0026 Strong Gene-Environment Interactions of Trank1 Gene Polymorphisms with Birth Difficulties in Kleine Levin Syndrome

Introduction

Kleine-Levin Syndrome (KLS) is a rare disorder affecting adolescents and characterized by relapsing-remitting episodes of severe hypersomnia, cognitive impairment, and behavioral disturbances such as hyperphagia and sexual disinhibition. Pathophysiology is unknown, although imaging studies indicate decreased activity in hypothalamic/thalamic areas and in cortical areas during episodes. Familial occurrence is increased, and risk is associated with reports of complicated birth.

Methods

A worldwide Genome wide association (GWA) study was conducted in 673 KLS patients and ethnically matched 15,341 control individuals.

Results

We found a strong genome-wide significant association (OR=1.48 at rs150168018, p=8.6x10-9) with 24 single nucleotide polymorphisms (SNPs) encompassing a 35kb region located in the 5’ region of TRANK1 gene previously associated with bipolar disorder and schizophrenia. Strikingly, KLS cases with TRANK1 had statistically increased reports of difficult birth. As perinatal outcomes have dramatically improved over the last 40 years, we further stratified our sample by birth years, and found that recent cases had a significantly reduced TRANK1 association. These findings were confirmed in an independent replication cohort of 171 new patients where polygenic risk scores constructed on the discovery cohort replicated (r2=0.15; p<2.7x10-22 at p=0.1 threshold) and the TRANK1 association was found to be dependent on reports of birth difficulties (OR=1.54, p=0.01 versus OR=1.12, p=0.4). Pathway analysis of the overall GWAS association revealed significant association (p=0.02) with 19 genes in a pathway modulating rhythmic behaviors.

Conclusion

Our results demonstrate links between hypersomnia, behavioral rhythmicity and bipolar disorder and indicate that a polymorphism in the TRANK1 region affect brain development in the presence of a perinatal injury, with pathophysiological consequences such as KLS, bipolar disorder and schizophrenia.

Support

NIH NIMH 1R01MH080957 to EM PHRC 070138 to IA

Topical Hemostatic-Anesthetic Solution to Reduce Bleeding During Mohs Micrographic Surgery: A Case Control Study

BACKGROUND

Between stages of Mohs micrographic surgery, the wound is dressed and the patient waits for the histopathological results.<br/>

OBJECTIVE

To investigate the efficacy of a hemostatic-anesthetic solution-impregnated gauze in decreasing bleeding between Mohs stages.<br/>

MATERIALS AND METHODS

Twenty patients were treated with a hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL), and 20 others were treated with a saline solution for control. At the second Mohs stage, size measurements of the blood stain on a Telfa pad and the defect were recorded. The Rotation Thromboelastometry Method (ROTEM) was used to investigate a possible effect of lidocaine and adrenaline on the clot stability induced by tranexamic acid.<br/>

RESULTS

The ratio of blood stain size to Mohs defect size in the hemostatic anesthetic solution group was 1:1.47, whereas the ratio in the control saline group was 1:3.37 (P&lt;.001). Results of the ROTEM test showed that lidocaine and adrenaline did not interfere with the effect of tranexamic acid on clot formation and stability.<br/>

CONCLUSION

The application of gauze impregnated with tranexamic acid, adrenaline, and lidocaine on a surgical wound may be effective in reducing bleeding between Mohs stages. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(7):851-855.

Adhesive skin closure technique for closure of fasciotomy wounds in pediatric patients: a case series

BACKGROUND

Closure of fasciotomy wounds poses a challenge, particularly in pediatric cardiac patients who are too high risk for general anesthesia and often require anticoagulant treatment. The adhesive skin closure technique enables wound closure without the need for a secondary procedure such as surgery requiring anesthesia.

OBJECTIVES

This study sought to describe a treatment modality that assists in fasciotomy wound edge approximation without the need for surgery, while additionally aiding in achieving fast and aesthetic results in the aforementioned patient population. A case series of 4 pediatric patients with fasciotomy wounds is presented.

MATERIALS AND METHODS

Adhesive skin closure strips (Steri-Strips, 3M, St. Paul, MN) were placed perpendicular to the cleansed wound leaving small gaps for drainage, thus achieving complete propinquity. The strips were replaced sequentially with new strips every 2 to 3 days. Digital pictures of the wounds were obtained until complete closure of the wounds was achieved. Outcome variables included wound closure success rates and complication rates including infection, bleeding, and late scar formation.

