Success rate of external, endonasal, and transcanalicular laser DCR with or without silicone stent intubation for NLD obstruction: a network meta-analysis of randomized controlled trials

PURPOSE

To define and compare the effectiveness of external dacryocystorhinostomy (EX-DCR), endonasal (EN-DCR), and transcanalicular laser-assisted (TL-DCR) with or without silicone stent (S) intubation.

METHODS

Studies were retrieved from PubMed, Scopus, and WoS. Frequentist and Bayesian network meta-analyses were performed and pooled estimations were expressed as risk ratio (RR). We included all original investigations of prospective, randomized controlled trials comparing success rate for any two of the following six surgical procedures: standard EX-DCR with or without S, cold EN-DCR with or without S, and TL-DCR with or without S. The primary outcome measure was the objective success rate.

RESULTS

Thirty-two studies with 3277 cases were included in the final quantitative analysis. TL-DCR with S was inferior to EN-DCR with S (RR: 1.20; 95% CI: 1.05-1.37), EX-DCR with S (RR: 1.17 95% CI: 1.05-1.29), EN-DCR without S (RR: 1.18; 95% CI: 1.03-1.35), and EX-DCR without S (RR: 1.15; 95%CI: 1.05-1.26) in frequentist statistics. No other statistical difference was found between other surgeries. When we excluded studies with additional interventions (nasal and revision surgery) for sensitivity analysis, 23 studies with 2468 cases were included to analysis. The success rates of TL-DCR with S and EN-DCR without S became similar (RR: 1.14 95% CI: 0.99-1.30) but there was no change in other outcomes. Similar results were found in Bayesian statistics. The surface under the cumulative ranking curve was higher for EN-DCR with S (0.75), whereas it was higher for EX-DCR with S (0.56) after sensitivity analysis.

CONCLUSION

Between endoscopic and external and transcanalicular laser without S procedures, there is no statistical difference. The rank probability showed that EN-DCR with S was a more appropriate surgical option when patients with nasal disease were included, whereas EX-DCR with S was a more appropriate surgical option when patients with nasal disease were excluded from the analysis.

GRADE concept 6: a novel application of external indirect evidence into GRADE ratings of evidence certainty in network meta-analysis

OBJECTIVES

We describe how consideration of external evidence may play an important role in judging certainty in the process of establishing the certainty of the evidence. Our example is a network meta-analysis (NMA) addressing treatment for Ebola virus disease, which informed a World Health Organization guideline.

STUDY DESIGN AND SETTING

Through Grading of Recommendations Assessment, Development, and Evaluations (GRADE) project group iterative online, in-person and email discussions, we developed this GRADE concept and obtained approval from the GRADE working group. Using the null as a threshold, we rated our certainty for network estimates in mortality, including consideration of evidence external to the NMA (i.e., did not meet eligibility criteria) and formal logical construction.

RESULTS

Based on the existing GRADE guidance, we rated the network estimate for one indirect comparison as low certainty. The formal logical construction that lead us reevaluate the certainty of the evidence is as follows: if A is superior to B, and B is not inferior to C, then A must be superior to C. After considering the logic and the external indirect evidence, we concluded at least moderate certainty for the comparison.

CONCLUSION

Systematic review authors and guideline developers should apply the fundamental logical construction for indirect comparisons and consider compelling external evidence in NMA certainty ratings.

Comparison of internal and external fixation after debridement in the Masquelet technique for Cierny-Mader type IV tibial post-traumatic osteomyelitis

OBJECTIVE

To compare the effect of internal fixation vs. external fixation after debridement in stage I of the Masquelet technique for Cierny-Mader (C-M) type Ⅳ chronic post-traumatic tibial osteomyelitis.

METHODS

This retrospective observational study included patients with tibial osteomyelitis who underwent staged treatment with the Masquelet technique between January 2016 and June 2020 at the 920 Hospital of Joint Logistic Support Force of the PLA. The patients were grouped according to the fixation they received after stage I. Infection recurrence, time to radiological bone healing and full weight-bearing, self-rating anxiety scale (SAS) score, Hospital for Special Surgery (HSS) Knee Score, and American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were compared.

