Internal Carotid Artery Dissection Presenting as Partial Horner's Syndrome and Vertigo.

Distinguishing between central and peripheral causes of vertigo can be challenging not only in an acute setting but also in chronic settings. A thorough review of systems and physical exam can assist providers in differentiating central versus peripheral etiologies and the need for urgent imaging. In this case, a 47-year-old man presented with vertigo, right-sided hearing loss, right-sided headache, and right-sided facial pain that began 4 weeks before while the patient was on a cruise ship. His physical exam findings were notable for anisocoria with right pupil 3.5 and left pupil 4.5, mild ptosis on the right side, positive Romberg test to the right, and Fakuda test with deviation to the right. Urgent magnetic resonance imaging revealed dissection of the right cervical internal carotid artery with a nonocclusive intramural hematoma. This case illustrates the importance of imaging in vertigo patients in which a central etiology is suspected. It further demonstrates that isolated partial Horner's or unilateral headache may indeed be the only presenting sign in a carotid dissection.

Military Medicine and the Academic Surgery Gender Gap.

INTRODUCTION: Gender disparity in academic medicine has been well described in the civilian sector. This has not yet been evaluated in the military health system where hundreds of female surgeons are practicing. Military service limits factors such as part time work and control over time spent away from family, which are often cited as contributors to the pay and promotion gap in civilian academic medicine. The military has explicit policies to limit discrimination based on gender. Pay between men and women is equal as it is based on rank and time in rank. One would expect to see less disparity in promotion through the academic ranks for military female surgeons given this otherwise equal treatment. This has not previously been objectively tracked or reported. It is beneficial to characterize the military academic medicine gender gap and benchmark against national data to define the academic gender gap and lay the groundwork for future work to identify factors contributing to the observed difference. MATERIAL AND METHODS: This study was granted exemption from the Walter Reed National Military Medical Center (WRNMMC) Internal Review Board (IRB). The Uniformed Services University (USU) Department of Surgery academic appointment list was reviewed to assess female representation in the categories of Instructor, Assistant Professor, Associate Professor, Professor, and Other. Defense Manpower Data Center (DMDC) and the US Navy Bureau of Medicine and Surgery (BUMED) were assessed for total numbers of female surgeons on active duty, and numbers were compared with nationally published Association of American Medical Colleges (AAMC) data using a logistic regression model. RESULTS: There was a higher proportion of women in academic positions in the civilian cohort than in the military cohort (OR: 1.84; CI: 1.53-2.21, p < .0001). This difference was observed at every level of academic achievement. A higher percentage of women were observed at lower levels of professorship than at higher levels; instructors were more likely to be women than assistant professor (OR: 1.44, CI:1.16-1.79), associate professor (OR: 2.24, CI: 1.77-2.84), or full professor (OR:4.61, CI: 3.57-5.94). CONCLUSIONS: Fewer female surgeons in military medicine hold academic appointment when compared with their counterparts in civilian medicine. Similar to the civilian sector, military academic surgery also demonstrates less likelihood of female representation in higher academic stations. This discrepancy in representation follows a linear trend over the different ranks. This discrepancy has not been previously documented. The military offers a unique opportunity to study the issue of gender imbalance in academic promotion practices given its otherwise equal treatment of males and females. Additional studies will be necessary to understand uniformed female surgeons' barriers to academic advancement.

Guided Imagery Improves Mood, Fatigue, and Quality of Life in Individuals With Multiple Sclerosis: An Exploratory Efficacy Trial of Healing Light Guided Imagery.

Multiple sclerosis is a disabling and progressive neurological disease that has significant negative effects on health-related quality of life. This exploratory efficacy study examined the effects of Healing Light Guided Imagery (HLGI), a novel variant of guided imagery, compared with a wait-list control in patients with relapsing-remitting multiple sclerosis. Changes in the Beck Depression Inventory, Fatigue Severity Scale, and Multiple Sclerosis Quality of Life instrument (physical and mental components) were compared between groups. Patients who completed HLGI (N = 9) showed significant reductions in depressed mood ( P < .05) and fatigue ( P < .01) and showed significant gains in physical ( P = .01) and mental ( P < .01) quality of life compared with journaling (N = 8). Our results suggest that HLGI can improve self-reported physical and mental well-being in patients with relapsing-remitting multiple sclerosis. Further research is needed to study the effectiveness of this therapy, as well as its mind-body mechanisms of action.

Reliability of a Standardized Nasal Anatomic Worksheet and Correlation With Subjective Nasal Airway Obstruction.