RESULTS

Patient ages ranged from 2 weeks to 2 years, 9 months (mean: 10.5 months), average period of open wound prior to closure was 6.75 days (range: 5-11 days), treatment duration ranged from 15 to 26 days (mean: 21 days), and average follow-up was 4.5 months. One patient died due to their primary condition. No local infections, wound dehiscence with the treatment regimen, or any other immediate complications were encountered. There was a late complication in 1 patient who presented with a hypertrophic scar.

CONCLUSIONS

Use of the adhesive skin closure method to close fasciotomy wounds in pediatric patients in which surgical procedures were nonadvisable produced favorable results.

Examining the Correlation between Objective Injury Parameters, Personality Traits, and Adjustment Measures among Burn Victims

BACKGROUND

Burn victims experience immense physical and mental hardship during their process of rehabilitation and regaining functionality. We examined different objective burn-related factors as well as psychological ones, in the form of personality traits that may affect the rehabilitation process and its outcome.

OBJECTIVE

To assess the influence and correlation of specific personality traits and objective injury-related parameters on the adjustment of burn victims post-injury.

METHODS

Sixty-two male patients admitted to our burn unit due to burn injuries were compared with 36 healthy male individuals by use of questionnaires to assess each group's psychological adjustment parameters. Multivariate and hierarchical regression analysis was conducted to identify differences between the groups.

RESULTS

A significant negative correlation was found between the objective burn injury severity (e.g., total body surface area and burn depth) and the adjustment of burn victims (p < 0.05, p < 0.001, Table 3). Moreover, patients more severely injured tend to be more neurotic (p < 0.001), and less extroverted and agreeable (p < 0.01, Table 4).

CONCLUSION

Extroverted burn victims tend to adjust better to their post-injury life while the neurotic patients tend to have difficulties adjusting. This finding may suggest new tools for early identification of maladjustment-prone patients and therefore provide them with better psychological support in a more dedicated manner.

An Improvised "Blow Glove" Device Produces Similar PEP Values to a Commercial PEP Device: An Experimental Study

BACKGROUND

Postoperative positive expiratory pressure (PEP) therapy promotes increased lung volume, secretion clearance, and improved oxygenation. Several commercial devices exist that produce recommended PEP values (10-20 cmH2O) when the patient breathes through a fixed orifice resistor. It was hypothesized that an inexpensive, improvised "blow glove" device would produce similar PEP values over a wider range of expiration volumes and flow rates.

METHODS

PEP for different expiration volumes (400-2000 mL) and expiratory flow rates (10-80 L/min) was compared between a commercial PEP device (Resistex, Mercury Medical, Clearwater, FL) and an improvised "blow glove" device, recorded by a Vela ventilator (CareFusion, San Diego, CA). Dynamics in positive end expiratory pressure (PEEP) values were evaluated following five consecutive expirations. The "blow glove" device was evaluated using various glove compositions and sizes.

RESULTS

The improvised "blow glove" device produced a significantly higher rate of PEP values in the recommended range than the Resistex device (88.9% vs. 20%, p<0.0001). No significant difference was observed between small and large glove sizes (88.9% vs. 82.9%, p>0.05), but the powdered latex glove showed a significantly higher rate of PEP values in the recommended range than the powder-free latex glove (88.9% vs. 44.4%, p<0.001).

CONCLUSIONS

A "blow glove" PEP device using a powdered latex glove produces PEP values in the recommended range over a wider spectrum of expiratory flow rates and expiration volumes than a commercial PEP device.

Treatment of wounds following breast reduction and mastopexy with subsequent wound dehiscence with charged polystyrene microspheres

BACKGROUND

Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM).

MATERIALS AND METHODS

Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented.

RESULTS

The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered.

CONCLUSIONS

Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

Hypoglossal nerve paralysis in a burn patient following mechanical ventilation

Traumatic injury resulting in isolated dysfunction of the hypoglossal nerve is relatively rare and described in few case reports. We present a patient with isolated unilateral palsy of the twelfth cranial nerve (CN XII) resulting from recurrent airway intervention following extensive burn injuries. The differential diagnosis for paralysis of the CN XII is also discussed herein. This case illustrates the significance of comprehensive diagnostic evaluation and the need for refined airway manipulation in patients that require multiple endotracheal intubations.

Examining disaster planning models for large scale burn incidents--a theoretical plane crash into a high rise building

BACKGROUND

The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters.

METHODS

Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01.

RESULTS

Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario.

CONCLUSION

Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities.

Birth wind and fire: raising awareness to operating room fires during delivery

OBJECTIVE

We researched whether the obstetric operating room (OR) qualified as a fire-risk environment so as to take preventive measures accordingly.

