Plaque contact surface area and lumen volume predict stroke risk in extracranial carotid artery stenosis.

BACKGROUND: The standard indication for intervention in asymptomatic disease is currently percent stenosis in the internal carotid artery as measured by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method, which remains limited in discriminating power. Computed tomography angiography (CTA) is widely used to calculate NASCET stenosis, but also offers the opportunity to analyze carotid artery plaques from a morphological perspective that has not been widely used. We aim to improve stroke risk stratification of patients with carotid artery stenosis using plaque three-dimensional (3D) modeling and image analysis. METHODS: Patients with computed tomography angiographies appropriate for 3D reconstruction were identified from a National Institutes of Health-designated stroke center database, and carotid arteries were segmented and analyzed using software algorithms to calculate contact surface area (CSA) between the plaque and blood flow, and volume of the flow lumen within the region of the plaque (lumen volume [LV]). These novel parameters factor in the 3D morphometry inherent to each carotid plaque and were compared between stroke and nonstroke groups. RESULTS: A total of 134 carotid arteries were analyzed, 33 of which were associated with an ipsilateral stroke. Plaques associated with stroke demonstrated statistically significant increases in average CSA (541.52 mm2) and LV (394.64 mm3) when compared with those not associated with stroke (371.18 mm2 and 245.92 mm3, respectively). When comparing area under the receiver operating characteristics curve between NASCET (0.65) percent stenosis, CSA (0.74), and LV (0.77), both CSA and LV demonstrated more favorable values in predicting stroke risk in patients with carotid stenosis. CONCLUSIONS: The data presented here demonstrate morphological features of carotid plaques that are independent of NASCET criteria stratification and may present an improved method in assessing stroke risk in patients with carotid artery stenosis.

The Principles and Practice of Endonasal Rhinoplasty: Special Topics for Clinics in Plastic Surgery Journal.

Endonasal rhinoplasty is a minimally invasive approach in which esthetic and functional improvements are made solely through intranasal, without transcolumellar, incisions and with limited soft tissue and skeletal disruption. In addition to intentionally limiting surgical dissection, the rhinoplasty surgeon must preoperatively recognize and surgically correct 4 common anatomic variants which predictably create all 3 patterns of secondary deformity. In combination, respecting these principles gives the surgeon greater predictability in achieving esthetic and functional improvements, and the ability to limit the adverse effects of skin contractility and postoperative scar contracture, thus reducing the risk of secondary deformity, patient dissatisfaction, and reoperation.

Devices to enhance organ perfusion during cardiopulmonary resuscitation.

INTRODUCTION: The recommended method of cardiopulmonary resuscitation (CPR) has been closed-chest cardiac compressions, but the development of CPR adjunctive devices has called into question the efficacy and role of these adjunctive devices. In this review, we provide a comprehensive evaluation and discussion on the commercially available noninvasive CPR adjuncts used during out-of-hospital cardiac arrest (OHCA). AREAS COVERED: We review the three most common CPR adjunctive devices: the piston mechanism, the load distributing band, and the impedance threshold device. All three CPR adjunctive devices have preclinical data to support their use during cardiac arrest. In clinical trials, limited data show improvement in survival and neurologic recovery for these devices, and there is insufficient high-level evidence to support their use over manual chest compressions. However, there is a role for them when adequate manual chest compressions are not feasible. EXPERT OPINION: The commercially available CPR adjuncts do not consistently show improved outcomes in the literature. There is still a need for research and development into innovative solutions to improve OHCA survival and neurologic recovery. Efforts focused on increasing the speed of CPR initiation and increasing perfusion to the cerebral and coronary vasculature have the potential to advance resuscitative practices.

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison.

OBJECTIVE: Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary care center. METHODS: An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ2 test and Student t test with statistical α set at .05. RESULTS: Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference (P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology (P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series. CONCLUSIONS: SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

Are metatarsal fractures indicative of osteoporosis in postmenopausal women?

Patients who sustain low trauma fractures are at a higher risk of osteoporosis. However, there are conflicting data concerning whether metatarsal fractures are also associated with low bone mineral density. The authors retrospectively analyzed data on 68 postmenopausal women who had sustained a low trauma metatarsal fracture. Routine assessment of these patients included identification of risk factors for fracture, height and weight measurement, and measurement of peripheral bone density at the heel by dual-energy X-ray absorptiometry (Calscan, Demetech AB, Täby, Sweden). Bone density in the patients was compared with manufacturer's reference database. The mean Z-score for the patients was -0.08. In total, 14 women (20.5% [confidence interval 10.5 to 29.5]) had a Z-score ≤-1, and 1 patient (1.5% [confidence interval -1.4 to 4.4]) had a Z-score ≤-2. Mean T-score in these women was -1.95. Since the number of women with a Z-score ≤-1 was not significantly greater than the 16% that would be expected, and the number of women with a Z-score ≤-2 was not significantly greater than the 2.5% expected, it is concluded that low trauma metatarsal fracture is not a risk factor for low calcaneal bone mineral density.