RESULTS

Sixty-three patients were included (50 males and 13 females). There were 40 and 23 patients with internal and external fixation, respectively. There were no significant differences between the two groups regarding the preoperative and intraoperative data (all P>0.05). After stage I operation, the infection control rates were 85.0% and 82.6% in the internal and external fixation groups (P=0.803), and these rates were 92.5% and 95.7% after stage II (P=0.621). There were no differences in the SAS scores (P=0.278), time to radiological union (P=0.795), time to full weight-bearing (P=0.725), AOFAS scores (P=0.302), HSS scores (P=0.085), and complication rates (P=0.593). There were 27 times complications in 19 patients, with an incidence of 42.9%, without significant differences between groups.

CONCLUSION

There were no differences between the two fixation methods after debridement in stage I of the Masquelet technique for C-M type Ⅳ chronic post-traumatic tibia osteomyelitis.

Clinical Trial to Compare Success Rate of Endonasal Dacryocystorhinostomy and External Dacryocystorhinostomy for Treatment of Primary Acquired Nasolacrimal Duct Obstruction

The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO). Prospective randomized comparative study. Study was conducted for 2 years duration in a teaching hospital with 300 cases of endoscopic and 300 cases of external DCR with a follow-up of minimum 6 months. Data regarding surgical outcome and complications were analyzed and compared using χ2 test. In our study, the overall success rate of DCR for PANLDO was 92.6%, there was difference in terms of anatomical or functional success rate between EN-DCR (93.6%) and EX-DCR (91.6%). The incidence rate of post operative complication in our study was lower in Endonasal DCR (27.33%) as compared to External DCR (48%). Patients who underwent EN-DCR had shorter recovery time, less complications and higher satisfaction due to lack of external incision, although final surgical outcomes were comparable between two groups.

Thinking about attention: Successive approximations to a productive taxonomy

Attention, the recruitment of processing resources, is viewed as pivotal for understanding normal behaviour and thought as well as the disorganizations associated with brain damage and disease. A brief history foreshadows aspects of a proposed taxonomy of attention that builds upon Posner's tripartite taxonomy. Posner's influential taxonomy views attention as a set of isolable neural systems (alerting, orienting and executive control), often working together to organize behaviour. For measuring the efficacy of these three networks, Posner and colleagues created the Attention Network Test (ANT). The impact of the taxonomy and this model task for exploring it is illustrated by the facts that they have spawned numerous variants designed for different purposes and that one or another variant has been used in almost a thousand publications. We have previously built upon this conceptual framework by considering: two modes of control over resource allocation which we labelled exogenous and endogenous and three domains over which these modes of control are presumed to operate (space, time and task or activity). The Combined Attention Systems Test (or CAST) was developed to measure the efficacy of the six kinds of attention implied by revised taxonomy. Lastly, this taxonomic effort is further developed by incorporating the distinction between overt, observable behaviour in the "real" world and covert "behaviour" in the realm of thought and imagination.

Knee-Spanning External Fixation for Recurrent Traumatic Anterior Prosthetic Knee Dislocation With Associated Vascular Injury

Traumatic anterior prosthetic knee dislocation after total knee arthroplasty is a rare event. We report the case of an 88-year-old female who presented with right traumatic anterior knee dislocation and concurrent popliteal artery injury requiring an emergent bypass graft. Postoperatively, the patient had redislocated her prosthetic knee, requiring urgent re-reduction and stabilization with an external fixator. We review her case, as well as additional reported cases of anterior knee dislocation. We also review the clinical considerations surrounding arterial injury, vascular bypass, and external fixation as a proposed management in unstable cases refractory to bracing.

A conceptual framework for external validity

Evidence-Based Medicine (EBM) encourages clinicians to seek the most reputable evidence. The quality of evidence is organized in a hierarchy in which randomized controlled trials (RCTs) are regarded as least biased. However, RCTs are plagued by poor generalizability, impeding the translation of clinical research to practice. Though the presence of poor external validity is known, the factors that contribute to poor generalizability have not been summarized and placed in a framework. We propose a new population-oriented conceptual framework to facilitate consistent and comprehensive evaluation of generalizability, replicability, and assessment of RCT study quality.

Increased external rotation of the osteoarthritic knee joint according to the genu varum deformity

PURPOSE

To evaluate the rotational profile of the lower extremity using computed tomography (CT) in accordance with the degree of varus deformity in medial condyle-affected knee joint osteoarthritis (OA).

