Severe epistaxis after posterior nasal nerve ablation requiring surgical intervention: A multi-center case series.

KEY POINTS: Severe epistaxis occurs in 2% of PNN ablation cases, independent of method or device type. Major epistaxis requiring intervention after PNN ablation can occur on average 20 days post-procedure.

Spontaneous Bilateral Facial Paralysis Secondary to Metastatic Breast Cancer.

Sudden onset, bilateral facial paralysis is a rare clinical entity, representing less than 2% of all diagnoses of facial nerve paralysis. The differential for these patients is necessarily broad and includes numerous etiologies. Metastatic breast carcinoma to the bilateral parotid glands is also exceedingly rare with only 2 reported case reports noted in the literature, neither of which demonstrated facial nerve paralysis. Here, we report the only known occurrence of a patient presenting with synchronous bilateral facial nerve paralysis secondary to metastatic breast carcinoma to the bilateral parotid glands. This exceedingly rare clinical presentation was further confounded by the presence of autoimmune antibodies, highlighting the importance of the diagnostic process and maintaining broad clinical suspicion.

Clinical Factors and Outcomes When Real-World Heart Teams Overruled STS Risk Scores in TAVR Cases.

Objectives: This study was conducted to determine why heart teams recommended transcatheter aortic valve replacement (TAVR) versus surgical AVR (SAVR) for patients at low predicted risk of mortality (PROM) and describe outcomes of these cases. Background: Historically, referral to TAVR was based predominately on the Society of Thoracic Surgeons (STS) risk model's PROM >3%. In selected cases, heart teams had latitude to overrule these scores. The clinical reasons and outcomes for these cases are unclear. Methods: Retrospective data were gathered for all TAVR and SAVR cases conducted by 9 hospitals between 2013 and 2017. Results: Cases included TAVR patients with STS PROM >3% (n = 2,711) and ≤3% (n = 415) and SAVR with STS PROM ≤3% (n = 1,438). Leading reasons for recommending TAVR in the PROM ≤3% group were frailty (57%), hostile chest (22%), severe lung disease (16%), and morbid obesity (13%), and 44% of cases had multiple reasons. Most postoperative and 30-day outcomes were similar between TAVR groups, but the STS PROM ≤3% group had a one-day shorter length of stay (2.5 ± 3.4 vs. 3.5 ± 4.7 days; p ≤ 0.001) and higher one-year survival (91.6% vs. 86.0%, p=0.002). In patients with STS PROM ≤3%, 30-day mortality was higher for TAVR versus SAVR (2.0% vs. 0.6%; p < 0.001). Conclusions: Heart teams recommended TAVR in patients with STS PROM ≤3% primarily due to frailty, hostile chest, severe lung disease, and/or morbid obesity. Similar postoperative outcomes between these patients and those with STS PROM >3% suggest that decisions to overrule STS PROM ≤3% were merited and may have reduced SAVR 30-day mortality rate.

In-office Bone-Anchored Hearing Implants via Minimally Invasive Punch Technique in a Veteran Population.

OBJECTIVE: Describe the feasibility and safety of completing bone-anchored hearing implants via the minimally invasive punch technique in the in-office setting. STUDY DESIGN: This single-institution case series included 20 patients who underwent in-office bone-anchored hearing implant placement under local anesthesia from 2018 to 2021. SETTING: Veterans Affairs Northern California Healthcare System. METHODS: Following completion of the case series, patients were retrospectively surveyed regarding their satisfaction with this approach via a modified SSQ-8 (Surgical Satisfaction Questionnaire) to fit our purposes. RESULTS: A total of 23 implants were completed in the in-office setting on 20 patients. Intra- and postoperative complication rates, including skin changes, irritation, infection, and poor wound healing, were similar to or better than currently published complication rates in the literature. In addition, patients reported overwhelmingly positive responses on the SSQ-8, almost universally stating that they were "very satisfied" with their clinic experience. CONCLUSION: This case series suggests that it is feasible and safe to complete this procedure in the clinic under local anesthesia, but further prospective studies are needed to evaluate this in a more generalized population.

Computed Tomography Findings of Complete Branchial Cleft Fistula.

Branchial cleft anomalies are embryonic remnants of the branchial arches and are described as the second most common congenital neck mass. Depending on their extent, these anomalies are classified as a cyst, sinus, or fistula with branchial cysts being the most common. Branchial cysts deriving from the second branchial arch are by far the most common, accounting for approximately 95% of all cases. Complete second branch arch fistulas with both an internal and external opening are a rare variant of this anomaly, and even less have been well-documented on computed tomography (CT) imaging in the literature. We present here a case of a 20-year-old female with CT findings consistent with a complete second branchial arch fistula extending from the tonsillar fossa to the external lateral neck.

