Otoacoustic emissions as a screening test for hearing impairment in children recovering from acute bacterial meningitis

OBJECTIVES: To study the efficacy of otoacoustic emissions (OAEs) as a screening test for hearing impairment in children with acute bacterial meningitis. Hearing tests were performed before discharge from the hospital in an attempt to improve coverage and avoid delays in the diagnosis of postmeningitic hearing loss. METHODS: Children with bacterial meningitis were recruited from 21 centers. In the 48 hours before discharge from the hospital, all patients underwent a thorough audiologic assessment consisting of transient evoked OAEs, auditory brainstem responses (ABRs), otoscopy, and tympanometry. Hearing loss was defined as ABR threshold >/=30 dB. The results of OAE screening were compared with the gold standard of ABR threshold. RESULTS: Of 124 children recruited, we were able to perform both OAEs and ABRs on 110 children. Seven (6.3%) of the 110 children had ABR threshold >/=30 dB; 2 had sensorineural hearing loss and 5 had conductive hearing loss. At follow-up, hearing loss persisted in both cases of sensorineural hearing loss and no new cases were identified. All 7 children with hearing loss failed the OAE screening test. Ninety-four children with normal hearing thresholds passed the test, and 9 failed. Thus, the screening test had a sensitivity of 1.00 (95% confidence interval, 0.59 to 1.00), a specificity of 0.91 (0.85 to 0.97), a positive predictive value of 0. 44 (0.20 to 0.70), and a negative predictive value of 1.00 (0.96 to 1.00). CONCLUSIONS: OAE screening in children recovering from meningitis was found to be feasible and effective. The test was highly sensitive and reasonably specific. Inpatient OAE screening should allow early diagnosis of postmeningitic hearing loss and prompt auditory rehabilitation.     

Primary right atrial synovial sarcoma manifesting as transient ischemic attacks

Primary tumors of the heart are rare and most of them benign. The majority of benign cardiac tumors are myxomas while almost all malignant cardiac tumors are sarcomas. We present a case of primary right atrial synovial sarcoma, a form of sarcoma particularly rare in the heart. The tumor manifested clinically as transient ischemic attacks probably related to a patent foramen ovale allowing paradoxical tumor embolization.     

Advances in Trace Element Supplementation for Parenteral Nutrition

Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT^® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.     

Management of lower extremity arterial injuries

Past and current military experience has contributed considerably to the advances made in the treatment of extremity vascular injuries. However, the management of arterial injuries of the lower extremity is still associated with significant rates of limb loss and functional deficits. The incidence of civilian arterial limb injuries, including those related to iatrogenic vessel catheterization, has increased over time, but remains fortunately uncommon. Several related issues, such as the initial order of intervention for associated bony injuries, use of temporary intravascular shunt, repair of concomitant venous injuries, and prophylactic fasciotomy, have been debated extensively and remain controversial. The current treatment of extremity arterial injuries continues to evolve with the availability of superior imaging modalities and emerging endovascular technology. Additionally, the multi-disciplinary approach to the injured patients has produced improved limb-salvage and patient survival. In this review, we discuss the diagnostic evaluation, surgical and endovascular treatment of arterial injuries in the lower extremity.     

Phylogenetic and Phylogeographic Analyses of Porcine Circovirus Type 2 Among Pig Farms in Vietnam

This study demonstrated the prevalence of Porcine circovirus type 2 (PCV2) among pig farms in Vietnam. Analyses of the genome, capsid protein and phylogeny classified all 30 Vietnamese PCV2 strains as the PCV2b genotype, belonging to the clusters of 1A, 1B, 1C and recombinant forms. Each viral genome was 1767 nucleotides long and shared 96.0–100% nucleotide sequence identity. The amino acid substitutions in the capsid protein of the Vietnamese PCV2 strains were in immunodominant regions, and the majority of strains (24/30) contained a lysine extension at the C‐terminus. Bayesian phylogeographic analysis revealed epidemic links of the PCV2 recombinant cluster within and among countries, which supports a circulating recombinant form of PCV2. Further analysis by the Jameson–Wolf antigenic index indicated antigenic alterations at important sites in the capsid protein (sites 131–133) among the recombinant cluster and the other clusters of PCV2b.     

Anterior cervical discectomy and fusion with implantable titanium cage: initial impressions, patient outcomes and comparison to fusion with allograft.