METHODS

We analyzed a series of iatrogenic burns inflicted during birth by collecting clinical data and comparing it with known OR fire risk factors and with other factors that repeated in all cases in search of unique characteristics of the obstetric OR.

RESULTS

All three cases shared in common the same type of oxygen-rich open ventilation system, alcohol-based prepping solution, and the hastiness of cesarean delivery while spontaneous vaginal delivery was already in progress.

CONCLUSION

The obstetric OR is, as suspected, a fire-prone zone in more ways than the regular OR. Therefore, preventive measures should be undertaken and awareness for the possibility for such occurrences should be raised.

The temporal suspension flap for malar defects: a novel technique

Close opposition of full-thickness skin grafts to the recipient wound bed is felt to be critical for graft survival. This is usually accomplished by bolster dressings, basting sutures, or both. Herein, we describe a facile and rapid technique for placing quilting sutures in full-thickness grafts on the ear using a plain gut suture with a short, straight needle. This technique is especially valuable in facilitating precise approximation of grafts within the fossae of the anterior ear. In our experience, this approach promotes graft survival and produces excellent cosmetic results.

Post-facelift flap necrosis treatment using charged polystyrene microspheres

BACKGROUND

Flap necrosis following facial rhytidectomy constitutes a vexing and grievous complication to the patient and the surgeon. Treatment modalities that can expedite wound healing and re-epithelialization rates are highly desired.

OBJECTIVES

To assess wound healing and re-epithelialization rates of open wounds following postrhytidectomy flap necrosis treated with commercially available charged polystyrene microspheres (Polyheal-1, Polyheal Ltd, Israel).

METHODS

Flap necrosis following rhytidectomy with open wounds in three female patients were treated using dressings soaked with Polyheal-1. Wound closure rates were documented.

RESULTS

The wounds demonstrated both accelerated granulation tissue formation and rapid re-epithelialization rates. No complications or side effects were encountered.

CONCLUSIONS

Charged polystyrene microspheres may offer a new and efficacious way to treat open wounds due to flap necrosis following facial rhytidectomy. Further research with larger patient numbers is still needed to verify these findings.

"Wet behind the ears": the postauricular training ground for local flaps

Early in the course of surgical education, dermatologic and plastic surgery trainees shift from theory to practice. This shift must be done cautiously so as not to cause unnecessary damage to the patient, especially when attempting to reconstruct soft tissue defects on the face. Helical rim defects present an excellent opportunity because the postauricular region provides a safe environment for novice surgeons to practice the theoretical and manual aspects of basic flap reconstruction. This paper explains key features on how to plan basic flaps based on postauricular tissues.

Delay techniques for local flaps in dermatologic surgery

Local flaps may be required to reconstruct defects on the face, neck, and scalp. Occasionally, delay techniques are indicated to reduce the risk for flap ischemia and subsequent necrosis. Delay may be employed before the flap is raised, as done to improve blood supply to a random flap when length to breadth proportions are not ideal, or after the flap is raised and before separation of the pedicle in the final reconstructive step to improve vascularity in the distal end of an interpolation flap. We present our techniques and results of delay procedures for interpolation and similar flaps.

Reconstruction of a lower eyelid defect with a V to Y island flap

Repair of full thickness defects in the lower eyelid following extirpation of malignant tumors presents a challenge to the reconstructive surgeon. There are several techniques to choose from, depending on the defect's size and location.

Reconstruction of full-thickness defects with bovine-derived collagen/elastin matrix: a series of challenging cases and the first reported post-burn facial reconstruction

Reconstruction of full-thickness defects may benefit from integration of dermal substitutes, which serve as a foundation for split-thickness skin grafts, thus enhancing short and long-term results. We present a series of 7 patients who were treated between 2010 and 2012 for complicated full-thickness defects by the second-generation collagen/elastin matrix Matriderm® covered by a split-thickness skin graft. The defects resulted from malignancy resection, trauma, and post-burn scar reconstruction. Overall graft take was excellent and no complications were noted regarding the dermal substitute. Graft quality was close to normal skin in terms of elasticity, pliability, texture, and color. Good contour and cushioning of defects in weight bearing areas was also achieved. Matriderm was found to be a useful adjunct to full-thickness defect reconstruction, especially in difficult areas where the desired result is a scar of the highest quality possible.