Reduction of silver ions in molybdates: elucidation of framework acidity as the factor controlling charge balance mechanisms in aqueous zinc-ion electrolyte.

A percolating network of high electrical conductivity needed to operate electrodes at a fast rate can be formed by in situ reduction of Ag+ originating from mixed metal oxide lattices, but few studies have elucidated trends in this mechanism as a function of Ag+ concentration and structure. Candidates compared for the first time here are spinel Ag2MoO4, monoclinic and triclinic Ag2Mo2O7, and Ag2Mo3O10·2H2O, which have reduction potentials for Ag+ and Mo6+ strongly decoupled by up to ∼600 mV in aqueous zinc-ion electrolyte. Under these conditions, Ag0 is the first reduction product and a decrease of charge transfer resistance by ∼100× is observed within 2.5% consumption of total Ag+ independent of initial structure. However, resistance metrics alone poorly describe materials which are robust to reducing silver with high energy at faster rates. Instead, after accounting for crystallinity and morphology differences, we find that the acidity of the molybdate framework is responsible for a switch in charge balance mechanism from the bulk formation of a mixed ZnMoO x to pseudocapacitive Zn2+ precipitation, and that this mechanism switch is associated with minimized losses to rate, voltage and capacity yields as carbon/binder free electrodes relative to composites. The location of this acidity cutoff near the pH of the ZnSO4 electrolyte may suggest a design principle for future low-carbon electrodes beyond molybdate framework structures.

Temporal trends in first-line outpatient anticoagulation treatment for cancer-associated venous thromboembolism.

BACKGROUND: First-line treatment and secondary prevention of venous thromboembolism (VTE) in patients with cancer consisted, historically, of unfractionated heparin or low-molecular weight heparin (LMWH). With recent clinical trials of direct oral anticoagulants (DOAC) showing similar efficacy as LMWH, little is known about anticoagulant prescribing patterns in patients with cancer and a VTE. This study characterized the temporal trends in first-line outpatient anticoagulation therapy for cancer-associated VTE. MATERIALS AND METHODS: This retrospective cohort study of patients who were hospitalized for a cancer-associated venous thromboembolism (VTE) between 01/01/2000 and 10/31/2017 identified patients from the cancer registries at two regions of an integrated healthcare delivery system. The primary outcome was the trend in age- and sex-adjusted rates of first-line anticoagulant therapy during the 30 days post-hospital discharge. Therapies were categorized as 1) injectable LMWH monotherapy, 2) warfarin ± injectable, 3) injectable fondaparinux monotherapy, or 4) DOAC ± injectable. RESULTS: Overall, 9816 patients were included with a mean age of 66 ± 13 years and 54% were female. From 2000 to 2003, warfarin ± injectable was used in ≈90% of cases. After 2003, there was a steady decline in warfarin use (25% in 2017) corresponding with increased LMWH use: 11% in 2003 to 55% in 2017. The DOAC ± injectable use has rapidly increased from <1% in 2014 to 20% in 2017. CONCLUSIONS: From 2000 to 2017, first-line anticoagulant therapy for cancer-associated VTE has experienced a substantial increase in LMWH and DOAC use with a resultant decline in warfarin use.

Impact of Asynchronous Training on Radiology Learning Curve among Emergency Medicine Residents and Clerkship Students.

CONTEXT: Web-based learning (WBL) modules are effectively used to improve medical education curriculum; however, they have not been evaluated to improve head computed tomography (CT) scan interpretation in an emergency medicine (EM) setting. OBJECTIVE: To evaluate the effectiveness of a WBL module to aid identification of cranial structures on CT and to improve ability to distinguish between normal and abnormal findings. DESIGN: Prospective, before-and-after trial in the Emergency Department of an academic center. Baseline head CT knowledge was assessed via a standardized test containing ten head CT scans, including normal scans and those showing hemorrhagic stroke, trauma, and infection (abscess). All trainees then participated in a WBL intervention. Three weeks later, they were given the same ten CT scans to evaluate in a standardized posttest. MAIN OUTCOME MEASURES: Improvement in test scores. RESULTS: A total of 131 EM clerkship students and 32 EM residents were enrolled. Pretest scores correlated with stage of training, with students and first-year residents demonstrating the lowest scores. Overall, there was a significant improvement in percentage of correctly classified CT images after the training intervention from a mean pretest score of 32% ± 12% to posttest score of 67% ± 13% (mean improvement = 35% ± 13%, p < 0.001). Among subsets by training level, all subgroups except first-year residents demonstrated a statistically significant increase in scores after the training. CONCLUSION: Incorporating asynchronous WBL modules into EM clerkship and residency curriculum provides early radiographic exposure in their clinical training and can enhance diagnostic head CT scan interpretation.