METHODS

This retrospective study included 1036 patients (872 lower extremities) with end-stage knee OA. The coronal alignment of the lower extremity was measured using standing anteroposterior radiography. The CT parameters of femoral anteversion and tibial torsion were assessed in relation to the knee joint. The axes were the femoral neck axis; the distal femoral axis, which was composed of the anterior trochlear axis, the clinical transepicondylar axis, and the posterior condylar axis; the axis of the proximal tibial condyles; and the bimalleolar axis.

RESULTS

There was a tendency for increased external rotation of the knee joint parameters in relation to the hip and ankle joints as varus deformity of the lower extremity increased. The relative external rotational deformity of the knee joint in relation to the hip joint had a positive value with a good correlation. The relative external rotational deformity of the knee joint in relation to the ankle joint also demonstrated a positive value with a good correlation.

CONCLUSION

The distal femur and proximal tibia (knee joint) tended to rotate externally in relation to the hip and ankle joint, respectively, as the degree of varus deformity increased. This study identified the relationship between lower extremity varus deformity and rotational deformity of knee joints with OA.

LEVEL OF EVIDENCE

III.

The European human biomonitoring platform - Design and implementation of a laboratory quality assurance/quality control (QA/QC) programme for selected priority chemicals

A fundamental objective of the human biomonitoring for Europe initiative (HBM4EU) is to progress toward comparable and robust exposure data for a wide variety of prioritized chemicals in human samples. A programme for Quality Assurance/Quality Control (QA/QC) was designed in HBM4EU with the purpose of creating a network of European laboratories providing comparable analytical data of high quality. Two approaches were chosen for two sets of prioritized chemicals with different timelines: (i) Scheme 1, where interested candidate laboratories participated in multiple rounds of proficiency tests (ii) Scheme 2, where selected expert laboratories participated in three rounds of interlaboratory comparison investigations. In both cases, the results were used to identify laboratories capable of generating consistent and comparable results for sample analysis in the frame of HBM4EU. In total, 84 laboratories from 26 countries were invited to participate in Scheme 1 that covered up to 73 biomarkers from Hexamoll® DINCH, phthalates, bisphenols, per- and polyfluoroalkyl substances, halogenated flame retardants (HFRs), organophosporous flame retardants (OPFRs), polycyclic aromatic hydrocarbons (PAH), cadmium, chromium and aromatic amines. 74 of the participants were successful for at least one biomarker in Scheme 1. Scheme 2 involved 22 biomarkers and successful results were obtained by 2 expert laboratories for arsenic, 5 for acrylamide, 4 for mycotoxins, 2 for pesticides and 2 for UV-filters in skin care products. The QA/QC programme allowed the identification of major difficulties and needs in HBM analysis as well of gaining insight in the analytical capacities of European laboratories. Furthermore, it is the first step towards the establishment of a sustainable European network of HBM laboratories.

Balance training monitoring and individual response during unstable vs. stable balance Exergaming in elderly adults: Findings from a randomized controlled trial

OBJECTIVE

Exercise-based fall prevention programs mainly refer to multimodal and challenging balance exercises. Individual load monitoring and interpretations are crucial to enable adequate adaptation responses on the individual level. Thus, assessing internal responses to external stimuli throughout an intervention period need to be adequately addressed. The aim of this secondary analysis of a 3-armed randomized controlled trial was to analyze internal and external loads of unstable vs. stable balance Exergame training in healthy seniors. We intended to elucidate whether differences of external and internal load criteria occur over the intervention period.

METHODS

A total of 51 healthy seniors (females: n = 34; males: n = 17; age: 69 ± 6 years; BMI: 27 ± 5) were allocated to either volitional stepping (VOL), volitional stepping under unstable conditions (VOL + US) or an inactive control group (CON). VOL and VOL + US completed 8 weeks of Exergame based step training (three weekly sessions, 45 min each) using the Dividat Senso device. Twelve different balance Exergames were used, consisting of virtual reality like video games. The original nonswinging, stable platform was employed for VOL, whereas VOL + US used an adapted Senso mounted on a swinging Posturomed Rack. The instability level was increased for VOL + US only every second week. External (game scores) and internal (perceived efforts, using the rated perceived exertion scale (RPE)) load measures were individually recorded for every session. Statistical analysis was carried out using linear mixed-effects modelling.