BACKGROUND CONTEXT: The use of metal cage prosthetic devices in anterior cervical discectomy with fusion (ACDF) has increased rapidly. One of these devices is the titanium Rabea cage (Signus, Alzenau, Germany) [correction]. There are no peer-reviewed objective reports on the use of these cages in cervical discectomy. PURPOSE: The authors present preliminary outcomes data on the Rabea cage. This study is intended to provide adjunct data for surgeons who are using or are considering the use of these devices. STUDY DESIGN/SETTING: Patients in a private practice were studied prospectively as part of a long-term assessment of outcomes using several surgical procedures. Data were collated and analyzed by an independent researcher. PATIENT SAMPLE: Rabea cages were used in consecutive candidates (n=37) for ACDF. The results using Rabea cages were compared with two prospectively studied control groups, one historical (n=66) and one concurrent (n=28), both groups using ACDF with bone allograft and no instrumentation. OUTCOME MEASURES: Success at 6 months after surgery was determined using six major patient-reported outcome measures, including visual analog scales (VAS) for arm and neck pain, the Oswestry pain and disability scale, four-part (excellent-through-poor) scales for measurement of return to activities of daily living or to work and satisfaction with the results of surgery. Perioperative complications, number of vertebral levels fused, and worker's compensation and smoking status were also compared among the study groups. Fusion and subsidence were evaluated for the Rabea cage group. METHODS: Criteria for inclusion consisted of consecutive patients who presented with unremitting radicular arm pain, with or without neck pain, and/or a neurological deficit that correlated with appropriate level and side neural compression on magnetic resonance imaging or computed tomography. Questionnaire follow-up was at 6 months after surgery with 100% compliance. RESULTS: A total of 50 cages were implanted in the 37 patients. At 6-month follow-up, 78% of patients reported successful arm pain relief (VAS scores below 5). Patient satisfaction was successful in 78% of the cases. Other success rates included neck pain relief in 73% and Oswestry pain and disability scale in 70%. There was a median improvement in the Oswestry scores of 28 points (61% change). Worker's compensation patients fared dramatically worse than did the noncompensation patients in all outcome measurements. Combining all three study groups resulted in significantly worse outcomes for multilevel than for single-level procedures and for smokers compared with nonsmokers, but low case numbers precluded conclusive analysis for the Rabea group alone. In the Rabea group there were two complications, neither cage related, whereas none were reported for the ACDF controls. Rabea group fusion rates were 84% at 3 months and 95% at 6 months, but the clinical relevance of this radiological evidence when metal prostheses are used is questionable. The outcomes results were clinically and statistically indistinguishable from those of our control groups and were similar to published studies using other titanium cages. CONCLUSIONS: This is the first prospective, independently conducted report on Rabea cages. Results of the short-term (6 months) follow-up did not differ from outcomes results in our patients who have undergone ACDF with bone allograft. Although this is a preliminary assessment, the Rabea cage may represent an alternative to bone dowels and hip graft. As is the case for other allografts, artificial or bone, the main advantage is elimination of donor site complications, and the disadvantages include difficulty in radiographic assessment of fusion and potential for cage subsidence.     

Determinants of early and late outcome for reoperations of the proximal aorta

Background

The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome.

Methods

Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%), and ascending aorta in 27 (26.0%). The median interval between operations was 69 months. Retrograde cerebral perfusion was used in 80 (77%) cases.

Results

Chronic dissection was the most common indicator for reoperation in our population, followed by progression of aneurysm and infection. Thirty-day and in-hospital mortality was 13.5% (14 of 104) and 15.4% (16 of 104), respectively. Chronic obstructive pulmonary disease, renal dysfunction, and increased pump time were risk factors for mortality. Median follow-up was 5.02 years. Eight patients died during that period. Estimated survival at 1, 5, and 10 years was 83%, 80%, and 62%, respectively. Freedom from second proximal reoperations was 97.1% (10 of 104). Freedom from subsequent distal thoracic aortic repair was 84.6% (8 of 104).

Conclusions

Reoperations of the ascending aorta and aortic arch can be performed safely with good long-term results. Patients with previous proximal aortic dissection repair need long-term surveillance. Renal dysfunction and chronic obstructive pulmonary disease must be carefully considered before reoperations of the proximal aorta.     

Intramuscular nerve distribution pattern of ankle invertor muscles in human cadaver using sihler stain

Introduction: We sought to the ideal sites for botulinum toxin injection by examining the intramuscular nerve patterns of the ankle invertors. Methods: A modified Sihler method was performed on the flexor hallucis longus, tibialis posterior, and flexor digitorum longus muscles (10 specimens each). The muscle origins, nerve entry points, and intramuscular arborization areas were measured as a percentage of the total distance from the most prominent point of the lateral malleolus (0%) to the fibular head (100%). Results: Intramuscular arborization patterns were observed at 20–50% for the flexor hallucis longus, 70–80% for the tibialis posterior, and 30–40% for the flexor digitorum longus. Conclusions: These findings suggest that treatment of muscle spasticity of the ankle invertors involves botulinum toxin injections in specific areas. These areas, corresponding to the areas of maximum arborization, are recommended as the most effective and safest points for injection. Muscle Nerve 53 : 742–747, 2016     

Comparison of Patient Characteristics and Outcomes of Contralateral Prophylactic Mastectomy and Unilateral Total Mastectomy in Breast Cancer Patients

Background

There has been an increasing trend toward contralateral prophylactic mastectomy (CPM) in the management of breast cancer (BCa). This study??s objective was to compare clinicopathologic characteristics of BCa patients who elected CPM to those who elected unilateral total mastectomy (UTM) and to determine whether CPM improved survival.

Methods

Comparison was performed on 355 patients with stage 0?CIII BCa matched by age and stage who underwent mastectomy from 1995 to 2008: 177 patients had CPM; 178 patients had UTM. Clinicopathological characteristics and survival outcomes were analyzed.

Results

Women who underwent preoperative MRI were twice as likely to have CPM (40.9 vs. 19.7%, P?P?=?0.001; 64.3 vs. 41.4%, P?P?=?0.04, respectively). CPM patients elected nipple preservation (26 vs. 5.2%, P?P?P?=?0.01). CPM identified occult BCa in 11 patients (6.6%), and three UTM patients (1.7%) developed contralateral BCa. With median follow-up of 61?months, by univariable/multivariable analyses, CPM did not improve overall, disease-free, or distant metastases-free survival.

Conclusion

Factors that may influence choice of CPM included preoperative MRI, history of prior breast biopsies, immediate reconstruction, nipple preservation, family history, and BRCA status. Those who chose CPM did not have improved survival.