Missed pituitary microadenoma during endoscopic transsphenoidal surgery for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing with symptom relief: illustrative case.

BACKGROUND: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare headache disorder that has been associated with pituitary adenomas. Resection has been posited to be curative. OBSERVATIONS: A 60-year-old female presented with a 10-year history of SUNCT, which had been medically refractory. Sellar magnetic resonance imaging (MRI) showed a 2 × 2 mm nodule in the right anterolateral aspect of the pituitary. Endoscopic endonasal transsphenoidal resection of the pituitary microadenoma with neuronavigation was performed. The patient felt immediate relief from the headaches. Postoperative MRI showed persistence of the pituitary microadenoma and the resection tract to be inferomedial to the lesion. The right middle and partial superior turbinectomy site was close to the sphenopalatine foramen (SPF). The patient was discharged on postoperative day 1 and remained headache-free without any medications at the 4-month follow-up. LESSONS: Resection of pituitary lesions associated with SUNCT may not necessarily be the cause of SUNCT resolution. Manipulation of the middle and superior turbinate close to the SPF may lead to a pterygopalatine ganglion block. This may be the mechanism of cure for SUNCT in patients with related pituitary lesions who undergo endonasal resection.

Donor site morbidity following radial forearm free flap reconstruction with split thickness skin grafts using negative pressure wound therapy.

BACKGROUND: Donor site complications secondary to radial forearm free flap (RFFF) reconstruction can limit recovery. Optimizing hand and wrist function in the post-operative period may allow more efficient self-care and return to activities of daily living. Negative pressure wound dressings (NPD) may increase blood flow and perfusion as compared to static pressure dressings (SPD) designed to minimize shear forces during the healing period. This study aims to compare subjective and objective hand and wrist functional outcomes following RFFF reconstruction with split thickness skin grafts (STSG) in patients treated with NPD and SPD. METHODS: Adult patients undergoing RFFF with STSG were identified preoperatively and randomized to receive NPD or SPD following their RFFF reconstruction. NPD involved a single-use, portable device capable of applying 80 mmHg of negative pressure to the forearm donor site. SPD involved a volar splint. Dressings were left in place for seven days with subjective and objective function assessed at seven days, one month and three months postoperatively. The primary outcome was self-reported hand function as measured with the function subscale of the Michigan Hand Questionnaire (MHQ). Secondary outcomes included hand and wrist strength, range of motion, sensation, scar aesthetics, and skin graft complications. RESULTS: Twenty-four patients undergoing RFFF were randomized to NPD or SPD. Patients treated with NPD had improved MHQ self-reported functional scores as compared to those treated with SPD at seven days postoperatively (P = 0.016). Flexion at seven days was improved in NPD group (P = 0.031); however, all other strength and range of motion outcomes were similar between groups. There were no differences in rates of graft complications, scar aesthetics, or sensation. CONCLUSIONS: In the immediate post-operative period, NPD was associated with improved patient-reported hand and wrist function. Wound care to optimize hand and wrist function could allow for improved patient outcomes in the immediate postoperative period.

Long-term survival and swallowing outcomes in advanced stage oropharyngeal squamous cell carcinomas.

BACKGROUND: There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities. METHODS: OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment. RESULTS: A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28-0.61) and surgery (HR 0.47, 0.32-0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61-3.77), smoking (HR 2.37, 1.41-3.99) and higher stage (HR 1.68, 1.05-2.68). CONCLUSIONS: In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

A General Model of Sensitized Luminescence in Lanthanide-Based Coordination Polymers and Metal-Organic Framework Materials.