RESULTS

Although VOL + US completed similar games at identical training volumes under unstable conditions, the achieved game scores did not significantly differ between both training groups (p = 0.71). Both intervention groups notably improved their game scores over the 8 training weeks (p < 0.01). A significant time x group interaction effect was observed for perceived effort (p < 0.01), serving as an internal load measure. Subsequent post-hoc testing revealed significant greater perceived exertion values in each of the first 7 weeks (p < 0.05) in VOL + US compared to VOL. No between-group differences were found for RPE in week 8. Whereas RPE values in VOL + US decreased over time (week 1: 4.6 ± 1.9; week 8: 3.1 ± 1.6), VOL indicated similar RPE values for all weeks (week 1: 3.1 ± 1.3; week 8: 2.9 ± 1.4). A detailed analysis of all twelve games revealed that differences in perceived exertion depend on the game content: in 75% of the involved games the RPE level was significantly higher in VOL + US compared to VOL (p < 0.05).

CONCLUSION

Monitoring internal and external loads on individual level are paramount for gaining adequate training adaptations. Our results indicate that between-group differences in perceived efforts a) can funnel over time, b) depend on game content and c) do not necessarily affect overall scoring. Future studies should individually employ and monitor measures of perceived efforts to guarantee an adequate challenge to the balance system within exercise-based fall prevention programs.

Relationship between follow-up periods and the low-dose ranges with statistically significant radiation-induced risk of all solid cancers in the Russian cohort of Chernobyl emergency workers

Radiation-induced risks for all solid cancer incidence and mortality were studied in the cohort of Russian Chernobyl emergency workers. The cohort included 69,440 persons with documented individual radiation dose accrued over the time of working in the Chernobyl zone. The mean age at entry into the zone of recovery operations was 33.9 years and accumulated radiation dose was 132.9 mGy. A total of 6981 solid cancer incident cases and 4272 deaths occurred in this cohort from 1992 to 2017. Three follow-up periods were studied: 1992-2009, 1992-2013, and 1992-2017. For each follow-up period, the lowest dose range with statistically significant (p < 0.05) radiation-induced risk of all solid cancer incidence and mortality were obtained. For the incidence of all solid cancer during the follow-up period 1992-2009, this lowest dose range was estimated to be 0-250 mGy with an excess relative risk per dose of ERR Gy^-1 = 0.51 and 95% confidence interval (CI) (0.02; 1.05) Gy^-1. For the period 1992-2013, the lowest dose range was 0-175 mGy with ERR Gy^-1 = 0.85 (95% CI 0.03; 1.78), while for the whole follow-up period 1992-2017, it was 0-175 mGy with ERR Gy^-1 = 0.81 (95% CI 0.08; 1.62). For mortality from all solid cancers during the follow-up period 1992-2009, the lowest dose range with statistically significant radiation-induced risk was estimated to be 0-225 mGy with ERR Gy^-1 = 1.07 (95% CI 0.31; 0.97). For the period 1992-2013, the lowest dose range was 0-225 mGy with ERR Gy^-1 = 0.86 (95% CI 0.23; 1.58), while for the whole follow-up period 1992-2017, the lowest dose range was 0-200 mGy with ERR Gy^-1 = 0.82 (95% CI 0.10; 1.65). Thus, it was found that the minimal level of significant exposure (D_min), for which a statistically significant radiation-induced risk of all solid cancers was obtained for Russian emergency workers (with individual doses of 0 - D_min), decreases with increasing duration of cohort observation, both for cancer incidence and mortality.

The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review

Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.

The incidence of significant venous sinus stenosis and cerebral hyperemia in childhood hydrocephalus: prognostic value with regards to differentiating active from compensated disease

BACKGROUND

Symptomatic or active hydrocephalus in children is linked to an elevation in intracranial pressure (ICP), which is likely to be multifactorial in origin. The CSF outflow resistance, venous sinus resistance and total cerebral blood flow are likely factors in the ICP elevation. The purpose of this paper is to define the incidence, site and significance of venous sinus stenosis and/or cerebral hyperemia in a cohort of children diagnosed with hydrocephalus at a tertiary referral hospital.

METHODS

The imaging database was reviewed over a 10 year period and the index MRI of all children between the ages of 4 months and 15 years, who were diagnosed with treatment naive hydrocephalus of any type (excluding secondary to tumor) and had magnetic resonance venography (MRV) and flow quantification were selected. Patients were compared with children undergoing an MRI with MRV and flow quantification who were subsequently shown to have no abnormality. The cross-sectional area and circumference of the sinuses were measured at 4 levels. The hydraulic and effective diameters were calculated. An area stenosis of 65% or greater was deemed significant. A total cerebral blood flow greater than two standard deviations above the mean for controls was taken to be abnormal.

