Incidental coronary calcifications on routine chest CT: Clinical implications.

Coronary artery calcification (CAC) is a marker of atherosclerosis and an independent risk factor for cardiac-related mortality, with much of the 50% decline in mortality over the past 30 years being attributed to early detection of coronary disease and intervention of modifiable risk factors. With over 10 million computed tomography (CT) examinations of the chest performed in the United States yearly, CAC can be identified in a very large number of patients. In this review, we discuss the clinical evidence underlying the relationship between radiologic identification of CAC, atherosclerosis, and cardiac outcomes and the implications of its assessment on standard chest CT. We conclude that reporting of incidental coronary calcification found on non-gated chest CT would have a great impact on both management and mortality and thus, in the appropriate setting, should be noted in the impression of the radiologic report when identified.

Mapping the distribution of nodal metastases in papillary thyroid carcinoma: Where exactly are the nodes?

OBJECTIVE: To characterize nodal disease of patients presenting with papillary thyroid carcinoma (PTC) STUDY DESIGN: Retrospective chart review. METHODS: PTC patients who underwent thyroidectomy and/or neck dissection (revision/primary) from 2004 to 2009 at a tertiary-care hospital were reviewed. Preoperative computed tomography (CT) scan and ultrasonography were utilized to identify macroscopic, clinically apparent nodal metastasis (cN+). Demographic data, type of surgery, nodal disease, and primary tumor information were recorded. RESULTS: Of 416 patients reviewed, 35% had cN+ on initial presentation (IP); of these, 88% and 50% had central (CND) and lateral nodal disease (LND), respectively. The presence of ectopic nodal (END) metastases (nodal disease outside typical CND or LND locations) was absent on IP but occurred in 9% of patients with nodal recurrence. END was typically found in the retropharyngeal area but also was noted in the sublingual region, subcutaneous location, axilla, and chest wall. Extrathyroidal extension (ETE) was found in 8.9% without nodal disease, 33.1% with nodal disease, and 57.1% with END (P < 0.0001). Primary tumor size greater than 4 cm (P = 0.05) was associated with nodal disease. CONCLUSION: This report represents a large series describing characteristics of the primary PTC tumor and associated nodal disease not only in the central and lateral neck but also in the ectopic locations. Our results suggest that a significant proportion of patients will have nodal disease in the central compartment on IP, especially younger patients. ETE and tumor size are associated with macroscopic nodal disease (including END). Nine percent of the patients with nodal recurrence had ectopic nodes occurring in various locations, most commonly in the retropharynx. CT scan can assist with identification and surgical planning of recurrent nodal disease. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1959-1964, 2017.

Sporadic Hemangioblastoma Arising from the Infundibulum.

Hemangioblastomas are rare vascular tumors most often found in the posterior fossa and cervical spinal cord and commonly associated with von Hippel-Lindau Disease. We report a case of sporadic hemangioblastoma in a patient without von Hippel-Lindau Disease. Imaging characteristics included a solid, suprasellar mass that was homogeneously enhancing. These findings most resembled a pituicytoma or choroid glioma because of the close association with the infundibulum and the homogeneous avid enhancement. Microscopically, the neoplasm was seen to be composed of vascular channels associated with foamy stromal cells, containing clear cytoplasmic vacuoles. Microscopic and immunohistochemical findings were consistent with hemangioblastoma. Hemangioblastomas are a rare form of vascular tumor most commonly associated with von-Hippel Lindau disease. Our finding of non-cystic hemangioblastoma arising from the infundibulum demonstrates that, while rare, hemangioblastomas should be considered on the differential diagnosis for an avidly enhancing suprasellar mass.

The effects of the DDS-1 strain of lactobacillus on symptomatic relief for lactose intolerance - a randomized, double-blind, placebo-controlled, crossover clinical trial.