Luminescent lanthanides containing coordination polymers and metal-organic frameworks hold great potential in many applications due to their distinctive spectroscopic properties. While the ability to design coordination polymers for specific functions is often mentioned as a major benefit bestowed on these compounds, the lack of a meaningful understanding of the luminescence in lanthanide coordination polymers remains a significant challenge toward functional design. Currently, the study of these compounds is based on the antenna effect as derived from molecular systems, where organic antennae are used to facilitate lanthanide-centered luminescence. This molecular-based approach does not take into account the unique features of extended network solids, particularly the formation of band structure. While guidelines for the antenna effect are well established, they require modification before being applied to coordination polymers. A series of nine coordination polymers with varying topologies and organic linkers were studied to investigate the accuracy of the antenna effect in coordination polymer systems. By comparing a molecular-based approach to a band-based one, it was determined that the band structure that occurs in aggregated organic solids needs to be considered when evaluating the luminescence of lanthanide coordination polymers.

Transoral robotic surgery with radial forearm free flap reconstruction: case control analysis.

BACKGROUND: The resection of large oropharyngeal tumors traditionally involves a lip-splitting mandibulotomy for adequate margin visualization and free flap reconstruction of the surgical defect. Transoral robotic surgery (TORS) has emerged as a technique that can resect large and complex oropharyngeal tumors, avoiding a lip-splitting approach. The aim of this study is to compare the lip-splitting mandibulotomy approach versus TORS for the management of advanced stage oropharyngeal carcinomas. METHODS: Prospectively collected data from 18 patients with advanced stage oropharyngeal squamous cell carcinoma (OPSCC) who received TORS with radial forearm free flap reconstruction (RFFF) was compared to a matched cohort of 39 patients who received a lip-splitting mandibulotomy and RFFF. Patients were matched for stage, p16 positivity, smoking, age and gender. Length of hospital stay (LOHS), tracheostomy decanulation time, operative time, surgical margin status, and post-operative complications were compared between groups. RESULTS: Patients who received TORS with RFFF had a significantly lower mean LOHS, compared to patients who were treated by lip-splitting mandibulotomy and RFFF (14.4 vs 19.7 days, p = 0.03). No significant differences were seen between groups in terms of operative time, tracheostomy decannulation time, margin positivity and post-operative complications. CONCLUSION: TORS with radial forearm free flap reconstruction is a safe, effective and cost-saving alternative to the lip-splitting mandibulotomy approach for the treatment of advanced stage OPSCC.

Validation of the Questionnaire to Identify Knee Symptoms (QuIKS) using Rasch analysis.

BACKGROUND: The Questionnaire to Identify Knee Symptoms (QuIKS) was recently developed to promote activity by screening for experiences related to early symptoms in people with emergent chronic knee pain problems, such as osteoarthritis (OA) - like knee pain. The main purpose of the current study was to evaluate measurement properties of the QuIKS using Rasch analysis in a sample of people with knee symptoms consistent with symptomatic knee OA. METHOD: This study used cross-sectional data. The sample was 200 subjects along the following knee health continuum: pain-free healthy knees (n = 55) from a university community, knee pain with no knee OA diagnosis (n = 111) from a university-affiliated medical clinic, and patients with surgeon-diagnosed symptomatic knee OA awaiting high tibial osteotomy (n = 34) from a sports medicine surgical clinic. The 13-item QuIKS was evaluated for its factor structure, item- and person-fit, item's category response structure, differential item functioning by sex and obesity status, local item dependency, unidimensionality, and test precision. Subsequently, the QuIKS underwent known-groups analysis and convergent validity with the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: In the QuIKS, each item's category response structure was modified. No differential item functioning was observed. Local item dependency informed the formation of four testlets. This refined QuIKS obtained summary fit to the Rasch measurement model, unidimensionality, reliability (person separation index = 0.82), and interval-level scoring. Subsequently, the Rasch-validated QuIKS (QuIKS-R) demonstrated excellent known-groups validity and good convergent validity with the KOOS (Spearman's rho = 0.45 to 0.77). CONCLUSIONS: The QuIKS-R provides interval-level quantification of knee symptoms-related experiences in people with knee symptoms consistent with symptomatic knee OA. Its scores might be useful for clinicians for promoting activity in individuals with early symptoms consistent with symptomatic knee OA.

Questionnaire to identify knee symptoms: development of a tool to identify early experiences consistent with knee osteoarthritis.

