Polysomnographic outcomes of revision adenoidectomy in children with obstructive sleep apnea and recurrent/residual adenoidal hypertrophy.

INTRODUCTION: Recurrent/residual adenoidal hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the polysomnographic (PSG) outcomes of revision adenoidectomy in children with recurrent/residual adenoidal hypertrophy and OSA. METHODS: This was a single-center retrospective study that included children with sleep studies that confirmed OSA and known history of adenotonsillectomy who were diagnosed with adenoidal hypertrophy and subsequently underwent revision adenoidectomy. Pre- and postoperative PSG variables of revision adenoidectomy were included in the analysis. RESULTS: A total of 20 children were included in the study. The cohort included 13 males and 7 females with a mean age of 7.8 years (± 3.6 years). The mean BMI z score was 1.96 [1.31, 2.43]. The median duration from adenotonsillectomy performance was 2.3 years [1.4, 4.0]. Overall, revision adenoidectomy resulted in significant improvements in multiple respiratory parameters, including AHI 6.6 [1.4, 13. 7] vs 14.8 [7.4, 20.7], p = 0.02; oxygen desaturations nadir 88.0 [84.0, 93.0] vs 80.0 [72.2, 88.9], p = 0.01; supine AHI 8.6 [1.5, 14.3] vs 17.6 [8.3, 30.2], p = 0.02; and arousal index 12.2 [9.6, 15.7] vs 18.9 [13.4, 24.9], p = 0.04. CONCLUSIONS: Children with recurrent/residual adenoidal hypertrophy after adenotonsillectomy who undergo revision adenoidectomy experience improvements in respiratory event, gas exchange, and arousal index.

Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective.

STUDY OBJECTIVES: Recurrent/residual adenoid hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the role of soft tissue neck X-ray (STN-XR) in evaluating recurrent/residual adenoid tissue hypertrophy. METHODS: This was a single-center retrospective study that included children with sleep study-confirmed OSA and a known history of adenotonsillectomy who underwent STN-XR to evaluate for recurrent/residual adenoid tissue hypertrophy. STN-XR nasopharyngeal obliteration and baseline polysomnographic data were analyzed. Multiple linear regression was used to assess the independent relationship between the results of STN-XR and the total apnea-hypopnea index, while controlling for relevant characteristics. RESULTS: The study included 160 participants with a median age of 10 years (quartile [Q] 1 = 7, Q3 = 12.25). More than half of the children were male (59.4%) and the median body mass index z-score was 2.11 (Q1 = 1.23, Q3 = 2.54). STN-XR was normal in 39.4%, and it showed mild, moderate, and complete nasopharyngeal obliteration in 20.6%, 32.5%, and 7.5% of the participants, respectively. Multiple regression analysis showed that moderate and complete nasopharyngeal obliteration was associated with an increase in the mean total apnea-hypopnea index by 109% (P = .0002) and 185% (P = .001), respectively, when compared with children without nasopharyngeal obliteration. However, mild nasopharyngeal obliteration, body mass index z-score, age, sex, and race were not significantly associated with an increase in the total apnea-hypopnea index. CONCLUSIONS: STN-XR was useful in assessing recurrent/residual adenoid tissue hypertrophy in children with OSA and a history of adenotonsillectomy. Moderate and complete nasopharyngeal obliteration were associated with significantly increased apnea-hypopnea index. Pediatric sleep physicians may consider STN-XR in the evaluation of children with OSA and previous history of adenotonsillectomy. CITATION: Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med. 2023;19(6):1027-1033.

Fat Embolism Syndrome With Cerebral Involvement: An Underrecognized Complication of Long Bone Fractures.

Fat embolism syndrome (FES) occurs when fat particles are aberrantly distributed into the microcirculation, and it often manifests as either hypoxemia, neurological deficit, or petechial rash. Although cases have been reported in the literature since the twentieth century, no formal diagnostic criteria have been universally adopted, and FES remains a diagnostic challenge. We present a unique case of FES from a long bone fracture, leading to pulmonary embolism with paradoxical arterial embolization and cerebral infarction, and provide a review of the related literature.

Acute multidrug delivery via a wearable bioreactor facilitates long-term limb regeneration and functional recovery in adult Xenopus laevis.