Complex forehead defects: a novel reconstructive technique and review of available methods

Complex forehead defects may result from excision of tumors or trauma. The reconstructive challenge is determined by the extent of tissue loss, the quality of the remaining tissue, possibly comprised vascular supply to the affected region, and special considerations (eg, exposed bone or injury to underlying structures). This paper describes a novel reconstructive approach to correct a complex forehead defect with exposed bone and discusses the armamentarium of reconstructive options for such cases.

A new simple, safe, and easy solution for upper lip dermabrasion

BACKGROUND

Upper lip wrinkling is a common complaint of patients seeking perioral rejuvenation. Lately, manual dermabrasion has become more popular due to its safety, minimal cost, and favorable results. In several hospitals, the ability to efficiently sterilize sand paper has been questioned.

METHODS

Between 2007 and 2010, 29 patients underwent manual dermabrasion of the skin of the upper lip using an electric cautery scratch pad during their surgeries.

RESULTS

The average patient was aged 60.2 years. The average healing period was 5.8 days. Patient satisfaction from the procedure ranged from very good to excellent. No serious or long lasting complications have been encountered during our follow-up period.

Defying consensus: correct sizing of full-thickness skin grafts

BACKGROUND

Full-Thickness skin grafts are routinely used to reconstruct defects throughout the body. When planning the size of the graft, the surgeon usually copies a template from the defect and measures the graft to fit its full dimensions. This may lead to an oversized graft, resulting an unaesthetic outcome.

OBJECTIVE

To evaluate discrepancy in size between the excised full-thickness skin and the excision (donor) site.

METHODS

Data from 20 cases of full-thickness excisions was reviewed and analyzed.

RESULTS

There was a considerable difference in length of both the short and long axes between the excised full-thickness skin and the excision site.

CONCLUSIONS

The initial size of a full-thickness skin graft should be smaller than the defect it is planned to cover.

Nasal ala reconstruction with a crus helix composite graft: a stepladder approach

BACKGROUND

Defects of the nasal ala present a complex reconstructive challenge. Composite grafts comprise all layers required to successfully reconstruct these full thickness deformities making them the ideal reconstructive method, yet they are usually avoided because of unjustified disreputable failure rates.

OBJECTIVE

The authors introduce a stepladder approach for alar reconstruction with a crus of helix composite graft according to the severity and complexity of the defect.

METHODS

Data from 25 patients who underwent correction of full thickness alar defects with composite grafts was collected and reviewed.

RESULTS

There were no complete graft failures in any of the cases. Ten patients (40%) had partial graft necrosis ranging from 5 to 50% (average 18%); two of them (20%) were heavy smokers.

CONCLUSIONS

Composite grafts should be considered for reconstruction of full thickness nasal ala defects, given the correct surgical technique is implemented.

Back to basics: reconstruction of defects on the lower half of the nose

BACKGROUND

Surgical reconstruction of defects on the lower half of the nose mandates special considerations. Simple excision and suturing might cause a depressed scar and nostril flaring. Hence, the preoperative plan should be designed properly to avoid disfigurement and to achieve a successful reconstruction.

OBJECTIVE

Three basic reconstructive concepts are essentially combined: 1.) The ratio between scar length and defect diameter should be extended beyond the standard 3:1 ratio; 2.) The defect should be positioned asymmetrically within the inferior half of the excision outline; and 3.) Para-median defects mandate an inferior, horizontal advancement ("sliding") flap to avoid nostril flaring. A salvage technique is also discussed.

METHODS

Data from patients treated by Mohs micrographic surgery for tumors of the inferior aspect of the nasal dorsum and reconstructed according to the proposed course of action was collected and reviewed.

RESULTS

The proposed reconstructive path proved successful for all patients. Although one case required salvage skin grafting, all patients had aesthetically pleasing results. No postoperative complications were noted.

CONCLUSIONS

Simple excision and primary suturing is a viable method for treating lesions on the lower half of the nose, provided that the surgeon follows a set of basic reconstructive principles.

The hatchet and bilobed flaps revisited: shedding new light on traditional concepts

BACKGROUND

The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results.

OBJECTIVE

We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap.

METHODS

We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years.

RESULTS

Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity.

CONCLUSIONS

We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

3D Mohs surgery: a new concept

Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

Third generation cellular multimedia teleconsultations in plastic surgery

We conducted a study to test whether new third generation (3G) mobile phones could be integrated into service as a working tool between plastic surgeons. During an eight-month period, 58 multimedia consultations were performed involving 57 patients. The majority of the consultations were for trauma or wounds. All consultations comprised a digital photograph taken with the integrated camera and sent via the Multimedia Messaging Service (MMS). In 86% of the cases the residents reported that multimedia information contributed to their ability to independently handle similar cases in future. Satisfaction scores were high among all participants. We believe that a multimedia consultation in a hospital setting adds information to an ordinary telephone call, thus decreasing medico-legal risks. We recommend it for routine use.

