) and PM(2.5) (annual mean), while this percentage increased up to 5% of PM(1). During the winter period, regional-scale biomass burning emissions (agricultural waste burning) were estimated to contribute with 7±4% of PM(2.5) aerosols during night-time (period when emissions were clearly detected). Long-range transported biomass burning aerosols (possibly from forest fires and/or agricultural waste burning) accounted for 5±2% of PM(2.5) during specific episodes. Annually, biomass burning emissions accounted for 19%-21% of OC levels in PM(10), PM(2.5) and PM(1). The contribution of this source to K(+) ranged between 48% for PM(10) and 97% for PM(1) (annual mean). Results for K(+) from biomass burning evidenced that this tracer is mostly emitted in the fine fraction, and thus coarse K(+) could not be taken as an appropriate tracer of biomass burning.

Easy and difficult nasal intubation--a randomised comparison of Macintosh vs Airtraq® laryngoscopes

A new Airtraq(®) laryngoscope has been developed for nasal intubation. We prospectively compared tracheal intubation efficiency of the Airtraq for nasotracheal intubation vs that of the Macintosh laryngoscope in 200 patients. Depending on pre-operative airway evaluation, the patients were allocated to expected easy (n = 100) or difficult (n = 100) intubation groups, on the basis of mouth opening ≤ 2.5 cm, modified Mallampati score of 4, history of difficult intubation, obvious tumour or swelling. Patients were randomly allocated to the Macintosh or nasotracheal Airtraq technique. All easy intubations were successfully performed with the respective technique. In the expected difficult intubation group, the success rate was higher (47/50 vs 33/50; p < 0.01), the glottis view was better (Cormack and Lehane 1/2/3/4 grades: 29/17/1/3 vs 5/11/18/16, p < 0.01), mean (SD) intubation time was shorter (45(46) s vs 77(47)s, p < 0.01) and the number of optimising manoeuvres was reduced with the nasotracheal Airtraq compared with the Macintosh, respectively. For difficult nasal intubations, the nasotracheal Airtraq is more effective than the Macintosh laryngoscope.

Inter-rater reliability of the Developmental Behaviour Checklist for Adults in community accommodation settings

BACKGROUND

With the publication of the Developmental Behaviour Checklist for Adults (DBC-A), people of all ages with intellectual disability (ID) can now be assessed using a carer-completed screening checklist of emotional and behavioural disturbance. This provides a broad assessment framework across the life span, assists the process of clinical assessment, diagnosis and management, and, through efficient screening, helps ensure that people with ID and high levels of disturbed behaviour are more likely to receive the often scarce and costly behavioural and mental health services that are available. Earlier studies have reported acceptable results of test-retest reliability studies with family members and paid carers in community settings and the results of an inter-rater reliability study completed with family members. This study reports on another aspect of DBC-A reliability, inter-rater reliability with paid carers, in two small community-based accommodation settings.

METHOD

Participants were 38 pairs of paid carers employed by two non-government agencies providing residential services in small group homes to 38 adults with ID in the community.

RESULTS

An intraclass correlation coefficient (ICC) of 0.69 (n = 38, 95% CI 0.54-0.86) was found between pairs of paid carers employed in small group homes.

DISCUSSION

  Pairs of paid carers working with adults with ID in small group homes reliably completed DBC-A checklists. An ICC result of 0.69 compares favourably with the results of an earlier inter-rater study completed with the family members of people with ID living in the community. Inter-rater reliability on the six DBC-A sub-scales was also computed and the results were satisfactory.

CONCLUSIONS

The carer-completed DBC-A provides a broad and comprehensive survey of the emotional and behavioural problems of adults with ID. It has satisfactory psychometric properties, which have been further extended. The DBC-A can be used in clinical, research and service settings to assess psychopathology across the adult life span in people with ID.

Passiflora incarnata L. (Passionflower) extracts elicit GABA currents in hippocampal neurons in vitro, and show anxiogenic and anticonvulsant effects in vivo, varying with extraction method

Potential mechanisms of Passiflora incarnata extracts and the effect of extraction methods on ingredients and biological effects were explored. Using the same batch of plant material, total flavonoid yields as measured by high-performance liquid chromatography coupled to diode array detection (HPLC-DAD) increased substantially with hot versus cold extraction methods. Whole Passiflora extract induced prominent, dose-dependent direct GABA(A) currents in hippocampal slices, but the expected modulation of synaptic GABA(A) currents was not seen. GABA was found to be a prominent ingredient of Passiflora extract, and GABA currents were absent when amino acids were removed from the extract. Five different extracts, prepared from a single batch of Passiflora incarnata, were administered to CF-1 mice for 1 week in their drinking water prior to evaluation of their behavioral effects. Anticonvulsant effects against PTZ-induced seizures were seen in mice that received 2 of the 5 Passiflora extracts. Instead of the anxiolytic effects described by others, anxiogenic effects in the elevated plus maze were seen in mice receiving any of the 5 Passiflora extracts.

miR-145-dependent targeting of junctional adhesion molecule A and modulation of fascin expression are associated with reduced breast cancer cell motility and invasiveness

