Standardization of Intraoperative Neuromonitoring of Recurrent Laryngeal Nerve in Thyroid Operation

Background  

The lack of standardized procedures of intraoperative neuromonitoring (IONM) during thyroid operations may lead to highly variable results, and many of these results can cause misleading information and, conversely, increase the risk of recurrent laryngeal nerve (RLN) injury. Therefore, standardization of IONM procedures is necessary.     

Pentoxifylline ameliorates proteinuria through suppression of renal monocyte chemoattractant protein-1 in patients with proteinuric primary glomerular diseases

Proteinuria (albuminuria) reflects dysfunction of the glomerular permeability barrier in which inflammatory cytokines play a key role. Pentoxifylline (PTX) is a phosphodiesterase inhibitor that possesses potent anti-inflammatory and immunomudulatory effects. This study evaluated the effectiveness of PTX to reduce proteinuria and inflammatory mediators in patients with proteinuric primary glomerular diseases. Seventeen patients with primary glomerular diseases, a persistent spot proteinuria exceeding 1.5 g/g creatinine (Cr) and a glomerular filtration rate between 24 and 115 ml/min/1.73 m(2) were treated with PTX 400 mg twice daily for 6 months. Before and after the treatment, serum Cr, plasma renin activity and aldosterone concentrations, plasma and urinary tumor necrosis factor (TNF)-alpha, interleukin-1beta and monocyte chemoattractant protein (MCP)-1, as well as urinary protein and Cr were measured. PTX significantly reduced urinary protein excretion, along with an increase of serum albumin. A significant correlation existed between the basal urinary protein/Cr and the basal urinary MCP-1/Cr ratios. PTX lowered the urinary MCP-1/Cr ratio, and the percent reduction of urinary protein/Cr ratio correlated directly with the precent decrease of urinary MCP-1/Cr ratio after PTX treatment. There was no significant change in blood pressure, renal function, biochemical parameters, plasma renin activity and aldosterone concentrations, or plasma TNF-alpha and MCP-1 levels during the study. In conclusion, administration of PTX 800 mg per day is safe and effective for reducing proteinuria in patients with proteinuric primary glomerular diseases. This beneficial effect occurs in close association with a reduction of urinary MCP-1 excretion.     

The triple-phase CT image appearance of post-irradiated livers

Objective: To evaluate the sequential CT appearance of the liver after hepatic irradiation and to investigate the correlation between CT findings and radiation-induced hepatic injury.Material and Methods: The triple-phase CT images of 18 patients with hepatocellular carcinomas (HCC) after hepatic irradiation were retrospectively reviewed (in total 41 CT studies). The high-dose region within the liver was defined as the area receiving more than 90% of the prescribed irradiation dose. The mean radiation dose was 55.5 Gy. Density changes and patterns of enhancement in the high-dose region were classified as three types: type I, constant low-density change in all phases; type II, low-density change in both pre-contrast and arterial phases, and iso-density change in the portal phase; type III, low- or iso-density change in the pre-contrast phase, low- or high-density change in the arterial phase, and persistent high-density change in the portal phase. The interval between completion of radiotherapy and the CT examinations ranged from 9 to 469 days, with a mean of 147 days.Results: Nine of the 41 CT studies presented with type I, 9 with type II, and 16 with type III CT findings. The mean interval between completion of radiotherapy and the appearance of types I, II, and III CT findings were 74, 183, and 220 days, respectively. The interval was significantly shorter for type I findings than for type II and type III. The difference in interval was not significant between type II and type III. A type I finding with constant low-density change in the high-dose region of the liver was the most common pattern of CT findings within the first 3 months after hepatic irradiation. Either types II or III findings were frequently seen after 3 months.Conclusion: The sequential CT appearance and the density changes may indicate correlation with the pathogenesis of veno-occlusive disease.     

Breast cancer in young women: Imaging and clinical course

The purpose of this study was to characterize presenting imaging findings in women younger than 40 diagnosed with invasive breast cancer in the context of pathology and clinical course. Retrospective chart and imaging reviews were performed in patients under 40 diagnosed with breast cancer between July 1, 2004, and December 31, 2013. Patient demographic, imaging, pathology, and clinical data were collected. Overall and recurrence-free survival were estimated using the Kaplan-Meier method. Univariate Cox proportional hazards models were performed to identify factors associated with recurrence-free survival. Our study cohort consisted of 110 patients with invasive mammary carcinoma. One hundred one (91.8%) presented with a palpable mass. The mean size of all lesions on imaging was 3.5 cm ± 2.9 cm. Malignant calcifications were present in 54 (49.1%) cases. Imaging demonstrated multifocal or multicentric disease in 45 (40.9%) cases. Seventy four (67.3%) cancers were high grade. Luminal genomic subtypes were the most common (n = 61, 55.5%). At presentation, 4 (3.6%) patients had bilateral malignancy and 8 (7.3%) patients had distant metastatic disease. Ninety seven (88.2%) underwent neoadjuvant chemotherapy and 67 (60.9%) underwent radiation therapy. Seventy five (68.2%) of the patients underwent mastectomy. The restricted mean time to recurrence was 9.01 years (standard error 3.162 months). ER positivity was associated with compromised recurrence-free survival. The overall survival rate was 0.962 at 10 years. Young patients diagnosed with breast cancer typically present with advanced breast imaging findings and undergo aggressive treatment. Recurrence often occurs >5 years from diagnosis, and ER positive subtypes are at increased risk for recurrence.     