Limb regeneration is a frontier in biomedical science. Identifying triggers of innate morphogenetic responses in vivo to induce the growth of healthy patterned tissue would address the needs of millions of patients, from diabetics to victims of trauma. Organisms such as Xenopus laevis-whose limited regenerative capacities in adulthood mirror those of humans-are important models with which to test interventions that can restore form and function. Here, we demonstrate long-term (18 months) regrowth, marked tissue repatterning, and functional restoration of an amputated X. laevis hindlimb following a 24-hour exposure to a multidrug, pro-regenerative treatment delivered by a wearable bioreactor. Regenerated tissues composed of skin, bone, vasculature, and nerves significantly exceeded the complexity and sensorimotor capacities of untreated and control animals' hypomorphic spikes. RNA sequencing of early tissue buds revealed activation of developmental pathways such as Wnt/ß-catenin, TGF-ß, hedgehog, and Notch. These data demonstrate the successful "kickstarting" of endogenous regenerative pathways in a vertebrate model.

Recurrence of carcinoma showing thymus-like differentiation (CASTLE) involving the thyroid gland.

BACKGROUND: Carcinoma showing thymus-like differentiation (CASTLE) in the thyroid gland is a rare disease with generally a favorable prognosis. Treatment with surgery and adjuvant radiotherapy has been shown to improve local control and long-term survival rates. In this report, we present a case of a recurrent thyroid gland CASTLE and review the literature on the diagnosis and treatment of this disease. CASE PRESENTATION: A 60-year-old woman, who was diagnosed with a CASTLE thyroid tumor in 2015, had a total thyroidectomy and was maintained on thyroid hormone replacement (levothyroxine). After 5 years, the patient had a recurrence, in an advanced stage unsuitable for surgery. As the patient declined to undergo radiotherapy, she was followed up without intervention and is currently stable after 15 months. CONCLUSIONS: CASTLE is a rare disease, diagnosed based on postoperative pathology and immunohistochemistry analysis, especially upon CD5 marker. In case of relapse, treatment options include surgery and radiotherapy; however conservative management without intervention is an acceptable alternative in some cases.

Thiosemicarbazone-Modified Cellulose: Synthesis, Characterization, and Adsorption Studies on Cu(II) Removal.

Thiosemicarbazide-modified cellulose (MTC) has been studied for removing heavy metals in the water source or for extracting some precious metals. The conditions of synthesis of MTC and Cu(II) removal were optimized by single-variable analysis through oxidation-reduction on titration and photometry. The results of Fourier-transform infrared spectroscopy, Brunauer-Emmett-Teller, and thermogravimetric analyses show that MTC exists in the thioketone form with a high surface area and heat durability. The Cu(II) removal was of pseudo-second order and the isotherm equation correlated best with the Langmuir equation. MTC has the maximum capacity of adsorption, which is q m = 106.3829 mg g-1. Furthermore, MTC can be regenerated without the loss of adsorption efficiency after ten cycles of adsorption and desorption.

Family history, BRCA mutations and breast cancer in Vietnamese women.

The purpose of this report is to estimate the proportions of familial and hereditary breast cancers among unselected cases of breast cancer in Vietnam. Two hundred and ninety-two unselected cases of incident breast cancer were recruited from the National Cancer Hospital, Hanoi, the largest cancer centre in Vietnam. Family histories were collected for 292 cases and a DNA sample was obtained for 259 cases. DNA samples were screened for mutations in the large exons of BRCA1 and BRCA2 using the protein truncation test and by allele-specific testing for 17 founder mutations which have been reported in other Asian populations. Complete gene sequencing was performed on two cases of familial breast cancer. Seven of 292 cases reported a relative with breast cancer and one patient reported a relative with ovarian cancer. A pathogenic BRCA mutation was detected in 2 of 259 cases; one BRCA1 carrier was diagnosed at age 51 and one BRCA2 carrier was diagnosed at age 42. Neither case reported a relative with breast or ovarian cancer. A family history of breast cancer is very uncommon among Vietnamese breast cancer patients. The frequency of pathogenic BRCA mutations in Vietnamese breast cancer patients is among the lowest reported worldwide.

Complement-coated antibody-transfer (CCAT); serum IgA1 antibodies intercept and transport C4 and C3 fragments and preserve IgG1 deployment (PGD).