RESULTS

There were a total of 55 children with hydrocephalus compared to 118 age matched control MRV's and 35 control flow quantification studies. A high grade stenosis occurred in 56% of patients but in none of the controls (p < 0.0001). The commonest site of narrowing was in the distal sigmoid sinus. Cerebral hyperemia occurred in 13% of patients but did not occur in the controls.

CONCLUSIONS

The elevation in ICP in symptomatic hydrocephalus is multifactorial. Both high grade venous stenosis and cerebral hyperemia are common in childhood hydrocephalus. High grade stenosis was noted to be a risk factor for conservative management failure. Hyperemia was a good prognostic indicator.

The use of an external ultrasound fixator (Probefix) on intensive care patients: a feasibility study

Background

In critical care medicine, the use of transthoracic echo (TTE) is expanding. TTE can be used to measure dynamic parameters such as cardiac output (CO). An important asset of TTE is that it is a non-invasive technique. The Probefix is an external ultrasound holder strapped to the patient which makes it possible to measure CO using TTE in a fixed position possibly making the CO measurements more accurate compared to separate TTE CO measurements. The feasibility of the use of the Probefix to measure CO before and after a passive leg raising test (PLR) was studied. Intensive care patients were included after detection of hypovolemia using Flotrac. Endpoints were the possibility to use Probefix. Also CO measurements with and without the use of Probefix, before and after a PLR were compared to the CO measurements using Flotrac. Side effects in terms of skin alterations after the use of Probefix and patient’s comments on (dis)comfort were evaluated.

Results

Ten patients were included; in eight patients, sufficient recordings with the use of Probefix could be obtained. Using Bland–Altman plots, no difference was found in accuracy of measurements of CO with or without the use of Probefix before and after a PLR compared to Flotrac generated CO. There were only mild and temporary skin effects of the use of Probefix.

Conclusions

In this small feasibility study, the Probefix could be used in eight out of ten intensive care patients. The use of Probefix did not result in more or less accurate CO measurements compared to manually recorded TTE CO measurements. We suggest that larger studies on the use of Probefix in intensive care patients are needed.

Outcome of laparoscopic ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review, meta-analysis, and meta-regression analysis of the predictors for recurrence

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR.

METHODS

An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates.

RESULTS

Seventeen studies comprising 1242 patients of a median age of 60 years were included. The median operation time was 122.3 min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23 months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively.

CONCLUSION

LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

Implantable microphones as an alternative to external microphones for cochlear implants

Totally implantable cochlear implants may be able to address many of the problems cochlear implant users have around cosmetic appearances, discomfort, and restriction of activities. The major technological challenges that need to be solved to develop a totally implantable device relate to implanted microphone performance. Previous attempts at implanting microphones for cochlear implants have not performed as well as conventional cochlear implant microphones, and in addition have struggled with extraneous body or surface contact noise. Microphones can be implanted under the skin or act as sensors in the middle ear; however, evidence from middle ear implants suggest body and contact noise can be overcome by converting ossicular chain movements into digital signals. This article reviews implantable microphone systems and discusses the technology behind them.

Postoperative monitoring of free flap reconstruction: A comparison of external Doppler ultrasonography and the implantable Doppler probe

HYPOTHESIS

The time to detection of vascular compromise and the postoperative time to re-exploration are shorter using the implantable Doppler (ID) probe, thereby resulting in earlier surgical re-exploration and a higher flap salvage rate.

METHODS

A single-centre experience with 176 consecutive free flap reconstructions in 167 patients from 2000 to 2008 in a university-based teaching hospital by retrospective chart review is presented.

RESULTS

There was a significant difference in overall flap survival (ID 98.0%, external Doppler [ED] 89.3%) and total flap loss (ID 2.0%, ED 10.7%) between the two groups (P=0.03). The difference in flap salvage rate was not significant (ID 90.9%, ED 63.6%; P=0.068). The false-positive (ID 0%, ED 3%; P=0.18) and false-negative rates (ID 0.0%, ED 4.5%; P=1.0) were not significantly different. There was also a lower median postoperative time to re-exploration for the ID group, from 48 h to one week after initial surgery (ID 74.5 h, ED 136.8 h; P=0.05).