BACKGROUND: Lactose intolerance is a form of lactose maldigestion where individuals experience symptoms such as diarrhea, abdominal cramping, flatulence, vomiting and bowel sounds following lactose consumption. Lactobacillus acidophilus is a species of bacteria known for its sugar fermenting properties. Preclinical studies have found that Lactobacillus acidophilus supplementation may assist in breaking down lactose; however, no human clinical trials exist evaluating its efficacy in alleviating symptoms related to lactose intolerance. OBJECTIVE: The aim of this randomized, double-blind, placebo-controlled, crossover study was to evaluate the effect of a proprietary strain of Lactobacillus acidophilus on relieving discomfort related to lactose intolerance. METHODS: The study enrolled healthy volunteers between 18 and 75 years of age who complained of lactose intolerance. Screening visits included a lactose challenge visit to confirm eligibility based on a score of 10 or higher on subjective assessment of the following symptoms after lactose challenge: diarrhea, abdominal cramping, vomiting, audible bowel sounds, flatulence, and overall symptoms. Qualified subjects participated in a 2-arm crossover design, with each arm consisting of 4 weeks of intervention of either active or placebo product, with a 2-week washout period during crossover. The study product consisted of the DDS-1 strain of Lactobacillus acidophilus (Nebraska Cultures, Walnut Creek, California). The placebo was formulated from maltodextrin. Study participants were instructed to take the product once daily for 4 weeks. Data collected included subjective symptom scores related to lactose intolerance. RESULTS: Longitudinal comparison between the DDS-1 group and placebo group demonstrated statistically significant reductions in abdominal symptom scores during the 6-h Lactose Challenge at week 4 for diarrhea (p = 0.033), abdominal cramping (p = 0.012), vomiting (p = 0.0002), and overall symptom score (p = 0.037). No adverse events were reported. CONCLUSIONS: The present study has found that this unique DDS-1 strain of Lactobacillus acidophilus, manufactured by Nebraska Cultures, is safe to consume and improves abdominal symptom scores compared to placebo with respect to diarrhea, cramping, and vomiting during an acute lactose challenge.

Orbital inflammatory disease: Pictorial review and differential diagnosis.

Orbital inflammatory disease (OID) represents a collection of inflammatory conditions affecting the orbit. OID is a diagnosis of exclusion, with the differential diagnosis including infection, systemic inflammatory conditions, and neoplasms, among other conditions. Inflammatory conditions in OID include dacryoadenitis, myositis, cellulitis, optic perineuritis, periscleritis, orbital apicitis, and a focal mass. Sclerosing orbital inflammation is a rare condition with a chronic, indolent course involving dense fibrosis and lymphocytic infiltrate. Previously thought to be along the spectrum of OID, it is now considered a distinct pathologic entity. Imaging plays an important role in elucidating any underlying etiology behind orbital inflammation and is critical for ruling out other conditions prior to a definitive diagnosis of OID. In this review, we will explore the common sites of involvement by OID and discuss differential diagnosis by site and key imaging findings for each condition.

Effects of a Proprietary Freeze-Dried Water Extract of Eurycoma longifolia (Physta) and Polygonum minus on Sexual Performance and Well-Being in Men: A Randomized, Double-Blind, Placebo-Controlled Study.

Background. Physta is a proprietary product containing a freeze-dried water extract of Eurycoma longifolia (tongkat ali), which is traditionally used as an energy enhancer and aphrodisiac. We aim to evaluate a 300 mg combination of Physta and Polygonum minus, an antioxidant, with regard to sexual performance and well-being in men. Methods. Men that aged 40-65 years were screened for this 12-week randomized, double-blind, placebo-controlled, parallel-group study. Outcome measures included validated questionnaires that aimed to evaluate erectile function, satisfaction with intervention, sexual intercourse performance, erectile hardness, mood, and overall quality of life. Results. 12 subjects in the active group and 14 in the placebo group completed the study. Significant improvements were noted in scores for the Sexual Intercourse Attempt diary, Erection Hardness Scale, Sexual Health Inventory of Men, and Aging Male Symptom scale (P < 0.05 for all). Three adverse events were reported in the active group and four in the placebo group, none of which were attributed to study product. Laboratory evaluations, including liver and kidney function testing, showed no clinically significant abnormality. Conclusion. Supplementation for twelve weeks with Polygonum minus and the proprietary Eurycoma longifolia extract, Physta, was well tolerated and more effective than placebo in enhancing sexual performance in healthy volunteers.

