Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map.

BACKGROUND: Spontaneous intracranial hypotension is an important cause of treatable secondary headaches. Evidence on the efficacy of epidural blood patching and surgery for spontaneous intracranial hypotension has not been synthesized. PURPOSE: Our aim was to identify evidence clusters and knowledge gaps in the efficacy of treatments for spontaneous intracranial hypotension to prioritize future research. DATA SOURCES: We searched published English language articles on MEDLINE (Ovid), the Web of Science (Clarivate), and EMBASE (Elsevier) from inception until October 29, 2021. STUDY SELECTION: We reviewed experimental, observational, and systematic review studies assessing the efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension. DATA ANALYSIS: One author performed data extraction, and a second verified it. Disagreements were resolved by consensus or adjudicated by a third author. DATA SYNTHESIS: One hundred thirty-nine studies were included (median, 14 participants; range, 3-298 participants). Most articles were published in the past decade. Most assessed epidural blood patching outcomes. No studies met level 1 evidence. Most were retrospective cohort or case series (92.1%, n = 128). A few compared the efficacy of different treatments (10.8%, n = 15). Most used objective methods for the diagnosis of spontaneous intracranial hypotension (62.3%, n = 86); however, 37.7% (n = 52) did not clearly meet the International Classification of Headache Disorders-3 criteria. CSF leak type was unclear in 77.7% (n = 108). Nearly all reported patient symptoms using unvalidated measures (84.9%, n = 118). Outcomes were rarely collected at uniform prespecified time points. LIMITATIONS: The investigation did not include transvenous embolization of CSF-to-venous fistulas. CONCLUSIONS: Evidence gaps demonstrate a need for prospective study designs, clinical trials, and comparative studies. We recommend using the International Classification of Headache Disorders-3 diagnostic criteria, explicit reporting of CSF leak subtype, inclusion of key procedural details, and using objective validated outcome measures collected at uniform time points.

Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.

BACKGROUND: Oesophageal dilation is frequently used as an adjunct treatment to alleviate symptoms that develop from fibrostenotic remodelling in eosinophilic oesophagitis (EoE). Earlier reports described an increased risk of complications associated with dilation. AIM: Perform a systematic review and meta-analysis to assess the efficacy and safety of endoscopic dilation in children and adults with EoE. METHODS: Professional librarians searched MEDLINE, EMBASE, the Cochrane library, Scopus, and Web of Science for articles in any language describing studies of dilation in EoE through December 2016. Studies were selected and data were abstracted independently and in duplicate. Random effects modelling was used to generate summary estimates for clinical improvement and complications (haemorrhage, perforation, hospitalisation, and death). RESULTS: The search resulted in 3495 references, of which 27 studies were included in the final analysis. The studies described 845 EoE patients, including 87 paediatric patients, who underwent a total of 1820 oesophageal dilations. The median number of dilations was 3 (range: 1-35). Clinical improvement occurred in 95% of patients (95% CI: 90%-98%, I2 : 10%, 17 studies). Perforation occurred in 0.38% (95% CI: 0.18%-0.85%, I2 : 0%, 27 studies), haemorrhage in 0.05% (95% CI: 0%-0.3%, I2 : 0%, 18 studies), and hospitalisation in 0.67% (95% CI: 0.3%-1.1%, I2 : 44%, 24 studies). No deaths occurred (95% CI: 0%-0.2% I2 : 0%, 25 studies). CONCLUSIONS: Endoscopic dilation is consistently effective in children and adults with EoE, resulting in improvement in 95% of patients with very low rates (<1%) of major complications.

A model for the coupling of the Greater Bairam and local environmental factors in promoting Rift-Valley Fever epizootics in Egypt.