CONCLUSION

The present analysis revealed a potential benefit for the ID probe in the postoperative monitoring of free tissue transfers.

Salivary Alpha-Amylase Correlates with Subjective Heat Pain Perception

OBJECTIVE

Self-reports of pain are important for an adequate therapy. This is a problem with patients and infants who are restricted in providing an accurate verbal estimation of their pain. Reliable, real-time, economical, and non-invasive physiological correlates might contribute to a more comprehensive description of pain. Salivary alpha-amylase constitutes one candidate biomarker, which reflects predominantly sympathetic nervous system alterations under stressful conditions and can be measured non-invasively. The current study investigated the effects of acute heat pain on salivary alpha-amylase activity.

METHODS

Heat pain tolerance was measured on the non-dominant forearm. Participants completed visual analog scales on pain intensity and unpleasantness. Saliva samples were collected directly after pain induction.

SUBJECTS

Twenty-seven healthy volunteers were recruited for this study.

RESULTS

While salivary alpha-amylase levels correlated positively with intensity and unpleasantness ratings in response to acute heat pain stimuli, there was no corresponding association with pain tolerance.

CONCLUSIONS

Salivary alpha-amylase is suggested to be an indirect physiologic correlate of subjective heat pain perception. Future studies should address the role of salivary alpha-amylase depending on the origin of pain, the concerned tissue, and other pain assessment methods.

Mandibular Arteriovenous Malformation in an 8-year-old Child: A Case Report

Arteriovenous (AV) malformation is a congenital vascular anomaly in which there is an abnormal connection between the arterial and venous system resulting from developmental arrest during embryogenesis. In children, they are rare and potentially life-threatening. In the present case, an 8-year-old male patient presented with a simple gingival swelling associated with mobility of the corresponding teeth, which appeared relatively simple to excise but had an AV malformation associated with it. Timely diagnosis and investigations revealed its presence and hence prevented a catastrophy from occurring. Conventional method of surgical ligation of the external carotid artery was done as an emergency procedure and surgical resection was done without compromising the associated anatomic structures. This procedure helped control the bleeding as well as achieved an uneventful healing. This case report intends to create an awareness among Pediatric Dentists regarding the condition and thereby preventing an uncontrolled and unmanageable hemorrhage occurring in the Dental Office.

Temporising external fixation of calcaneus fractures prior to definitive plate fixation: a case series

INTRODUCTION

Surgical management of calcaneus fractures is technically demanding and has a high risk of wound complications. These fractures are traditionally managed with splinting until swelling has subsided, which can take weeks and leaves the fracture fragments displaced. We describe a novel protocol for the management of displaced intraarticular calcaneus fractures that utilises a temporising external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique was to enable earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the traditional extensile approach.

METHODS

The records of patients with displaced calcaneus fractures from 2010-2014 were reviewed retrospectively. A total of nine patients with 10 calcaneus fractures were treated using this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours after injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded.

RESULTS

The average Bohler's angle improved from 13.2 (range -2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight-bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up.

CONCLUSION

Early temporising external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. There were no complications related to the use of the external fixator in this series.

The assumption of heterogeneous or homogeneous radioactive contamination in soil/sediment: does it matter in terms of the external exposure of fauna?

The classical approach to environmental radioprotection is based on the assumption of homogeneously contaminated media. However, in soils and sediments there may be a significant variation of radioactivity with depth. The effect of this heterogeneity was investigated by examining the external exposure of various sediment and soil organisms, and determining the resulting dose rates, assuming a realistic combination of locations and radionuclides. The results were dependent on the exposure situation, i.e., the organism, its location, and the quality and quantity of radionuclides. The dose rates ranged over three orders of magnitude. The assumption of homogeneous contamination was not consistently conservative (if associated with a level of radioactivity averaged over the full thickness of soil or sediment that was sampled). Dose assessment for screening purposes requires consideration of the highest activity concentration measured in a soil/sediment that is considered to be homogeneously contaminated. A more refined assessment (e.g., higher tier of a graded approach) should take into consideration a more realistic contamination profile, and apply different dosimetric approaches.

External versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center

PURPOSE

To study the duration of surgery, outcomes, adverse events and success rates of external versus endonasal dacryocystorhinostomy (DCR) surgery in a specialized lacrimal surgery center.