BACKGROUND: Current diagnostic procedures for knee osteoarthritis (OA) identify individuals late in the disease process. A questionnaire may be a useful and inexpensive method to screen for early symptoms of knee OA. OBJECTIVE: The purpose of this study was to develop a brief, self-administered questionnaire for clinical and research settings to identify emerging knee problems in people who could benefit from conservative interventions. DESIGN: This prospective study utilized a mixed-methods approach. METHODS AND RESULTS: Questionnaire items were generated from interview data from individuals with emerging chronic knee problems. These items were reviewed by 16 rheumatology experts, resulting in a 35-item draft questionnaire. To reduce the number of items, questionnaires were mailed to 228 adults, aged 40 to 65 years, with evidence of ongoing knee problems. One hundred thirteen completed questionnaires were returned (63.1% response rate), with 105 usable questionnaires. Using principal components analysis, the number of items was reduced to a final 13-item version, the Questionnaire to Identify Knee Symptoms (QuIKS). The QuIKS has 4 subscales: medications, monitoring, interpreting, and modifying. The QuIKS demonstrated strong internal consistency. LIMITATIONS: A sampling bias among respondents who provided data for item reduction likely means that the QuIKS reflects those who self-report knee problems to a health care provider, which may not be generalizable to the population. CONCLUSIONS: The QuIKS is a short, self-administered questionnaire used to promote activity by identifying the experiences associated with early symptoms consistent with knee OA, such as monitoring intermittent symptoms, interpreting the meaning of these symptoms, modifying behaviors, and including the use of medications. If future work validates the QuIKS, its use in developing samples could expand our understanding of early disease and improve interventions.

Unilateral ankle immobilization alters the kinematics and kinetics of lifting.

BACKGROUND: Theoretical and empirical data support the notion that distal lower extremity joint dysfunction could influence the low-back injury potential of workers, but the impact of unilateral ankle immobilization on low-back loading during lifting has yet to be examined. OBJECTIVE: To examine the influence of unilateral ankle immobilization on the kinematics and kinetics of lifting. METHODS: With and without their right ankle immobilized, 10 men performed laboratory-simulated occupational lifting tasks. Together with force platform data, three-dimensional kinematics of the lumbar spine, pelvis, and lower extremities were collected, and a dynamic biomechanical model was used to calculate peak compressive and shear loads imposed on the L4/L5 intervertebral joint. RESULTS: In comparison to the unaffected conditions, ankle immobilization generally resulted in less knee (0.001 ≤ p ≤ 0.07) and greater lumbar spine (0.001 ≤ p ≤ 0.35) sagittal motion when lifting. Associated with this compensatory movement strategy were greater L4/L5 anterior/posterior reaction shear forces (0.001 ≤ p ≤ 0.25). However, there were cases when individual compensatory movement strategies differed from the "group" response (i.e., subjects increased their sagittal knee motion on the affected side about 8% of the time); this resulted in increased peak L4/L5 joint compression forces without changing the peak L4/L5 anterior-posterior shear forces. CONCLUSIONS: Ankle dysfunction can alter the way in which individuals move and load their low-backs when lifting. The different ways in which individuals compensate for personal movement constraints could alter the potential site and mechanism of occupational low-back injury.

Activity-Modifying Behaviour Mediates the Relationship between Pain Severity and Activity Limitations among Adults with Emergent Knee Pain.

PURPOSE: To determine whether activity-modifying behaviour mediates the relationship between the severity of knee pain and each of physical function and knee-related quality of life. METHODS: A total of 105 participants with medial knee pain and no diagnosis of knee osteoarthritis (mean age 52.2 [SD 6.7] y) completed two self-report questionnaires. The Questionnaire to Identify Knee Symptoms assessed activity-modifying behaviour; the Knee injury and Osteoarthritis Outcome Score assessed pain severity, physical function, and knee-related quality of life. Simple mediation analysis was performed using linear regression. RESULTS: The unstandardized regression coefficient for activity-modifying behaviour revealed partial mediation of the effect of pain severity on physical function (0.31 (SE 0.09), p<0.001) and on knee-related quality of life (0.24 (SE 0.07), p<0.001). After accounting for activity-modifying behaviour, the variance in physical function that was explained by pain decreased from 45% to 15%, and the variance in knee-related quality of life that was explained by pain decreased from 64% to 25%. CONCLUSION: Activity-modifying behaviour partially mediates the relationship between pain severity and physical function and between pain severity and knee-related quality of life. Activity-modifying behaviour may thus counteract the impact of knee pain on physical function and knee-related quality of life, which explains why it is used by people with emergent knee pain.