OBJECTIVES: Rift-Valley Fever (RVF) is a zoonotic mosquito-borne disease in Africa and the Arabian Peninsula. Drivers for this disease vary by region and are not well understood for North African countries such as Egypt. A deeper understanding of RVF risk factors would inform disease management policies. STUDY DESIGN: The present study employs mathematical and computational modeling techniques to ascertain the extent to which the severity of RVF epizootics in Egypt differs depending on the interaction between imported ruminant and environmentally-constrained mosquito populations. METHODS: An ordinary differential system of equations, a numerical model, and an individual-based model (IBM) were constructed to represent RVF disease dynamics between localized mosquitoes and ruminants being imported into Egypt for the Greater Bairam. Four cases, corresponding to the Greater Bairam's occurrence during distinct quarters of the solar year, were set up in both models to assess whether the different season-associated mosquito populations present during the Greater Bairam resulted in RVF epizootics of variable magnitudes. RESULTS: The numerical model and the IBM produced nearly identical results: ruminant and mosquito population plots for both models were similar in shape and magnitude for all four cases. In both models, all four cases differed in the severity of their corresponding simulated RVF epizootics. The four cases, ranked by the severity of the simulated RVF epizootics in descending order, correspond with the occurrence of the Greater Bairam on the following months: July, October, April, and January. The numerical model was assessed for sensitivity with respect to parameter values and exhibited a high degree of robustness. CONCLUSIONS: Limiting the importation of infected ruminants beginning one month prior to the Greater Bairam festival (on years in which the festival falls between the months of July and October: 2014-2022) might be a feasible way of mitigating future RVF epizootics in Egypt.

Differences in imaging characteristics of HPV-positive and HPV-Negative oropharyngeal cancers: a blinded matched-pair analysis.

BACKGROUND AND PURPOSE: Human papillomavirus-positive oropharyngeal cancers typically have younger age of onset, limited tobacco exposure, and more favorable prognosis than HPV-negative oropharyngeal cancers. We assessed whether HPV-positive and HPV-negative oropharyngeal cancers have consistent differences in pretreatment imaging characteristics. MATERIALS AND METHODS: A retrospective review of 136 pretreatment CT examinations of paired HPV-positive and HPV-negative oropharyngeal cancers matched for T stage, tumor subsite, and smoking status was performed with the reviewing radiologist blinded to HPV status and clinical stage. Demographic/clinical characteristics and imaging characteristics of primary lesions and metastatic nodal disease were compared by use of Fisher exact testing. The McNemar χ(2) test was used for the matched-pair analysis. RESULTS: By imaging, HPV-negative tumors were more likely to demonstrate invasion of adjacent muscle (26% versus 6%, P = .013). HPV-positive primary tumors were more likely to be enhancing and exophytic with well-defined borders, whereas HPV-negative primary tumors were more likely to be isoattenuated and demonstrate ill-defined borders, though these results were not statistically significant. HPV-positive tumors were more likely to demonstrate cystic nodal metastases than HPV-negative tumors (36% versus 9%, P = .002). CONCLUSIONS: In this matched and blinded analysis of the imaging differences between HPV-positive and HPV-negative oropharyngeal cancers, HPV-positive carcinomas often had primary lesions with well-defined borders and cystic nodal metastases, whereas HPV-negative primaries more often had poorly defined borders and invasion of adjacent muscle.

Unusual fungal niches.

Fungi are found in all aerobic ecosystems, colonizing a diversity of substrates and performing a wide diversity of functions, some of which are not well understood. Many spices of fungi are cosmopolitan and generalists or habitats. Unusual fungal niches are habitats where extreme conditions would be expected to prevent the development of a mycobiota. In this review we describe five unusual fungal habitats in which fungi occupy poorly understood niches: Antarctic dry valleys, high Arctic glaciers, salt flats and salterns, hypersaline microbial mats and plant trichomes. Yeasts, black yeast-like fungi, melanized filamentous species as well as representatives of Aspergillus and Penicillium seem to be dominant among the mycobiota adapted to cold and saline niches. Plant trichomes appear to be a taxa. The advent of new sequencing technologies is helping to elucidate the microbial diversity in many ecosystems, but more studies are needed to document the functional role of fungi in the microbial communities thriving in these unusual environments.