METHODS

Prospective, interventional case series. Standard external DCR technique was performed. Mechanical endonasal DCR was performed with enlargement of the ostium and full length opening of the lacrimal sac. Surgical time, duration of intubation, incidence of hemorrhage, infection, wound dehiscence; follow-up duration and functional success at the end of follow up were recorded.

RESULTS

Functional success and symptomatic relief were equivalent in both procedures. Endonasal DCR surgery was found to be quicker to perform than external DCR surgery. The follow-up duration was comparable in both groups (mean 9 months). Patient satisfaction was significantly higher in the endonasal DCR group (9.3 versus 8.6).

CONCLUSION

Endonasal DCR surgery offers a very attractive alternative to the well established technique of external DCR surgery for the treatment of primary acquired nasolacrimal duct obstruction with equivalent success rates, shorter surgical time and higher patient satisfaction.

The anatomy of the superficial temporal artery in adult koreans using 3-dimensional computed tomographic angiogram: clinical research

Objective

The increased use of bypass surgery in the treatment of ischemic cerebrovascular diseases requires a better understanding of the superficial temporal artery (STA) anatomy. This study is to describe the gross anatomy of STA in adult Korean population with respect to cranial surgery and to provide basic anatomic data for bypass surgery.

Methods

The study evaluated retrospectively 35 patients who visited the neurosurgery department at a single institution. For each patient, both the left and right STA (70 vessels) were evaluated by a 3-dimensional computed tomographic angiogramfor diameter and anatomic relationships to external landmarks.

Results

Of 70 STAs, 69 had a bifurcation. Among these, 57 (82.6%) were above the superior margin of the zygomatic arch. The STA bifurcation was 53.2 ± 5.9 mm posterior to the keyhole, 9.5 ± 5.3 mm anterior to the posterior margin of condylar process of the mandible, and 21.7 ± 15.8 mm superior to the superior margin of the zygomatic arch. The inner diameter of the STA was 1.8 ± 0.5 mm at the superior margin of the zygomatic arch, and 1.4 ± 0.4 mm and 1.4 ± 0.5 mm for frontal and parietal branches, respectively. The 75.7% of frontal and 66.7% of parietal branches were suitable for microvascular anastomosis.

Conclusion

This present study demonstrated the STA in Korean adults, which may benefit the clinician in dealing with the surgical procedures related to this STA.

External laryngeal injuries in children--comparison of diagnostic methods

OBJECTIVES

The injuries of the larynx constitute around 1% of all injuries. The great majority of the injuries of the larynx happens during playing. The effects of these injuries may appear insignificant however, not always the direct clinical symptoms correlate with the degree of respiratory tract failure. The symptoms of laryngeal injuries depend on the extension and strength of the trauma and always relate to impair patency of respiratory tract. The aim of the study is to compare two diagnostic methods: laryngoscopy and ultrasonography in evaluation of laryngeal injuries in children.

METHODS

In the Department of Pediatric Otolaryngology, Medical University of Warsaw, in the period between 2004 and 2010 there were hospitalised 15 children with external injury of the larynx.

RESULTS

From among 15 hospitalized children, 7 were qualified as not serious trauma and were treated preservatively and the other 8 as sever trauma. The mechanism of traumas was diverse. Dyspnea was a predominating symptom, the others included hoarsness, change in voice quality, even aphonia, pain while speaking and swallowing, cough and hemoptysis.

CONCLUSIONS

Direct laryngoscopy is a standard in diagnostics of the injuries of the larynx. Ultrasonography of the larynx is recommended in every case of laryngeal injury as an additional non-invasive complementary diagnostic examination.

Hybrid rhinoplasty: beyond the dichotomy of rhinoplasty techniques

Although rhinoplasty and the development of facial aesthetic criteria can be traced to several millennia, contemporary techniques have passed through a rapid evolutionary process in the past century (1) (2). Although understanding human anatomy and the consequences of surgical excision occupied the minds of the founders of rhinoplasty, the process moved towards preservation of supporting structures, and maintaining the physiological functions of the nose. Initially, this endonasal approach created its own series of problems due to excessive tissue removal. External rhinoplasty provided a new impetus for growth in this field, and since its inception, has swung the pendulum of reconstruction firmly into its own sphere of influence. However, as no rhinoplasty technique holds all the answers, hybrid rhinoplasty seeks to combine the best achievements of 20(th) century rhinoplasty, from all schools of thought, in order to provide a safe, sensible and planned approach to the most demanding operation for the facial plastic surgeon.