Undenatured type II collagen (UC-II®) for joint support: a randomized, double-blind, placebo-controlled study in healthy volunteers.

BACKGROUND: UC-II contains a patented form of undenatured type II collagen derived from chicken sternum. Previous preclinical and clinical studies support the safety and efficacy of UC-II in modulating joint discomfort in osteoarthritis and rheumatoid arthritis. The purpose of this study was to assess the efficacy and tolerability of UC-II in moderating joint function and joint pain due to strenuous exercise in healthy subjects. METHODS: This randomized, double-blind, placebo-controlled study was conducted in healthy subjects who had no prior history of arthritic disease or joint pain at rest but experienced joint discomfort with physical activity. Fifty-five subjects who reported knee pain after participating in a standardized stepmill performance test were randomized to receive placebo (n = 28) or the UC-II (40 mg daily, n = 27) product for 120 days. Joint function was assessed by changes in degree of knee flexion and knee extension as well as measuring the time to experiencing and recovering from joint pain following strenuous stepmill exertion. RESULTS: After 120 days of supplementation, subjects in the UC-II group exhibited a statistically significant improvement in average knee extension compared to placebo (81.0 ± 1.3º vs 74.0 ± 2.2º; p = 0.011) and to baseline (81.0 ± 1.3º vs 73.2 ± 1.9º; p = 0.002). The UC-II cohort also demonstrated a statistically significant change in average knee extension at day 90 (78.8 ± 1.9º vs 73.2 ± 1.9º; p = 0.045) versus baseline. No significant change in knee extension was observed in the placebo group at any time. It was also noted that the UC-II group exercised longer before experiencing any initial joint discomfort at day 120 (2.8 ± 0.5 min, p = 0.019), compared to baseline (1.4 ± 0.2 min). By contrast, no significant changes were seen in the placebo group. No product related adverse events were observed during the study. At study conclusion, five individuals in the UC-II cohort reported no pain during or after the stepmill protocol (p = 0.031, within visit) as compared to one subject in the placebo group. CONCLUSIONS: Daily supplementation with 40 mg of UC-II was well tolerated and led to improved knee joint extension in healthy subjects. UC-II also demonstrated the potential to lengthen the period of pain free strenuous exertion and alleviate the joint pain that occasionally arises from such activities.

Cochlear implantation in children with anomalous cochleovestibular anatomy.

Our aim was to determine the influence of inner-ear anomalies on surgical difficulty and postoperative audiologic outcomes among pediatric cochlear implant (CI) recipients at our institution. We reviewed medical and audiologic records from 78 consecutive pediatric CI cases between 1985 and June 2009. Thirty patients had high-resolution temporal bone computed tomography imaging available for retrospective interpretation. Seven of these 30 patients (23%) had cochleovestibular dysplasia. Fifty percent of patients with severe dysplasia had a cerebrospinal fluid gusher intraoperatively, compared with 13% of patients with no dysplasia. Of patients with available audiologic outcome data, 17 of 26 patients with normal/mild/moderate dysplasia were able to complete CNC testing, whereas neither of the 2 patients with severe dysplasia could complete the open set test. Our experience suggests that surgical difficulty and audiologic outcomes in pediatric CI recipients may be affected by the presence and severity of a cochleovestibular anomaly.

Cochlear implantation in children with anomalous cochleovestibular anatomy: a systematic review.