Periconia variicolor sp. nov., a new species from Puerto Rico.

Periconia variicolor was isolated from water of an evaporation pond used for salt production on the southwestern coast of Puerto Rico. On the basis of cultural and morphological characteristics and ITS sequence it is describe as a new species of Periconia.

Habitat preferences and phenology of Ochlerotatus triseriatus and Aedes albopictus (Diptera: Culicidae) in southwestern Virginia.

Recently, the number of reported human cases of La Crosse encephalitis, an illness caused by mosquito-borne La Crosse virus (LAC), has increased in southwestern Virginia, resulting in a need for better understanding of the virus cycle and the biology of its vectors in the region. This study examined the spatial and temporal distributions of the primary vector of LAC, Ochlerotatus triseriatus (Say), and a potential secondary vector, Aedes albopictus (Skuse). Ovitrapping surveys were conducted in 1998 and 1999 to determine distributions and oviposition habitat preferences of the two species in southwestern Virginia. Mosquitoes also were collected for virus assay from a tire dump and a human La Crosse encephalitis case site between 1998 and 2000. Oc. triseriatus and Ae. albopictus were collected from all ovitrap sites surveyed, and numbers of Oc. triseriatus eggs generally were higher than those of Ae. albopictus. Numbers of Oc. triseriatus remained high during most of the summer, while Ae. albopictus numbers increased gradually, reaching a peak in late August and declining thereafter. In Wise County, relative Ae. albopictus abundance was highest in sites with traps placed in open residential areas. Lowest numbers of both species were found in densely forested areas. Ovitrapping during consecutive years revealed that Ae. albopictus was well established and overwintering in the area. An oviposition comparison between the yard and adjacent forest at a human La Crosse encephalitis case site in 1999 showed that Ae. albopictus preferentially oviposited in the yard surrounding the home, but Oc. triseriatus showed no preference. LAC isolations from larval and adult collections of Oc. triseriatus females from the same case site indicated the occurrence of transovarial transmission.

Nitric oxide production by rat bronchoalveolar macrophages or polymorphonuclear leukocytes following intratracheal instillation of lipopolysaccharide or silica.

Exposure of the lung to lipopolysaccharide (LPS) or silica results in an activation of alveolar macrophages (AMs), recruitment of polymorphonuclear leukocytes (PMNs) into bronchoalveolar spaces, and the production of free radicals. Nitric oxide (NO) is one of the free radicals generated by bronchoalveolar lavage (BAL) cell populations following either LPS or silica exposure. The purpose of the present study was to assess the relative contributions of AMs and PMNs to the amounts of NO produced by BAL cells following intratracheal (IT) instillation of either LPS or silica. Male Sprague Dawley rats (265-340 g body wt.) were given LPS (10 mg/100 g body wt.) or silica (5 mg/100 g body wt.). BAL cells were harvested 18-24 h post-IT and enriched for AMs or PMNs using density gradient centrifugation. Media levels of nitrate and nitrite (NOx; the stable decomposition products of NO) were then measured 18 h after ex vivo culture of these cells. Following IT exposure to either LPS or silica, BAL cell populations were approximately 20% AMs and approximately 80% PMNs. After density gradient centrifugation of BAL cells from LPS- or silica-treated rats, cell fractions were obtained which were relatively enriched for AMs (approximately 60%) or PMNs (approximately 90%). The amounts of NOx produced by the AM-enriched fractions from LPS- or silica-treated rats were approximately 2-4-fold greater than that produced by the PMN-enriched fractions. Estimations of the relative contribution of AMs or PMNs to the NOx produced indicated that: (i) following LPS treatment, 75%-89% of the NOx was derived from AMs and 11%-25% from PMNs; and (ii) following silica treatment, 76%-100% of the NOx was derived from AMs and 0-24% from PMNs. Immunohistochemistry for inducible NO synthase on lung tissue sections supported these findings. We conclude that AMs are the major source of the NO produced by BAL cells during acute pulmonary inflammatory responses to LPS or silica.