In periodontal disease, IgG1 and IgA1 antibodies produced in situ deposit on antigens in the affected tissues. Thus, there is an interest in the effect of co-deposited IgA1 antibodies on complement activation by IgG1-immune complexes. In the present study, we first analyzed the effect of IgA1-immune complexes on complement using human IgA1 antibodies to dansyl (with dansylated human serum albumin serving as the immobilized antigen). It was observed that these IgA1-immune complexes when incubated for prolonged times with 33% human serum as a source of complement received C4b and C3b deposition. As C4b and C3b deposited on the IgA1 antibodies and on the antigenic surface, the complement-coated IgA1 antibodies departed. These fluid-phase complement-coated IgA1 antibodies were transferred to antigen-coated microtiter-ELISA plates, where they became bound to the antigens. Thus, the complement-coated IgA1 antibodies retained their antigen-binding function, especially as a proportion of their covalently bound C3b progressively degraded to iC3b and C3d. Genetically engineered carbohydrate-deficient mutant human IgA1 antibodies were used to assess the role of carbohydrate in accepting the C4b and C3b depositions, and these studies indicated that the carbohydrate on the Fc-region of IgA1 played a positive role. Another interesting finding generated by this study was that when IgA1 was co-deposited with IgG1 antibodies, and serum complement was added, the IgG1 antibodies tended to remain on the antigenic surface. The co-deposited IgA1 antibodies not only controlled (reduced) the rate of the consumption of the first component of complement (C1) and of classical complement pathway activation by IgG1-immune complexes (and therein reduced the rate of complement-mediated dissolution of the IgG1-immune complexes), but also the co-deposited IgA1 antibodies simultaneously intercepted/accepted C4b and C3b, then departed, as complement began to cover the antigenic surfaces. The process in which complement-coated IgA1 antibodies transferred to non-complement-coated antigens is termed complement-coated antibody-transfer/transport (CCAT). In this way, IgA1 antibodies extended the efficiency of the complement system by insuring the specific IgA1 antibody-mediated transport of the captured biologically active complement fragments to those antigens stimulating the IgA1 antibody response but not yet neutralized (completely coated) with complement. Simultaneously by impeding the rate of C1 consumption and by intercepting C4b and C3b, IgA1 antibodies slowed C4b and C3b deposition on the antigenic surface and on the co-deposited IgG1 antibodies. Thus, in the presence of ongoing complement activation, the deposition of serum IgA1 antibodies enabled the co-deposited IgG1 antibodies to better maintain their ability to interact with antigens. We termed this latter phenomenon, preservation of IgG antibody deployment (PGD). In summary, co-deposited IgA1 antibodies maximized the efficiency of the complement system, transported their covalently bound complement fragments to specific antigens and sustained the effective deployment of IgG1 antibodies directed to those same antigens.

[Sexual female mutilation]. / Les mutilations sexuelles féminines.

Each year, two million young girls are at risk of female sexual mutilation. Pediatricians are likely to be confronted with this problem. They must know to identify it as well as the complications to ensure a concerned assumption of the families, in the respect of the law.

Pretreatment of CD-1 mice with 4-methylpyrazole blocks toxicity from the gamma-hydroxybutyrate precursor, 1,4-butanediol.

1,4-Butanediol (1,4-BD) is the dihydroxy precursor of gamma-hydroxybutyrate (GHB), a popular recreational drug that has been banned by the United States Food and Drug Administration (FDA) and controlled as a federal schedule I drug. 1,4-BD is enzymatically converted in vivo to GHB by alcohol dehydrogenase (ADH), and overdoses can result in coma, severe respiratory depression, bradycardia, hypothermia, seizures, and death. Presently, there is no antidote. We pretreated CD-1 mice with the ADH antagonist, 4-methylpyrazole (4-MP), to determine if blocking ADH can prevent or decrease toxicity from 1,4-BD overdose. Pretreatment with 4-MP increased the Toxic Dose-50 (TD(50)) of 1,4-BD for the righting reflex from 585 mg/kg (95% CI, 484-707 mg/kg) in control mice to 5,550 mg/kg (95% CI, 5,353-5,756 mg/kg) in pretreated mice. Pretreatment with 4-MP also increased the TD(50) of 1,4-BD for the rotarod test from 163 mg/kg (95% CI, 136-196 mg/kg) in control mice to 4,900 mg/kg (95% CI, 4,812-4,989 mg/kg) in pretreated mice. Pretreatment with 4-MP significantly decreased the toxicity of 1,4-BD in CD-1 mice, presumably by inhibiting its ADH biotransformation to GHB. 4-MP warrants further investigation as a potential antidote for this increasingly abused drug.