Silicone nipple shields: an innovative postoperative dressing technique after nipple reconstruction

BACKGROUND

The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable.

METHODS

In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure.

RESULTS

No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments.

DISCUSSION

Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate.

Quality of life after breast cancer surgery with or without reconstruction

In the modern era, where breast-conserving surgery is a viable alternative to mastectomy, breast cancer patients and their healthcare providers have to consider the issue of quality of life in regards to the type of surgery. The choice of surgical procedure should consider the perceptions of women diagnosed with breast cancer as well as their functional and emotional well-being. A more holistic approach to the patient should be implemented with proper psychological evaluation before and psychological support after the crisis.

Cardiorespiratory fitness and plasma homocysteine levels in adult males and females

BACKGROUND

High levels of plasma homocysteine constitute a risk for cardiovascular disease. Physical activity, known to reduce CVD risk, has been related to levels of Hcy. Recently, higher Hcy was shown to be associated with lower cardiovascular fitness in women but not in men.

OBJECTIVES

To further explore the relationship between cardiorespiratory fitness and plasma total homocysteine levels in a large cohort of adult males and females.

METHODS

This cross-sectional study included 2576 fitness and Hcy examinations in adults (62% males) aged 30-59 years randomly drawn from a population undergoing a periodic health examination in the Sheba Medical Center's Executive Screening Survey. Blood tests were collected for tHcy and a sub-maximal exercise test was performed to estimate cardiorespiratory fitness. Information on CVD/CVD risk factors (coronary heart disease, cerebrovascular accident, diabetes, hypertension or dyslipidemia) was self-reported.

RESULTS

Mean tHcy plasma levels were 14.4 +/- 7.7 and 10.2 +/- 3.0 micromol/ml, and mean maximal oxygen uptake 36.5 +/- 11.7 and 292 +/- 9.5 ml/kg/min for males and females, respectively. A multiple regression analysis, adjusting for age, body mass index and CVD/CVD risk factors, showed no association between cardiorespiratory fitness and level of tHcy in males (P = 0.09) or in females (P = 0.62).

CONCLUSIONS

In this sample no association was found between level of cardiorespiratory fitness and plasma tHcy in men or women. The inconsistency of findings and the small number of studies warrant further research of the association between cardiorespiratory fitness and tHcy, an association that may have clinical implications for the modifications of cardiovascular risk factors.

The role of antibiotics in rhinoplasty and septoplasty: a literature review

BACKGROUND

Prophylactic antimicrobial therapy during nasal surgery is common among surgeons worldwide, although the effectiveness of this practice is controversial. The authors reviewed the literature to evaluate the value of antibiotic prophylaxis.

METHODS

A MEDLINE search was preformed using the key terms septoplasty, rhinoplasty, infections and antibiotics. The authors identified eleven studies written in English or German that addressed the effectiveness of prophylactic antibiotics, infection rate and bacteremia during nasal surgery. Due to the small number of studies statistical re-analysis was discarded.

RESULTS

The articles demonstrated an overall very low incidence of bacteremia or infection. The studies failed to demonstrate a difference between patients who received antibiotic prophylaxis during nasal surgery and patients who did not; with the only exception being cases of complicated revision rhinoplasties.

CONCLUSION

Our review suggests that the infection rate after elective nasal surgery is very low, making routine antibiotic prophylaxis redundant. Preventive systemic antibiotics are indicated in complicated revision rhinoplasties, prolonged placement of nasal packs and for patients who are susceptible to infections.

Hyperacusis in Williams syndrome: Characteristics and associated neuroaudiologic abnormalities

BACKGROUND

Hyperacusis and phonophobia are common, debilitating symptoms in Williams syndrome (WS), yet little is known about their underlying audiologic and neurologic processes.

METHODS

The mothers of 49 subjects with WS were asked to complete the Hyperacusis Screening Questionnaire. Subjects with reported hyperacusis and sufficient developmental capacity underwent comprehensive audiological and brain auditory evoked response (BAER) testing. Findings were compared with those from pair-matched typically developing control subjects.