A textile fibre survey as an aid to the interpretation of fibre evidence in the Sydney region.

Frequency figures of the fibre population on textile cinema seats were measured in Sydney, Australia, in winter. Sixteen seats were analysed from a very popular cinema complex, with 3025 fibres classified according to colour, generic class and fluorescence properties (100 grey-black cotton fibres only). The recovered fibres were mostly natural fibres (84%) with cotton the most common generic type (70%). On the contrary, man made fibres were relatively rare (15%) with rayon constituting the majority of these (51%). The most common colour/generic class combinations were grey-black cotton (33%) and blue cotton (30%) accounting for 63% of the total population. All other frequencies were below 5%, most below 1% using only the two properties of colour and generic class. Fluorescence properties were found to be very discriminating as far as grey-black cotton fibres were concerned. These features are considered and discussed and in particular, to emphasise the significance of fibres as evidence of contact.

2,3,7,8-Tetrachlorodibenzo-p-dioxin induces apoptotic cell death and cytochrome P4501A expression in developing Fundulus heteroclitus embryos.

Fundulus heteroclitus embryos were exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) during early development using nanoinjection or water bath exposure. TCDD caused developmental abnormalities that included hemorrhaging, loss of vascular integrity, edema, stunted development and death. The LC(50) and LD(50) of TCDD for Fundulus embryos were approximately 19.7+/-9.5 pg TCDD/microl (water bath) and 0.25+/-0.09 ng TCDD/g embryo (nanoinjection). To identify a possible cause for these developmental abnormalities we analyzed the effects of TCDD on apoptotic cell death and cytochrome P4501A (CYP1A) expression in the embryos. TCDD exposure increased apoptotic cell death in several tissues including brain, eye, gill, kidney, tail, intestine, heart, and vascular tissue. CYP1A expression was also increased in the TCDD-exposed embryos predominantly in liver, kidney, gill, heart, intestine, and in vascular tissues throughout the embryo. There was co-occurrence of TCDD-induced apoptosis and CYP1A expression in some, but not all, cell types. In addition the dose response relationships for apoptosis and mortality were similar, while CYP1A expression appeared more sensitive to TCDD induction.

Failure of hydroxyapatite cement to set in repair of a cranial defect: case report.

OBJECTIVE AND IMPORTANCE: Hydroxyapatite cement, a new biomaterial that is being marketed as a method for reconstructing cranial defects, offers many advantages. We document, herein, the complete dissolution and failure of this material to set in a surgically dry field, under optimal conditions, an occurrence that has not been previously reported. CLINICAL PRESENTATION: Hydroxyapatite cement was used for reconstruction of a frontal bone defect secondary to a traumatic depressed cranial fracture in a 9-year-old male patient. At the time of suture removal on postoperative Day 6, we observed serous discharge from the wound, a reappearance of the cranial defect, and brain pulsations visible subcutaneously. INTERVENTION: The patient was returned to the operating room, at which time we learned that the hydroxyapatite cement had migrated out of the defect; small concretions of the cement were scattered throughout the subgaleal space. The concretions of cement in the subgaleal space and the small amount of cement remaining in the defect were removed, and titanium mesh was used. An excellent cosmetic result was achieved. CONCLUSION: Although offering many advantages, hydroxyapatite cement does carry a risk of failure to set, despite optimal technique. Causes for failure to set, as well as possible modifications in the use of material and technique, are discussed.

Correlation of 2,3,7,8-tetrachlorodibenzo-p-dioxin-induced apoptotic cell death in the embryonic vasculature with embryotoxicity.