Lacunar stroke: transoesophageal echocardiographic factors influencing long-term prognosis.

OBJECTIVE: Since little is known concerning factors which may influence long-term prognosis of patients presenting with lacunar stroke, we conducted a longitudinal study of this stroke subtype. Variables likely to affect outcome were assessed at baseline, including those from transoesophageal echocardiographic studies. METHODS: Consecutive patients presenting with first-ever lacunar stroke underwent diagnostic workup that included brain CT or MRI, carotid duplex, and transthoracic and transoesophageal echocardiography. An assessment of patients was planned at entry (baseline), and thereafter every 12 months (clinic visit or telephone call), drop-out, or endpoint. The primary endpoint was nonfatal or fatal stroke. Secondary endpoint was death due to any cause. RESULTS: Among 60 consecutive lacunar patients with the mean follow-up period of 3.9 years, 12 patients (20%) had stroke recurrence. The mean annual rate for stroke was 5.2%, and for death 2.8%. For multivariate Cox proportional hazards analysis, the following three variables with the values of p < 0.1 after univariate testing were chosen: age (p = 0.095); aortic atheroma (p = 0.066); and any source of embolism from heart (p = 0.007). Any source of embolism from heart was the only factor which significantly enhanced the risk of stroke recurrence (p = 0.015). Using Kaplan-Meier life table analysis, the curves of percent free of recurrent stroke were significantly different (log rank test p = 0.002). CONCLUSIONS: Until the mechanism of lacunar stroke is better understood, it is reasonable to suggest that its investigation and prevention should be directed at all potential causes of future strokes including cardioembolism.

Past, present, and future role of ipecac syrup.

Historically, ipecac syrup has played a principal role in the management of acute poisonings and overdoses. Presently, its role largely has been relegated to prompt decontamination of acute childhood poisonings for which emesis is not contraindicated. However, even this specific and limited role has undergone rigorous re-evaluation, and many toxicologists have discouraged against its use in any circumstance. This article reviews the history, scientific literature, and public health implications of ipecac syrup that support its present clinical application.

Risk factors for lacunar stroke: a case-control transesophageal echocardiographic study.

To reassess the independent risk factors for lacunar stroke and to clarify the role of potential embolic sources, we conducted a case-control study using transesophageal echocardiography and duplex ultrasonography. Among 62 consecutive patients with their first lacunar stroke and 202 normal controls, we found that hypertension (p < 0.001), smoking (p = 0.001), and aortic arch atheroma (p = 0.006) were independently associated with an increased risk of lacunar stroke. Whether proximal aortic arch atheroma is mechanistically associated with lacunar stroke or merely coexistent is uncertain.

Gamma-hydroxybutyrate, gamma-butyrolactone, and 1,4-butanediol: a case report and review of the literature.

GHB, GBL, and 1,4-BD are prevalent drugs of abuse in the United States. Unfortunately, attempts to regulate GHB have been circumvented by clandestine trafficking through the Internet and marketing of "natural" chemical precursors . Despite repeated FDA warnings to the public about their dangers as well as recent federal scheduling of GHB and GBL, they remain accessible as "club drugs" on Internet websites, as natural dietary supplements in health food stores, and as illicit products manufactured at home or in clandestine laboratories. EDs and poison control centers nationwide will undoubtedly continue to manage GHB, GBL, and 1,4-BD toxicities.

Mammographic screening: measurement of the cost in a population based programme in Victoria, Australia.