Micro RNAs are small non-coding RNAs, which regulate fundamental cellular and developmental processes at the transcriptional and translational level. In breast cancer, miR-145 expression is downregulated compared with healthy control tissue. As several predicted targets of miR-145 potentially regulate cell motility, we aimed at investigating a potential role for miR-145 in breast cancer cell motility and invasiveness. Assisted by Affymetrix array technology, we demonstrate that overexpression of miR-145 in MDA-MB-231, MCF-7, MDA-MB-468 and SK-BR-3 breast cancer cells and in Ishikawa endometrial carcinoma cells leads to a downregulation of the cell-cell adhesion protein JAM-A and of the actin bundling protein fascin. Moreover, podocalyxin and Serpin E1 mRNA levels were downregulated, and gamma-actin, transgelin and MYL9 were upregulated upon miR-145 overexpression. These miR-145-dependent expression changes drastically decreased cancer cell motility, as revealed by time-lapse video microscopy, scratch wound closure assays and matrigel invasion assays. Immunofluorescence microscopy demonstrated restructuring of the actin cytoskeleton and a change in cell morphology by miR-145 overexpression, resulting in a more cortical actin distribution, and reduced actin stress fiber and filopodia formation. Nuclear rotation was observed in 10% of the pre-miR-145 transfected MDA-MB-231 cells, accompanied by a reduction of perinuclear actin. Luciferase activation assays confirmed direct miR-145-dependent regulation of the 3'UTR of JAM-A, whereas siRNA-mediated knockdown of JAM-A expression resulted in decreased motility and invasiveness of MDA-MB-231 and MCF-7 breast cancer cells. Our data identify JAM-A and fascin as novel targets of miR-145, firmly establishing a role for miR-145 in modulating breast cancer cell motility. Our data provide a rationale for future miR-145-targeted approaches of antimetastatic cancer therapy.

Course of pattern-reversed visual evoked cortical potentials in 30 eyes after bony orbital decompression in dysthyroid optic neuropathy

AIM

To investigate optic nerve function using the pattern-reversed visual evoked cortical potentials (VECP) before and after bony orbital decompression in dysthyroid optic neuropathy (DON) due to Graves' disease.

METHODS

A total of 30 eyes of 15 patients (n=14 female) were observed over 30 ± 13 months after bony three-wall orbital decompression. We examined visual acuity (VA), VECP P100 amplitudes and latencies, as well as proptosis using Hertel's exophthalmometry.

RESULTS

Mean logarithm of the minimum angle of resolution (logMAR) VA increased, statistically significantly, by 2.4 lines during 30 ± 13 months (from 0.38 ± 0.25 before surgery to 0.14 ± 0.1 at the end of observation, p=0.0001). All eyes maintained or improved vision by at least one line. Mean postoperative reduction of proptosis was 6.4 ± 3 mm. While VECP P100 amplitudes improved significantly, P100 latencies remained abnormal in 18 eyes (60%) during follow-up of 10 ± 7 months. Nine eyes (30%) with previous latency defects improved in at least one check test, five of which normalised completely. Worsening was evident in seven eyes (23%), and three previously normal eyes developed new pathological latencies. P100 latencies in 14 eyes (47%) remained unchanged.

CONCLUSION

After decompression surgery, DON remission was observed in all patients regarding vision and VECP amplitudes. New or persistent P100 latency defects were seen in 60% of eyes after surgery. DON is considered to be caused by compressive ischaemic damage, which further underlines the importance of early decompression surgery.

Vesicular GABA release delays the onset of the Purkinje cell terminal depolarization without affecting tissue swelling in cerebellar slices during simulated ischemia

Neurosteroids that can enhance GABA(A) receptor sensitivity protect cerebellar Purkinje cells against transient episodes of global brain ischemia, but little is known about how ischemia affects GABAergic transmission onto Purkinje cells. Here we use patch-clamp recording from Purkinje cells in acutely prepared slices of rat cerebellum to determine how ischemia affects GABAergic signaling to Purkinje cells. In voltage-clamped Purkinje cells, exposing slices to solutions designed to simulate brain ischemia caused an early, partial suppression of the frequency of spontaneous inhibitory post synaptic currents (sIPSCs), but after 5-8 min GABA accumulated in the extracellular space around Purkinje cells, generating a large (approximately 17 nS), sustained GABA(A) receptor-mediated conductance. The sustained GABA(A) conductance occurred in parallel with an even larger (approximately 117 nS) glutamate receptor-mediated conductance, but blocking GABA(A) receptors did not affect the timing or magnitude of the glutamate conductance, and blocking glutamate receptors did not affect the timing or magnitude of the GABA(A) conductance. Despite the lack of interaction between GABA and glutamate, blocking GABA(A) receptors significantly accelerated the onset of the Purkinje cell "ischemic" depolarization (ID), as assessed with current-clamp recordings from Purkinje cells or field potential recordings in the dendritic field of the Purkinje cells. The Purkinje cell ID occurred approximately 2 min prior to the sustained glutamate release under control conditions and a further 1-2 min earlier when GABA(A) receptors were blocked. Tissue swelling, as assessed by monitoring light transmittance through the slice, peaked just after the ID, prior to the sustained glutamate release, but was not affected by blocking GABA(A) receptors. These data indicate that ischemia induces the Purkinje cell ID and tissue swelling prior to the sustained glutamate release, and that blocking GABA(A) receptors accelerates the onset of the ID without affecting tissue swelling. Taken together these data may explain why Purkinje cells are one of the most ischemia sensitive neurons in the brain despite lacking NMDA receptors, and why neurosteroids that enhance GABA(A) receptor function protect Purkinje cells against transient episodes of global brain ischemia.