Objectif : Déterminer si un comportement modifiant les activités peut influer sur la relation entre la sévérité d'une douleur au genou et chacune des fonctions physiques et la qualité de vie associée au genou. Méthode : Au total, 105 participants avec douleur au genou interne et aucun diagnostic d'arthrose du genou (âge moyen de 52,2 ans; écart type de 6,7 ans) ont rempli deux questionnaires d'auto-évaluation. Le questionnaire pour déterminer les symptômes au genou (Questionnaire to Identify Knee Symptoms, QuIKS) visait à évaluer les comportements qui modifient les activités; le pointage obtenu au questionnaire sur les blessures au genou et l'arthrose (Knee injury and Osteoarthritis Outcome Score, KOOS) permettait d'évaluer la sévérité de la douleur, la fonction physique et la qualité de vie associée au genou. Une analyse de médiation simple a été réalisée à l'aide d'un modèle de régression linéaire. Résultats : Le coefficient de régression non normalisé (±erreur type) du comportement modifiant l'activité a révélé une réduction partielle de l'effet de la sévérité de la douleur sur la fonction physique (0,31±0,09, p<0,001) et sur la qualité de vie associée au genou (0,24±0,07, p<0,001). Après la mise en place d'un comportement modifiant l'activité, la variation de la fonction physique causée par la douleur est passée de 45 % à 15 %, et la variation dans la qualité de vie associée au genou provoquée par la douleur est passée de 64 % à 25 %. Conclusion : Un comportement qui modifie l'activité réduit partiellement la relation entre la sévérité de la douleur et la fonction physique et entre la sévérité de la douleur et la qualité de vie associée au genou. On a donc recours à une modification de l'activité chez les personnes aux prises avec une douleur émergente au genou, et cette modification pourrait contrer les effets de la douleur au genou sur la fonction physique et sur la qualité de vie.

Longitudinal gait and strength changes prior to and following an anterior cruciate ligament rupture and surgical reconstruction: a case report.

STUDY DESIGN: Case report. BACKGROUND: Cross-sectional studies have examined deficits following anterior cruciate ligament (ACL) rupture and subsequent reconstructive surgery. Few studies present preinjury data that may assist in identifying risk factors for ACL rupture. This case report compares gait and strength measures obtained prior to ACL rupture, with follow-up assessments of these measures after rupture and reconstructive surgery. CASE DESCRIPTION: A 23-year-old woman sustained a noncontact rupture of her right ACL. Kinematic and kinetic gait data were collected using 3-dimensional motion analysis and a synchronized force plate. Knee strength was measured using an isokinetic dynamometer. Data for knee active range of motion (AROM) and the Lower Extremity Functional Scale (LEFS) were also collected. The analyses were descriptive and interpreted based on previously published minimal detectable change and minimal clinically important difference values. OUTCOMES: Before her injury, the patient demonstrated a low external knee flexion moment during gait. Kinematic and kinetic gait abnormalities were present following rupture and persisted at 13 months postsurgery. The patient demonstrated knee strength deficits following ACL rupture and surgery. Steady gains in LEFS and knee AROM occurred following rupture and surgery. DISCUSSION: Preinjury data may identify risk factors for ACL rupture. Future studies should examine whether a low external knee flexion moment during gait or sport-related activity is a risk factor for ACL rupture. The patient demonstrated deficits in gait and strength that persisted at 13 months postsurgery. LEVEL OF EVIDENCE: Therapy, level 4.