RESULTS

Forty-one of the 49 children with WS (84%) had hyperacusis of moderate to severe degree, which began in infancy. Of these, 21 (mean age 15.8 +/- 5.5 years) were quantitatively tested. Subjects with WS reported discomfort at sound intensities on average 20 dB lower than control subjects. Pure-tone audiometry and distortion products otoacoustic emission test revealed a high-frequency cochlear hearing loss. An absence of ipsilateral acoustic reflex responses to maximum stimulation was significantly more common in the subjects with WS than controls. On BAER testing, the WS group had a significant prolongation in wave I latency.

CONCLUSIONS

Hyperacusis in Williams syndrome (WS) is associated with a high-frequency hearing loss resembling the configuration of noise-induced hearing loss. The hyperacusis and hearing loss in WS may stem from a deficiency in the acoustic reflex resulting from auditory nerve dysfunction. Additional mechanisms that may mediate hyperacusis in WS and should be evaluated in future studies include recruitment, malformation of the facial canal, and haploinsufficiency of the elastin gene.

Kleine-Levin syndrome: a systematic review of 186 cases in the literature

Kleine-Levin syndrome (KLS) is a rare disorder with symptoms that include periodic hypersomnia, cognitive and behavioural disturbances. Large series of patients are lacking. In order to report on various KLS symptoms, identify risk factors and analyse treatment response, we performed a systematic review of 195 articles, written in English and non-English languages, which are available on Medline dating from 1962 to 2004. Doubtful or duplicate cases, case series without individual details and reviews (n = 56 articles) were excluded. In addition, the details of 186 patients from 139 articles were compiled. Primary KLS cases (n = 168) were found mostly in men (68%) and occurred sporadically worldwide. The median age of onset was 15 years (range 4-82 years, 81% during the second decade) and the syndrome lasted 8 years, with seven episodes of 10 days, recurring every 3.5 months (median values) with the disease lasting longer in women and in patients with less frequent episodes during the first year. It was precipitated most frequently by infections (38.2%), head trauma (9%), or alcohol consumption (5.4%). Common symptoms were hypersomnia (100%), cognitive changes (96%, including a specific feeling of derealization), eating disturbances (80%), hypersexuality (43%), compulsions (29%), and depressed mood (48%). In 75 treated patients (213 trials), somnolence decreased using stimulants (mainly amphetamines) in 40% of cases, while neuroleptics and antidepressants were of poor benefit. Only lithium (but not carbamazepine or other antiepileptics) had a higher reported response rate (41%) for stopping relapses when compared to medical abstention (19%). Secondary KLS (n = 18) patients were older and had more frequent and longer episodes, but had clinical symptoms and treatment responses similar to primary cases. In conclusion, KLS is a unique disease which may be more severe in female and secondary cases.

Physicians' attitudes about involvement in lethal injection for capital punishment

BACKGROUND

Physicians could play various roles in carrying out capital punishment via lethal injection. Medical societies like the American Medical Association (AMA) and American College of Physicians have established which roles are acceptable and which are disallowed. No one has explored physicians' attitudes toward their potential roles in this process.

METHODS

We surveyed physicians about how acceptable it was for physicians to engage in 8 actions disallowed by the AMA and 4 allowed actions involving lethal injection. Questions assessing attitudes toward capital punishment and assisted suicide were included. The impact of attitudinal and demographic variables on the number of disallowed actions deemed acceptable was analyzed via analysis of variance and multiple logistic regression analysis.

RESULTS

Four hundred eighty-two physicians (51%) returned questionnaires. Eighty percent indicated that at least 1 of the disallowed actions was acceptable, 53% indicated that 5 or more were acceptable, and 34% approved all 8 disallowed actions. The percentage of respondents approving of disallowed actions varied from 43% for injecting lethal drugs to 74% for determining when death occurred. All 4 allowed actions were deemed acceptable by the majority of respondents. Favoring the death penalty (P<.001) and the acceptance of assisted suicide (P<.001) were associated with an increased number of disallowed actions that were deemed acceptable.

CONCLUSIONS

Despite medical society policies, the majority of physicians surveyed approved of most disallowed actions involving capital punishment, indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes. It is possible that the lack of stigmatization by colleagues allows physicians to engage in such practices. Arch Intern Med. 2000;160:2912-2916

Use of mediastinoscopy for foreign body removal

Foreign body removal from the aerodigestive tract can be a challenging endeavor despite improvements in technology. Rigid bronchoscopy has been demonstrated to be a safe and effective means of airway foreign body removal with appropriate training and expertise. However, potential complications exist and include extraluminal impaction of a penetrating foreign body during removal. This report details such a complication and the first known use of mediastinoscopy to remove the impacted foreign body to avoid the need for thoracotomy.