Are fibromyalgia patients as inactive as they say they are?

Both fibromyalgia and rheumatoid arthritis (RA) patients self-report similar disability. These diseases are viewed differently by the medical profession as one has ample evidence of tissue damage and inflammation and the other does not. We were interested to see if an objective measure produced similar results. Twelve patients with RA were matched with 12 fibromyalgia patients by sex, age, and Health Assessment Questionnaire (HAQ) score. The 24-h ambulatory activity of these patients was recorded using the Numact monitor. Statistical analysis was performed using independent group t test for the ambulatory activity data and Spearman's correlation coefficients for HAQ and total energy. There were no significant differences found between the two groups in terms of total activity. Other compared analyses for activity included the number of steps taken, vigor of steps, and time spent standing, which were not statistically different. The correlation coefficients of HAQ and total ambulatory activity for the fibromyalgia group were rho = -0.638 (p = 0.026). Patients with RA and fibromyalgia displaying similar levels of self-reported disability have objective evidence of similar levels of total ambulatory activity. There is a statistically significant correlation between self-reported and objective measurements of disability for the fibromyalgia patients. Either of these measures merits further study as outcome measures for fibromyalgia.

The cabbage aphid: a walking mustard oil bomb.

The cabbage aphid, Brevicoryne brassicae, has developed a chemical defence system that exploits and mimics that of its host plants, involving sequestration of the major plant secondary metabolites (glucosinolates). Like its host plants, the aphid produces a myrosinase (beta-thioglucoside glucohydrolase) to catalyse the hydrolysis of glucosinolates, yielding biologically active products. Here, we demonstrate that aphid myrosinase expression in head/thoracic muscle starts during embryonic development and protein levels continue to accumulate after the nymphs are born. However, aphids are entirely dependent on the host plant for the glucosinolate substrate, which they store in the haemolymph. Uptake of a glucosinolate (sinigrin) was investigated when aphids fed on plants or an in vitro system and followed a different developmental pattern in winged and wingless aphid morphs. In nymphs of the wingless aphid morph, glucosinolate level continued to increase throughout the development to the adult stage, but the quantity in nymphs of the winged form peaked before eclosion (at day 7) and subsequently declined. Winged aphids excreted significantly higher amounts of glucosinolate in the honeydew when compared with wingless aphids, suggesting regulated transport across the gut. The higher level of sinigrin in wingless aphids had a significant negative impact on survival of a ladybird predator. Larvae of Adalia bipunctata were unable to survive when fed adult wingless aphids from a 1% sinigrin diet, but survived successfully when fed aphids from a glucosinolate-free diet (wingless or winged), or winged aphids from 1% sinigrin. The apparent lack of an effective chemical defence system in adult winged aphids possibly reflects their energetic investment in flight as an alternative predator avoidance mechanism.

Endoscopic transnasal management of intracranial foreign bodies.

Foreign bodies may be introduced into the paranasal sinuses or cranium through a variety of traumatic or iatrogenic events. A variety of open and, more recently, endoscopic approaches have been used for the removal of sinonasal foreign bodies. Intracranial foreign bodies, however, typically require retrieval via a craniotomy approach, which continues to carry significant perioperative risks. We describe the first reported case of an intracranial foreign body removed using the transnasal endoscopic approach with intraoperative image guidance. We discuss the preoperative evaluation required for this approach to be applied safely and successfully in properly selected cases.

Spatial organization of the glucosinolate-myrosinase system in brassica specialist aphids is similar to that of the host plant.

Secondary metabolites are important in plant defence against pests and diseases. Similarly, insects can use plant secondary metabolites in defence and, in some cases, synthesize their own products. The paper describes how two specialist brassica feeders, Brevicoryne brassicae (cabbage aphid) and Lipaphis erysimi (turnip aphid) can sequester glucosinolates (thioglucosides) from their host plants, yet avoid the generation of toxic degradation products by compartmentalizing myrosinase (thioglucosidase) into crystalline microbodies. We propose that death, or damage, to the insect by predators or disease causes disruption of compartmentalized myrosinase, which results in the release of isothiocyanate that acts as a synergist for the alarm pheromone E-beta-farnesene.