STUDY OBJECTIVES: To estimate the cost per woman participating in a mammographic screening programme, and to describe methods for measuring costs. DESIGN: Expenditure, resource usage, and throughput were monitored over a 12 month period. Unit costs for each phase of the screening process were estimated and linked with the probabilities of each screening outcome to obtain the cost per woman screened and the cost per breast cancer detected. SETTING: A pilot, population based Australian programme offering free two-view mammographic screening. PARTICIPANTS: A total of 5986 women aged 50-69 years who lived in the target area, were listed on the electoral roll, had no previous breast cancer, and attended the programme. RESULTS: Unit costs for recruitment, screening, and recall mammography were $17.54, $60.04, and $175.54, respectively. The costs of clinical assessment for women with subsequent clear, benign, malignant (palpable), and malignant (impalpable) diagnoses were $173.71, $527.29, $436.62, and $567.22, respectively. The cost per woman screened was $117.70, and the cost per breast cancer detected was $11,550. CONCLUSIONS: The cost per woman screened is a key variable in assessment of the cost effectiveness of mammographic screening, and is likely to vary between health care settings. Its measurement is justified if decisions about health care services are to be based on cost effectiveness criteria.

The capsular warning syndrome: pathogenesis and clinical features.

Transient ischemic attacks (TIAs) are not homogeneous and may consist of subsets with mechanisms as varied as their stroke counterparts. We describe a form of TIA in 50 patients where crescendo episodes of ischemia were restricted to the region of the internal capsule, usually causing symptoms affecting face, arm, and leg. These patients composed 4.5% of a consecutive series of patients admitted with TIAs over a 15-year period and 33% of all TIAs classified as subcortical. We believe that the ischemia was most often due to hemodynamic phenomena in diseases, single, small penetrating vessels. When cerebral infarction developed, it was usually lacunar and involved a single penetrating vessel, although occasionally striatocapsular or anterior choroidal artery territory infarction occurred. There was no evidence of artery-to-artery or heart-to-artery embolism. Resistance to various forms of therapy, including hemodiluting, anticoagulant, and thrombolytic agents, was common. Because of dramatic and easily recognizable clinical presentation, apparent specific pathophysiologic mechanism, and the development of early capsular stroke in a high proportion of cases (42%), we have termed this the "capsular warning syndrome."

Smoking as a risk factor for cortical ischaemia presumably due to carotid occlusive disease.

Smoking is now a well established risk factor for ischaemic stroke. However, the risk associated with smoking may differ between subgroups of ischaemic stroke. To test the hypothesis that cortical ischaemia due to carotid artery occlusive disease, the latter of which has previously been linked to smoking, may have a higher smoking risk compared to other forms of cerebral ischaemia, we identified 178 cases of cortical ischaemia presumably due to carotid occlusive disease in our previous case-control population and compared the odds ratios (OR) for smoking risk in this group with that in group of 244 cases of other forms of cerebral ischaemia combined. All cases were individually matched for age (+/- 5 years) and sex with neighbourhood controls. Multiple conditional logistic regression was used to adjust for potentially confounding factors. The OR for current smokers in the cortical group was higher than that in the non-cortical group [OR 4.4, 95% confidence interval 2.2, 8.9 vs. 2.1 (1.1, 4.1)], particularly for those who smoked more than 60 pack-years [5.5 (2.2, 14.0) vs. 1.5 (0.6, 3.8)] and those who currently smoked more than one pack per day [20.2 (3.3, 122.3) vs. 2.6 (0.8, 8.2)], but not significantly. Overall, there is some evidence to suggest that smoking may be a more potent risk factor for cortical than for other forms of cerebral ischaemia, particularly at high smoking rates. Further studies are needed to substantiate this finding.

[Incomplete spontaneous rupture of the supravalvular aorta complicated by pericarditis and aortic insufficiency]. / Rupture spontanée incomplète de l'aorte sus-sigmoïdienne compliquée de péricardite et d'insuffisance aortique.

The natural history of an incomplete spontaneous rupture of the ascending aorta over a 4-year period is reported. The initial presentation was subacute pericarditis which regressed spontaneously. Aortic regurgitation developed on the 100th day of the disease and was perfectly well tolerated haemodynamically for 4 years. This favourable course was interrupted by type I aortic dissection. The post-mortem examination provided an explanation for the peculiar development and course of the aortic regurgitation: it was due not to the usual prolapse of the cups but to displacement of the left posterior commissure by the retractile fibrosis arising from the lower lip of the spontaneous rupture.