Perceptions of pregnancy risk: a comparison by class and race

Perceptions of pregnancy risk by class and race were examined in a small sample of adolescent mothers. Findings from in-depth interviews indicated differences by class, but not by race, in the degree to which these adolescents, prior to conception, maintained a "personal fable" about their invulnerability to becoming pregnant through unprotected sexual intercourse.

Neuronal vacuolization and necrosis induced by the noncompetitive N-methyl-D-aspartate (NMDA) antagonist MK(+)801 (dizocilpine maleate): a light and electron microscopic evaluation of the rat retrosplenial cortex

MK(+)801 (dizocilpine maleate) is a noncompetitive antagonist at the N-methyl-D-aspartate (NMDA) receptor, the major glutamate receptor at excitatory synapses in the central nervous system. Since NMDA antagonists are neuroprotective, there is interest in their development for treatment of cerebral ischemia. Unfortunately, many of these compounds also induce vacuole formation in neurons of the rat retrosplenial cortex (Olney et al., Science 244: 1360-1362, 1989). Although vacuolization was initially reported to be reversible with MK(+)801, preliminary data later suggested that higher doses might produce neuronal necrosis. To explore this issue, young male Sprague-Dawley rats were given a single subcutaneous dose of vehicle or 1, 5, or 10 mg/kg MK(+)801. At 4 h and 1, 2, 3, 4, 7, and 14 days postdose (DPD), the retrosplenial cortex was examined by light and electron microscopy. At 4 h, vacuoles occurred in neurons of retrosplenial cortical layers 3 and 4 in all rats given MK(+)801. Mitochondria and endoplasmic reticulum contributed to vacuole formation. At 1 DPD, vacuoles or necrotic neurons were rarely observed. At all subsequent time points, necrotic neurons were readily evident in rats given 5 or 10 mg/kg MK(+)801, but only rarely evident in rats given 1 mg/kg. Necrotic neurons were associated with reactive microglial cells that contained electron-dense debris ultrastructurally. If similar dose-dependent neuronal necrosis proves to be a feature of other NMDA antagonists, such effects might raise concerns for the development and use of these compounds in human cerebrovascular diseases.

Recombinant murine GM-CSF increases resistance of some factor dependent hematopoietic progenitor cells to low-dose-rate gamma irradiation

The effects of murine recombinant IL-3 (multi-CSF) and murine recombinant GM-CSF (granulocyte-macrophage colony stimulating factor) on the radiation biology of clonal hematopoietic progenitor cell lines were evaluated. Four clonal cell lines with growth response to either IL-3 or GM-CSF (FDCP-1JL26, and bg/bg d64) or exclusively dependent on IL-3 (32D cl 3 and B6SUtA), were pre-incubated in IL-3, or GM-CSF, for 7 days prior to gamma irradiation, then washed and irradiated at 5 cGy/min, or 116 cGy/min, and transferred to semisolid medium supplemented with either IL-3, or GM-CSF, for assay of 7 day greater than or equal to 50 cell colonies. The cell lines demonstrated similar radiosensitivity and lack of a detectable dose-rate effect when grown in IL-3 (FDCP-1JL26: D0 154, n 1.05 at 5 cGy/min, and D0 138, n 1.16 at 116 cGy/min; bg/bg d64: D0 95.7, n 1.16 at 5 cGy/min, and D0 97.7 n .993 at 116 cGy/min; B6SUtA: D0 101, n 1.29 at 5 cGy/min, D0 100, n 1.27 at 116 cGy/min; and cell line 32D cl 3: D0 123, n 1.65 at 5 cGy/min, and D0 126, n 1.17 at 116 cGy/min). In contrast, FDCP-1JL26 cells demonstrated a significant relative radioresistance at low-dose-rate when grown in recombinant GM-CSF, (D0 217, n 1.27 at 5 cGy/min, D0 138, n 1.34 at 116 cGy/min, p less than .005). The increase in radioresistance of FDCP-1 cells at low-dose-rate was induced either by preincubation in GM-CSF with transfer to IL-3, or by preincubation in IL-3 and transfer to recombinant GM-CSF. Growth factor independent malignant subclones of lines B6SUtA and FDCP-1JL26 demonstrated a significant increase in radioresistance at low-dose-rate (B6SUtA EL4JL: D0 187, n 1.39 at 5 cGy/min, and D0 133, n 1.73 at 116 cGy/min (p. less than .05); and FDCP-1JL26 F7 cl 2: D0 191, n 1.17 at 5 cGy/min, and D0 150, n 1.31 at 116 cGy/min [p less than .05]). Thus, some hematopoietic progenitor cell lines are induced by GM-CSF to grow after irradiation at low-dose-rate similar to the growth of clonal malignant cell lines. The data may have implications for the radiation biology of normal hematopoietic progenitor cells in two circumstances: (a) selective survival of GM-CSF responsive cells after total body irradiation, and (b) selective survival of some hematopoietic progenitors in vivo during clinical recombinant GM-CSF infusion.