IMPORTANCE: Nasal obstruction is a common chief concern; however, a comprehensive standardized worksheet for evaluating nasal obstruction has not been developed. OBJECTIVE: To evaluate the interrater reliability between staff surgeons and otolaryngology residents using a worksheet-based standardized nasal examination and to identify specific examination findings correlated with the Nasal Obstruction Symptom Evaluation quality-of-life score. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study conducted from June to July 2012 involved 50 adults presenting to an otolaryngology clinic at a tertiary care hospital. The patients were examined by 2 board-certified facial plastic surgeons and 2 otolaryngology residents. EXPOSURES: The inferior turbinates, septum, and internal and external nasal valve narrowing and collapse were graded bilaterally from a scale of 0 to 3 with the aid of a standardized nasal anatomy worksheet. The findings were compared between the attending staff, residents, and the entire group. MAIN OUTCOMES AND MEASURES: The Cohen κ coefficient for interrater reliability was calculated for each of the graded metrics. The Nasal Obstruction Symptom Evaluation scores were correlated with anatomic scores. RESULTS: Of the 49 patients included in the final analysis, the mean age was 43.6 years (range, 21-82 years), and 31 were male (66.3%). Among all attending and resident examiners, a moderate to fair, statistically significant interrater reliability coefficient (P < .001) was observed in the following nasal anatomic measurements: left and right Cottle (κ = 0.582 [95% CI, 0.463-0.700] and κ = 0.580 [95% CI, 0.461-0.698], respectively), modified Cottle (κ = 0.491 [95% CI, 0.373-0.609] and κ = 0.560 [95% CI, 0.442-0.679], respectively), dynamic internal nasal valve collapse (κ = 0.204 [95% CI, 0.118-0.290] and κ = 0.232 [95% CI, 0.140-0.323], respectively), and inferior turbinate hypertrophy (κ = 0.252 [95% CI, 0.152-0.352] and κ = 0.235 [95% CI, 0.153-0.317], respectively). The trend of examination interrater reliability was similar for attending staff and the otolaryngology residents. The Nasal Obstruction Symptom Evaluation score correlated with the mean total anatomic worksheet score (Spearman ρ = 0.301; P = .048). CONCLUSIONS AND RELEVANCE: Interrater reliability is high in both residents and attending staff for dynamic nasal airway examinations evaluating the internal and external nasal valves and for turbinate hypertrophy assessment. The total nasal anatomic score using a standardized worksheet correlates to patient-reported nasal-specific quality of life. LEVEL OF EVIDENCE: NA.

The Synthesis of Structurally Diverse Macrocycles By Successive Ring Expansion.

Structurally diverse macrocycles and medium-sized rings (9-24 membered scaffolds, 22 examples) can be generated through a telescoped acylation/ring-expansion sequence, leading to the insertion of linear fragments into cyclic ß-ketoesters without performing a discrete macrocyclization step. The key ß-ketoester motif is regenerated in the ring-expanded product, meaning that the same sequence of steps can then be repeated (in theory indefinitely) with other linear fragments, allowing macrocycles with precise substitution patterns to be "grown" from smaller rings using the successive ring-expansion (SuRE) method.

Nintendo Wii rehabilitation ("Wii-hab") provides benefits in Parkinson's disease.

Parkinson's disease (PD) impairs both activities of daily living (ADLs) and motor function and has adverse effects on mood in many patients. While dopaminergic medications are quite helpful for motor and ADLs impairments in PD, complementary therapies are also important in helping patients achieve maximum benefits and quality of life. We hypothesized that the Nintendo Wii (Wii) is a useful tool in improving motor and non-motor aspects in patients with PD, given its ability to drive functional movements and interactive nature. We enrolled twenty subjects with early to mid-stage PD in an open-label within-subjects study design where each subject was evaluated at baseline and then re-evaluated after playing the Wii three times per week for four weeks. Subjects were then re-evaluated one month later after not playing the Wii for a month to see if effects carried over. Subjects demonstrated significant improvements in the primary outcome measure (Nottingham Extended Activities of Daily Living Test (NEADL)), quality of life (PDQ-39) and motor function (UPDRS), and a trend toward improved mood (HAM-D) after four weeks of Wii therapy. Follow-up assessments one month later showed continued improvement for quality of life and UPDRS scores. The results demonstrate that Wii therapy provides short-term motor, non-motor, and quality of life benefits in PD. Further studies are needed to determine if there are long-term benefits of Wii therapy in PD.

Catalytic decarboxylative alkenylation of enolates.

A palladium-catalyzed decarboxylative alkenylation of stabilized enolates has been developed, which gives rise to alkenylated dicarbonyl products from enol carbonates regioselectively with concomitant installation of a quaternary all-carbon center. The broad scope of the reaction has been demonstrated by successfully utilizing a range of enolates and external phenol nucleophiles.

Epidermal cell proliferation in calorie-restricted aging rats.