Duration of Lactation and Incidence of the Metabolic Syndrome in Women of Reproductive Age According to Gestational Diabetes Mellitus Status: A 20-Year Prospective Study in CARDIA (Coronary Artery Risk Development in Young Adults)

OBJECTIVE

The objective of the study was to prospectively assess the association between lactation duration and incidence of the metabolic syndrome among women of reproductive age.

RESEARCH DESIGN AND METHODS

Participants were 1,399 women (39% black, aged 18–30 years) in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, an ongoing multicenter, population-based, prospective observational cohort study conducted in the U.S. Women were nulliparous and free of the metabolic syndrome at baseline (1985–1986) and before subsequent pregnancies, and reexamined 7, 10, 15, and/or 20 years after baseline. Incident metabolic syndrome case participants were identified according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. Complementary log-log models estimated relative hazards of incident metabolic syndrome among time-dependent lactation duration categories by gestational diabetes mellitus (GDM) adjusted for age, race, study center, baseline covariates (BMI, metabolic syndrome components, education, smoking, physical activity), and time-dependent parity.

RESULTS

Among 704 parous women (620 non-GDM, 84 GDM), there were 120 incident metabolic syndrome case participants in 9,993 person-years (overall incidence rate 12.0 per 1,000 person-years; 10.8 for non-GDM, 22.1 for GDM). Increased lactation duration was associated with lower crude metabolic syndrome incidence rates from 0–1 month through >9 months (P < 0.001). Fully adjusted relative hazards showed that risk reductions associated with longer lactation were stronger among GDM (relative hazard range 0.14–0.56; P = 0.03) than non-GDM groups (relative hazard range 0.44–0.61; P = 0.03).

CONCLUSIONS

Longer duration of lactation was associated with lower incidence of the metabolic syndrome years after weaning among women with a history of GDM and without GDM, controlling for preconception measurements, BMI, and sociodemographic and lifestyle traits. Lactation may have persistent favorable effects on women''s cardiometabolic health.Lactation has favorable effects on cardiometabolic risk factors in women with and without a history of gestational diabetes mellitus (GDM), a strong predictor of type 2 diabetes (1,2) and the metabolic syndrome after pregnancy (3). In the general population, lactating compared with nonlactating women exhibit a less atherogenic lipid profile (4) and lower blood glucose and insulin concentrations (5). Consistent with these findings, lactating women with recent GDM experience lower fasting plasma glucose and insulin levels, higher plasma HDL cholesterol levels, and 50% lower prevalence of type 2 diabetes at 12–16 weeks postpartum (6,7).Yet, few studies have investigated whether lactation''s favorable effects on cardiometabolic risk factors persist after weaning to protect women against future disease. The only study, to our knowledge, to measure changes from preconception to after weaning reported 6-mg/dl higher average HDL cholesterol levels among women who lactated for ≥3 months versus <3 months independent of preconception plasma HDL cholesterol levels and weight gain (8). Epidemiologic studies have reported weak to modest protective associations between lactation and disease risk in midlife to late life, including lower prevalence of the metabolic syndrome (9,10) or cardiovascular risk factors (11) and lower incidence of myocardial infarction (12) and type 2 diabetes (13). Yet, evidence is lacking that directly links risk factor changes that persist after weaning to subsequent disease onset, because disease status and lactation history were ascertained decades after pregnancy, and preconception and/or postweaning risk factor measurements were not available (9–13). Other limitations include classification of outcomes via self-report only (11–13), and failure to account for mediating or confounding effects of lifestyle habits during the reproductive years. Lastly, lactation duration in relation to disease risk has not been examined separately among women with a history of GDM, with the exception of one study reporting a null association with incident diabetes (13).To our knowledge, studies have never examined lactation and incidence of the metabolic syndrome, or variation in disease risk by GDM status. To address these gaps, we prospectively examined whether increasing duration of lactation was associated with lower incidence of the metabolic syndrome during a 20-year period among women of childbearing age. We examined incidence rates for GDM and non-GDM pregnancies and controlled for preconception risk factor levels, sociodemographics, and follow-up behavioral attributes.     