Improvement in functional recovery of stunned canine myocardium by long-term pretreatment with oral propranolol

We investigated the effect of long-term oral pretreatment with the beta-adrenergic antagonist, propranolol (Inderal LA, 160 mg daily for 8 days) on the functional recovery of myocardium after 15-minute coronary artery occlusion followed by 3 hours of reperfusion in barbital-anesthetized dogs. Propranolol-pretreated dogs (N = 9) displayed a significantly lower left ventricular peak-positive rise in ventricular pressure (dP/dt), heart rate, and rate-pressure product throughout the experiment compared with the control group (N = 15). Subendocardial percent segment shortening as measured by sonomicrometry recovered to 65.4 +/- 7.2% of the preocclusion level after pretreatment with propranolol, whereas the control group recovered to only 11.1% +/- 10.2% after 3 hours of reperfusion. To ascertain the beneficial role of a lower heart rate on the recovery of regional contractile function, a third group of dogs (N = 6) was pretreated with propranolol, but heart rate was maintained at control levels by atrial pacing. The beneficial effects of pretreatment with propranolol were abolished in this group. There were no differences between groups in myocardial perfusion in the normal region as measured by the radioactive microsphere technique. However, in postischemic, reperfused myocardium, there was a significantly higher blood flow to subepicardium, mid-myocardium, and subendocardium after reperfusion in the propranolol-pretreated, unpaced group. Thus long-term oral pretreatment with propranolol enhances the contractile recovery of postischemic, reperfused myocardium. This protective effect of beta-adrenergic blockade is primarily related to the reduction in heart rate and enhanced perfusion in the postischemic region.

Stimulation of hematopoiesis in vivo by recombinant bacterial murine interleukin 3

Mouse interleukin 3 (IL-3) cDNA was cloned into a plasmid construction, allowing the synthesis of very high quantities of IL-3 in Escherichia coli. The recombinant (r) IL-3, purified to homogeneity, was active in vitro on the proliferation and differentiation of various hematopoietic progenitor cells at 1 pM. To maintain detectable blood levels of IL-3, osmotic pumps containing rIL-3 or control solutions were placed under the skin of normal and irradiated C3H/HeJ and (BALB X B10) F1 mice. The effect of IL-3 on hematopoietic progenitor cell numbers in spleen and bone marrow was evaluated 3 and 7 days later by using an in vitro clonal assay. The results demonstrated the following: (i) Doses of IL-3 infused at the rate of 2.5-5 ng per g of body weight per hr were sufficient to increase the numbers of hematopoietic progenitors in normal mice by at least 2-fold within 3 days. (ii) In mice with progenitor cell levels depressed by sublethal irradiation, 7-day treatment with IL-3 resulted in a 10-fold increase to near normal levels. (iii) The erythroid and myeloid lineages appeared to be enhanced to the same extent. (iv) Enhancement of hematopoiesis occurred primarily in spleen, but hematopoietic foci were also evident in the liver; in contrast, total cell and progenitor cell numbers were decreased in the bone marrow.

Comparison of the structures of free and ribosome-bound tRNAPhe by using slow tritium exchange

The rate of incorporation of tritium from the solvent into the C-8 position of purines in RNA is markedly sensitive to the microenvironment. This slow tritium exchange reaction has been used to study the structure and interactions of yeast tRNAPhe bound to poly(U)-programed tight-couple 70S ribosomes of Escherichia coli. The tritium incorporation into specific sites of the tRNA was determined by enzymatic digestion and measurement of the specific activity of each of the isolated radioactive fragments. Ribosome binding leads to marked suppression in the exchange rate of a number of fragments. This delineates extensive regions of tRNA-ribosome contact. No change in exchange rates is seen for fragments from the corner of the molecule, indicating that this region of bound tRNA is readily accessible to the solvent. Ribosome binding results in an enhanced exchange rate at the T loop. This appears to be the result of a conformational change that is most likely an unfolding of the T and D loops. Additional tritium exchange reactions suggest this conformational change is induced by ribosomes and not by messenger.