Vertebrate embryos are particularly sensitive to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Identification of tissues that are susceptible to the adverse effects of TCDD is requisite for understanding the embryo toxic effects of TCDD. The objective of the present study was to quantitate the temporal appearance of and dose dependence of apoptosis in TCDD-exposed medaka embryos (Oryzias latipes). A fluorescent-based DNA end-labeling assay provided a sensitive method for detection of TCDD-induced apoptosis in tissue sections of medaka embryos. Apoptotic cells were readily apparent in the medial yolk vein at all observed embryonic stages in TCDD-exposed embryos. Slope-comparison analysis indicated that TCDD-induced programmed cell death in the embryonic medial yolk vein was mechanistically linked to embryo mortality. These data are consistent with the hypothesis that vascular damage contributes to the acute embryo toxic effects of TCDD. However, as sublethal concentrations of dioxin-like compounds are more typical of environmental exposures, tissue damage was also assessed in medaka fry that were exposed to low doses of TCDD during embryonic development. Cell death was detected in gill and digestive tissues in visibly healthy medaka fry that had been exposed to low doses of TCDD during embryonic development. Increased expression of cytochrome P450 1A is a major biochemical consequence of TCDD exposure and is often used as a biomarker for exposure to dioxin-like compounds. Therefore, we compared the tissue distribution of TCDD-induced P450 1A expression and TCDD-induced programmed cell death. TCDD-induced programmed cell death co-localized with TCDD-induced P450 1A expression in both embryos and in visibly healthy post-hatch fry. Our results suggest that aberrant programmed cell death may be a suitable marker for exposure of feral organisms to dioxin-like compounds.

Embryotoxicity of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD): the embryonic vasculature is a physiological target for TCDD-induced DNA damage and apoptotic cell death in Medaka (Orizias latipes).

Vertebrate embryos are extremely sensitive to environmental contaminants known as planar halogenated hydrocarbons (PHHs). The physiological targets that mediate PHH-induced embryotoxicity are not known. We have characterized embryotoxicity in medaka (Orizias latipes) caused by 2,3,7,8-tetrachlorodibezo-p-dioxin (TCDD), the prototypic PHH. DNA degradation in cells of the embryonic vasculature and loss of functional integrity of the medial yolk vein were demonstrated in TCDD-exposed embryos. Pharmacological intervention with piperonyl butoxide inhibited TCDD-induced DNA degradation, restored the functional integrity of the medial yolk vein, and protected against the embryotoxicity of TCDD. Treatment of TCDD-exposed embryos with the antioxidant N-acetylcysteine also provided significant protection against the embryotoxicity of TCDD. These results demonstrate that DNA damage and consequent cell death in the embryonic vasculature are key physiological mediators of TCDD-induced embryotoxicity.

Pfeiffer syndrome: a clinical review.

The combination of bicoronal craniosynostosis, broad thumbs and great toes, and partial variable soft tissue syndactyly of the hands and feet (i.e., Pfeiffer syndrome) classically followed a benign clinical course. A review of the clinical features of those Pfeiffer syndrome patients presenting to our unit confirm another subgroup in whom the craniofacial and associated manifestations are more extreme, with a significant risk of early demise. The early aggressive surgical management of craniostenosis, hydrocephalus, exorbitism, faciostenosis, and upper airway obstruction has provided the potential for prolonged useful survival in these cases.

Phenotypic variation in acrocephalosyndactyly syndromes: unusual findings in patient with features of Apert and Saethre-Chotzen syndromes.

The acrocephalosyndactyly syndromes have presented diagnostic challenges because of overlap in their clinical manifestations. We present a patient with features most suggestive of Apert syndrome, but with a pattern of syndactyly not previously described. In contrast to the complex syndactyly reported as a universal feature of this syndrome, this patient shows close to total simple syndactyly of the index through ring fingers of each hand. Differential diagnoses are discussed. Because the features are reminiscent of Apert syndrome, we suggest that a new classification of hand morphology should be added to include the pattern described here.

Realistic venipuncture simulation.

Both educators and nursing administrators are eager to find instruction methods that prepare practitioners for skillful venipuncture. A second concern, shared by everyone, is providing such instruction in the most cost-effective manner possible. The authors present a plan that enhances the teaching of venipuncture, through stimulation, using inexpensive, easily obtained equipment.