The Overlap of Interstitial Cystitis/Painful Bladder Syndrome and Overactive Bladder

Objective:

We evaluated the prevalence of positive potassium sensitivity and cystoscopy with hydrodistention findings in patients with overactive bladder.

Method:

This was a prospective cohort study of 98 patients who presented with overactive bladder symptoms. The diagnosis of overactive bladder is established by the presence of irritable voiding symptoms. All patients completed a PUF questionnaire and underwent potassium sensitivity testing. Eighty patients underwent urodynamic testing, and 42 patients underwent cystoscopic hydrodistention while under general anesthesia.

Results:

The Potassium Sensitivity Test was positive in 59 (60.2%) of the 98 patients, 37 (56%) of wet overactive bladder patients, and 22 (68.8%) of dry overactive bladder patients. Their mean PUF score was 7. Thirty-three (78.5%) of the patients who underwent cystoscopic hydrodistention had glomerulations consistent with NIH criteria for interstitial cystitis, and 26 of these patients tested positive for potassium sensitivity. Fifty-one (63.8%) of the patients who underwent urodynamics tested positive for potassium sensitivity.

Conclusion:

Many patients with symptoms of overactive bladder with little or no pain have cystoscopic evidence of interstitial cystitis and a positive Potassium Sensitivity Test. Therapies directed toward the uroepithelial dysfunction and neural upregulation associated with interstitial cystitis/painful bladder syndrome may be an important adjunct for patients who have failed or have had a partial response to anticholinergic therapy and behavior modification.     

Local suppressive effect of clonidine on penile erection in the dog

Dogs, 8.5 to 10 kg. in weight, were anesthetized with sodium pentobarbital (35 mg./kg.), intraperitoneally. Penile erection as indicated by an increase in the intracorporal pressure (ICP-increase) was produced by electrical stimulation of the right cavernous nerves. Drugs were administered into the internal pudendal artery (IPA) and femoral vein. A low dose (0.2 to 0.4 microgram/kg.) of clonidine, an alpha 2 adrenoceptor agonist, which could not affect either ICP or systemic arterial pressure (SAP) through an intravenous route, did suppress the ICP-increase markedly via direct injection into the IPA which supplies the penile blood flow. By intra-IPA injection, yohimbine (2.5 micrograms/kg.), an alpha 2 adrenoceptor antagonist, remarkably restored the ICP to the erection state. By intravenous injection, clonidine at a dose of 1.6 to 3.2 micrograms/kg. also profoundly reduced the ICP-increase, but only negligibly lowered the SAP. The IPA blood flow (IPAF) decreased coincidentally when the ICP-increase was effectively reduced by either intravenous or intra-IPA injection of clonidine. These findings suggest clonidine could act locally in the penile structure to suppress penile erection, possibly resulting from a penile vasoconstriction involving alpha 2 adrenoceptor. Whether this vasoconstriction is caused by a direct alpha 2 stimulating effect on the vascular smooth muscle or by an alpha 2 presynaptic inhibition of the vasodilator nerve (cavernous nerve) endings has been discussed.     

Maternal employment and atopic dermatitis in children: a prospective cohort study

Background Considering the early onset of atopic dermatitis (AD), which most often arises in the first year of life, risk factors occurring very early in life must be considered. Little is known about the effects of maternal occupational exposure on the development of atopic disorders in children. Objectives The aim of this study was to evaluate associations between maternal employment and childhood AD. Methods We used multistage stratified systematic sampling to recruit 24 200 mother–newborn pairs from the Taiwan national birth register. Information on maternal occupation categories, work stress, working time, shift work and potential confounders during pregnancy was gathered by questionnaires after birth. At 3 years of age, information on the development of AD was assessed by home interviews. Multiple logistic regression analysis was performed to estimate the association of maternal employment and AD. Results Overall, 11 962 out of 19 381 mothers (61·7%) worked during pregnancy. The children of mothers who worked during pregnancy had an increased risk of AD compared with those whose mothers did not work [odds ratio (OR) 1·38, 95% confidence interval (CI) 1·25–1·53]. The children of mothers with a professional or technical occupation had a higher risk of AD (OR 1·64, 95% CI 1·44–1·87). The risk of AD was found to increase with maternal work stress during pregnancy in a dose–response manner (P_trend < 0·01). The mothers of children with AD had a longer working time than those without AD (P < 0·0001). However, no significant association between AD and maternal shift work was found. Conclusions Working in professional or technical occupations increased the risk of childhood AD in addition to work stress during pregnancy.