Calorie restriction (CR) has been known to produce many beneficial health effects, and lowered cell proliferation from CR has been shown to produce anti-cancer effects in some tissues. In this study the rate of epidermal cell proliferation in aging Fischer 344 rats from ad libitum fed (AL) and CR colonies was assessed in relation to changes in epidermal thickness with age. Proliferating cell nuclear antigen (PCNA) was detected using immunohistochemical method on paraffin sections in the epidermis of dorsal skin and footpad in these animals obtained from the National Institute on Aging. The proliferating cell index was compared with morphometric measurement of epidermis in young, young adult and old animals (six per group). Data were analyzed by Excel and SPSS 14.0 softwares for statistical evaluation. Two-way analysis of variance (ANOVA) was applied to data to test the effects of age, diet, and age-diet interaction. The following significant effects were noted: (I) age and age-diet effects in dorsal skin epidermal width, and PCNA; (II) age, and diet effect on footpad epidermal thickness, and PCNA index. There was a trend of increasing epidermal thickness in the dorsal skin in normally feeding aging rats which was depressed with CR in the two younger groups. PCNA index showed a trend of attrition from young to old. The thickness of epidermis in foot pad showed a curvilinear trend in both AL and CR groups with lowest mean values in the old group, and more predominant effect in CR-exposed animals. The proliferation index in the foot pad demonstrated a trend of reduction in old specimens with lower mean values in each corresponding CR age group. This report agrees with CR-inhibited cell proliferation reported in many organs by other investigators, and the observed results might have been caused by physiological or endocrine mechanisms affecting the epithelium in these calorie-restricted animals.

Partitioning of soil water among tree species in a Brazilian Cerrado ecosystem.

Source water used by woody perennials in a Brazilian savanna (Cerrado) was determined by comparing the stable hydrogen isotope composition (deltaD) of xylem sap and soil water at different depths during two consecutive dry seasons (1995 and 1996). Plant water status and rates of water use were also determined and compared with xylem water deltaD values. Overall, soil water deltaD decreased with increasing depth in the soil profile. Mean deltaD values were -35 per thousand for the upper 170 cm of soil and -55 per thousand between 230 and 400 cm depth at the end of the 1995 dry season. Soil water content increased with depth, from 18% near the surface to about 28% at 400 cm. A similar pattern of decreasing soil water deltaD with increasing depth was observed at the end of the 1996 dry season. Patterns consistent with hydraulic lift were observed in soil profiles sampled in 1995 and 1997. Concurrent analyses of xylem and soil water deltaD values indicated a distinct partitioning of water resources among 10 representative woody species (five deciduous and five evergreen). Among these species, four evergreen and one deciduous species acquired water primarily in the upper soil layers (above 200 cm), whereas three deciduous and one evergreen species tapped deep sources of soil water (below 200 cm). One deciduous species exhibited intermediate behavior. Total daily sap flow was negatively correlated with xylem sap deltaD values indicating that species with higher rates of water use during the dry season tended to rely on deeper soil water sources. Among evergreen species, minimum leaf water potentials were also negatively correlated with xylem water deltaD values, suggesting that access to more readily available water at greater depth permitted maintenance of a more favorable plant water status. No significant relationship between xylem water deltaD and plant size was observed in two evergreen species, suggesting a strong selective pressure for small plants to rapidly develop a deep root system. The degree of variation in soil water partitioning, leaf phenology and leaf longevity was consistent with the high diversity of woody species in the Cerrado.

Regulation of water flux through trunks, branches, and leaves in trees of a lowland tropical forest.

We studied regulation of whole-tree water use in individuals of five diverse canopy tree species growing in a Panamanian seasonal forest. A construction crane equipped with a gondola was used to access the upper crowns and points along the branches and trunks of the study trees for making concurrent measurements of sap flow at the whole-tree and branch levels, and vapor phase conductances and water status at the leaf level. These measurements were integrated to assess physiological regulation of water use from the whole-tree to the single-leaf scale. Whole-tree water use ranged from 379 kg day-1 in a 35 m-tall Anacardium excelsum tree to 46 kg day-1 in an 18 m-tall Cecropia longipes tree. The dependence of whole-tree and branch sap velocity and sap flow on sapwood area was essentially identical in the five trees studied. However, large differences in transpiration per unit leaf area (E) among individuals and among branches on the same individual were observed. These differences were substantially reduced when E was normalized by the corresponding branch leaf area:sapwood area ratio (LA/SA). Variation in stomatal conductance (g s) and crown conductance (g c), a total vapor phase conductance that includes stomatal and boundary layer components, was closely associated with variation in the leaf area-specific total hydraulic conductance of the soil/leaf pathway (G t). Vapor phase conductance in all five trees responded similarly to variation in G t. Large diurnal variations in G t were associated with diurnal variation in exchange of water between the transpiration stream and internal stem storage compartments. Differences in stomatal regulation of transpiration on a leaf area basis appeared to be governed largely by tree size and hydraulic architectural features rather than physiological differences in the responsiveness of stomata. We suggest that reliance on measurements gathered at a single scale or inadequate range of scale may result in misleading conclusions concerning physiological differences in regulation of transpiration.