OBJECTIVE: To determine the influence of inner ear dysplasia on both surgical and audiologic outcomes following pediatric cochlear implant (CI) surgery. DATA SOURCES: MEDLINE (1982-2009) and data from Massachusetts Eye and Ear Infirmary. REVIEW METHODS: A systematic review of the literature was performed. Variables assessed included age at implantation, duration of CI use, radiologic and operative findings, and speech perception outcome data. RESULTS: The initial search yielded 1326 articles. Including data from our own study, twenty-two fulfilled criteria for inclusion, representing 311 patients. Data for bilateral implants were recorded only for the first implant. Data on simultaneous bilateral implants were not recorded. The most common anomaly seen was large vestibular aqueduct (89/311 or 29%). When comparing patients with mild-moderate or severe dysplasia, rates of cerebrospinal fluid gusher were 31% versus 35% (odds ratio [OR] = 0.50), anomalous facial nerve anatomy was seen in 11% versus 51% (OR = 0.15), and postoperative speech perception abilities were found in 84% versus 54% (OR = 1.93), respectively. A large heterogeneity was found among studies regarding all outcome measures. CONCLUSION: Although we found that severe inner ear dysplasia was associated with increased surgical difficulty and lower speech perception, the lack of uniformity in published clinical data limited the strength of these results. Standardization of surgical and radiologic reporting as well as more consistent speech perception testing is needed to better determine the association between anomalous cochleovestibular anatomy and clinical outcomes.

Fungi linking the pathophysiology of chronic rhinosinusitis with nasal polyps and allergic asthma.

The immunologic reaction to fungal stimuli has long been thought to be a contributor to the development of sinonasal disease. We aim to review the role of fungi in upper and lower airway inflammatory diseases. The immune response to fungi in the pathogenicity of specific respiratory inflammatory diseases such as allergic bronchopulmonary aspergillosis and a subtype of CRS known as allergic fungal rhinosinusitis has been relatively well described. Fungi are thought to serve both as immunogenic antigens and as adjuncts to inflammation through protease activity. Development of a recent murine mouse model of asthma bypassing the pre-sensitization of allergen further suggests a broader role for fungi in allergic asthma. The literature is lacking in defining a clear presence of fungi within the inflamed sinus cavity of CRS patients and its potential immunologic effects, as well as the utility of antifungal therapy for CRS management. We will review these data and potential common molecular mechanisms activated by fungi in the common pathway toward upper and lower airway inflammatory pathology.

The links between chronic rhinosinusitis and asthma.

PURPOSE OF REVIEW: Chronic rhinosinusitis (CRS) and asthma are two leading causes of morbidity with many shared clinical features. Their relationship has initially been linked by the atopic pathway. However, understanding of the true pathophysiology of each of these conditions is still under investigation. RECENT FINDINGS: Recent studies have described new common pathogens, such as fungi and Staphylococcus aureus, as well as disease biomarkers such as nitric oxide and interleukin (IL)-17A, involved in both asthma and CRS pathophysiology. These new discoveries offer insight into understanding these upper and lower airway diseases and may potentially affect treatment management. In the following review, we intend to provide an overview of the recent developments in the relevant areas of research within the past year. SUMMARY: Reactions to fungal stimuli and superantigens, as well as biomarkers such as nitric oxide and IL-17A, may play a role in the pathogenesis of asthma and CRS and may explain their historic relationship.

Bilateral papillary thyroid cancer and associated histopathologic findings.