Predictive power of statistical significance.

A statistically significant research finding should not be defined as a P-value of 0.05 or less, because this definition does not take into account study power. Statistical significance was originally defined by Fisher RA as a P-value of 0.05 or less. According to Fisher, any finding that is likely to occur by random variation no more than 1 in 20 times is considered significant. Neyman J and Pearson ES subsequently argued that Fisher's definition was incomplete. They proposed that statistical significance could only be determined by analyzing the chance of incorrectly considering a study finding was significant (a Type I error) or incorrectly considering a study finding was insignificant (a Type II error). Their definition of statistical significance is also incomplete because the error rates are considered separately, not together. A better definition of statistical significance is the positive predictive value of a P-value, which is equal to the power divided by the sum of power and the P-value. This definition is more complete and relevant than Fisher's or Neyman-Peason's definitions, because it takes into account both concepts of statistical significance. Using this definition, a statistically significant finding requires a P-value of 0.05 or less when the power is at least 95%, and a P-value of 0.032 or less when the power is 60%. To achieve statistical significance, P-values must be adjusted downward as the study power decreases.

The diagnostic utility of sonographic carotid flow time in determining volume responsiveness.

OBJECTIVE: We aimed to predict volume responsiveness and to assess the diagnostic accuracy of carotid flow time (FTc) with the change in hydration status before and after a passive leg raise (PLR) maneuver. METHODS: Participants who presented at a community health fair in a dehydrated state following a prolonged fast while observing the month of Ramadan were recruited. Sonographic FTc measurements were obtained in the semi-Fowler position and after a PLR maneuver while participants were in a fasting state and repeated approximately 3 hours after breaking their fast. RESULTS: In total, 123 participants with mean age of 47±14 years, 55% male, were enrolled. Participants had fasted for an average of 16.9 hours and consumed an average of 933 mL between the 2 ultrasound measurements. Mean FTc values were significantly lower in the fasting state compared with the nonfasting state (312±22 vs 345±25milliseconds, P value < .001). Relative increases in FTc following a PLR maneuver demonstrated strong discrimination of volume status (area under the receiver operating curve: 0.86 [95% confidence interval, 0.81-0.91]). CONCLUSIONS: The use of point-of-care ultrasound to measure FTc may provide a noninvasive alternative to determine fluid status. Percentage change in FTc of ≥5% provides a reliable diagnostic accuracy for predicting fluid status.

Discovery and Subsequent Confirmation of Novel Serum Biomarkers Diagnosing Alzheimer's Disease.

BACKGROUND: Alzheimer's disease (AD) remains challenging to diagnose, especially early disease. Having serum AD biomarkers would be of significant interest both in the clinical setting and in drug development efforts. OBJECTIVE: We applied a novel serum proteomic approach to interrogate the low-molecular weight proteome for serum AD biomarkers. METHODS: A discovery study used sera from 58 any-stage AD cases and 55 matched controls analyzed by capillary liquid chromatography-electrospray ionization-tandem mass spectrometry. Candidate biomarkers were statistically modeled and promising biomarkers were retested in a second, blinded confirmatory study (AD cases = 68, controls = 57). Biomarkers that replicated in the second study were modeled for the diagnosis of any-stage and very early stage AD. Further, they were chemically identified by tandem MS. RESULTS: The initial discovery study found 59 novel potential AD biomarkers. Thirteen recurred in more than one multi-marker panel. In a second, blinded, confirmatory study, these same biomarkers were retested in separate specimens. In that study, four markers validated comparing controls to patients with any-stage AD and also with very early AD. The four biomarkers with replicable ability to diagnose AD were then chemically identified. CONCLUSION: These results suggest novel serum AD diagnostic biomarkers can be found using this approach.

Furunculoid myiasis in a dog caused by Cordylobia anthropophaga.

Two days after returning with its owners from a 60-day visit to Liberia, an 8-year-old 6.5-kg spayed female Miniature Schnauzer was examined by a veterinarian in the United States. A 1.0 x 1.0-cm raised erythematous nodule was noticed on the medial aspect of the right pinna. In the center of the nodule was a 1.0 x 1.0-mm pore from which a 0.5 x 0.5 x 1.0-cm white larva was extracted. The larva was identified as a third-stage larva of Cordylobia anthropophaga, the African Tumbu fly, a fly restricted to sub-Saharan Africa. Cordylobia anthropophaga does have zoonotic potential, but the owners did not have any skin lesions. Detection of C anthropophaga in the United States warranted reports to state and federal authorities and personnel at the Centers for Disease Control and Prevention. The situation described here illustrated the potential of tourists' pets to import foreign diseases.