OBJECTIVE: To determine the incidence of bilateral papillary thyroid cancer (PTC) at total thyroidectomy (TT) and compare demographic risk factors (gender and age) and histopathologic findings (tumour size, extrathyroidal extension [ETE], T staging, and multifocality) between patients with PTC in both thyroid lobes and those with PTC limited to the ipsilateral lobe and/or isthmus. DESIGN: Retrospective study. SETTING: University teaching hospital. METHODS: The pathology results of 1047 consecutive patients who underwent TT between 2002 and 2008 were reviewed. Statistical significance was obtained using the chi-square test. MAIN OUTCOME MEASURES: Incidence of bilateral PTC and its association with demographic risk factors and histopathologic findings. RESULTS: Among 592 patients with PTC, 13.2% had bilateral PTC and 86.8% had unilateral and/or isthmian PTC. Bilaterality was present in 12.4% of women and 16.7% of men (p = .24) and in 12.9% of patients aged > or = 45 years and 13.5% < 45 years (p = .83). Bilateral PTC was found in 12.6% of patients with a primary tumour < or = 2 cm and 13.5% > 2 cm (p = .75); 23.6% of tumours with ETE demonstrated bilaterality compared to 9.7% without (p < .0001), and 8.7% of pT1 (p = .08), 9.2% of pT2 (p = .02), 23.0% of pT3 (p < .0001), and 12.5% of pT4 (p = .87) tumours were bilateral, respectively. Among bilateral PTC patients, 43.2% had multifoci in at least one lobe compared to 6.4% when nonbilateral (p < .0001). CONCLUSIONS: After TT, 13.2% of patients had bilateral PTC. No significant correlation was established between bilaterality and gender, age, and tumour size. Bilaterality was more commonly found in patients with ETE, advanced T stage, and at least one multifocal lobe.

Body mass index in the evaluation of thyroid cancer risk.

BACKGROUND: Obesity has been linked to numerous diseases including thyroid cancer, but the exact nature of the relationship, especially with respect to patients with thyroid nodules, remains unclear. The objective of this study was to evaluate the impact of body mass index (BMI) on thyroid cancer risk in a population of patients with indeterminate cytology on fine-needle aspiration biopsy (FNAB). METHODS: A total of 253 consecutive patients with indeterminate thyroid nodule FNABs who underwent total thyroidectomy in a tertiary care teaching hospital between 2002 and 2007 were reviewed. Height and weight reported on the anesthesia summary were recorded for each patient. Malignancy rates were calculated for the underweight, normal, overweight, and obese groups stratified according to their BMI. Subanalyses according to age and sex were also performed. RESULTS: The risk of malignancy tended to be lower in obese patients compared to patients with BMIs in the underweight, normal, and overweight ranges (52% vs. 61%, p = 0.195). In men, a BMI classified as obese was associated with a significantly lower rate of malignancy (36% vs. 72%, p = 0.003). Women older than 45 years were a subgroup in which higher malignancy rates were associated with obesity (65% vs. 54%, p = 0.293). Conversely, in men over the age of 45 years and women under 45 years, a BMI in the obesity range was linked to a lower incidence of malignancy (20% vs. 68% p = 0.009 and 36% vs. 68% p = 0.043, respectively). When older women were excluded from the population studied, the rate of malignancy in obese patients was 36% versus 70% in nonobese patients (p = 0.002) with an associated reduction of 5% in the risk of malignancy per increased unit of BMI. CONCLUSIONS: For patients with FNAB results of indeterminate significance, a higher BMI correlates with lower rates of thyroid malignancy for all patients except women over the age of 45 years.

Incidence and histopathological behavior of papillary microcarcinomas: study of 429 cases.

OBJECTIVE: We aim to present papillary microcarcinoma (PMC) incidence at a university teaching hospital, to compare characteristics of PMC in relation to size, and to assess for significant difference in PMC incidence among patients with non-PMC thyroid malignancies. MATERIALS AND METHODS: Pathology results were reviewed for consecutive total thyroidectomies between 2002 and 2007 (n = 860). Statistical significance was calculated using chi(2) or, when unavailable, Fisher exact test. RESULTS: PMC was found in 429 cases, which is 49.9 percent of all total thyroidectomies. In PMC > or =5 mm, 25.1 percent had extrathyroidal extension vs 9.1 percent for <5 mm (P < 0.001). When 4 mm is used as a threshold, P value was 300-fold smaller. Incidence in patients with any non-PMC thyroid malignancy was 51.6 percent against 47.2 percent in all other patients (P = 0.203). CONCLUSIONS: In this study, PMC was found in 49.9 percent of patients, which, to our knowledge, is higher than any other reported incidence. A threshold of > or =4 mm was more significant than 5 mm for carrying increased risk for extrathyroidal spread. There was no significant difference in PMC incidence in patients with malignant vs benign disease.