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Background: The history of conflicts in the Middle East has resulted in a high burden of complications from conflict-related wounds like posttraumatic osteomyelitis (PTO). This is particularly challenging to manage in settings like Mosul, Iraq and Gaza, Palestine, where healthcare systems are weakened. In nonconflict settings, PTO caused by Pseudomonas aeruginosa (PAPTO) can lead to >20% of treatment failures. We aim to describe the clinical characteristics, outcomes, and management, in PAPTO patients admitted to Médecins Sans Frontières (MSF) facilities in Mosul and Gaza between 1 April 2018 and 31 January 2022., Methods: We conducted a retrospective cohort study on patients with PAPTO diagnosed with culture of intraoperative bone biopsy, using routinely collected data., Results: Among 66 PAPTO episodes from 61 enrolled patients, 37.9% had a multidrug-resistant Pseudomonas aeruginosa , with higher antibiotic resistance in Gaza. Polymicrobial infections were prevalent (74.2%), mainly involving Staphylococcus aureus (74.1%), being predominantly methicillin-resistant (95.0%). Overall, 81.7% received appropriate antibiotic treatment, with monotherapy used in 60.6% of episodes and a median treatment duration of 45.5 days. Recurrence was observed in 24.6% of episodes within a median of 195 days (interquartile range, 64-440 days). No significant differences were found in recurrence rates based on the type of antibiotic treatment (mono- or dual therapy) or episode (mono- or polymicrobial)., Conclusions: Management of PAPTO in the conflict-affected, low-resource settings of Mosul and Gaza achieved a recurrence rate aligned with global reports through appropriate and targeted antibiotic use, primarily in monotherapy, provided over a mean treatment duration of 45.5 days., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: The primary objectives of this study were to assess the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) in the diagnosis of bacterial co-infections in coronavirus disease 2019 (COVID-19) and if their incorporation in antimicrobial stewardship (AMS) programs is safe and useful, stratified by severity of disease as level of care, intensive care unit (ICU) or non-ICU. Our secondary objectives were to identify cut-off values for antibiotic decision-making and identify reported results from low- and middle-income countries (LMICs)., Design: A scoping review of published literature, adhering to the PRISMA statement for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. The last search was performed in January 2024., Results: Fifty-nine studies were included in this scoping review: 20 studies reporting predictive values and/or sensitivity/specificity results for PCT, 8 reporting clear objectives on AMS, and 3 studies from LMICs., Conclusion: In the context of non-ICU hospitalized COVID-19 patients in high-income countries, a PCT value below 0.25 mg/L can be a useful tool to rule out bacterial co-infection. The wide range of reported negative predictive values suggests that PCT should be interpreted in the context of other clinical findings. Our results do not support the use of CRP in the same manner as PCT. There is a clear need for more studies in LMICs., Competing Interests: All authors report no conflicts of interest relevant to this article., (© The Author(s) 2024.)

Objective: To develop a French Short Version of the Questionnaire of Olfactory Disorders-Negative Statements (Fr-sQOD) to assess the quality of life impairments of patients with olfactory dysfunction (OD)., Methods: Patients with OD and controls were enrolled from 2 academic centers. Individuals completed the Fr-sQOD, an OD visual analog scale severity, and the French version of the sinonasal outcome tool-22 (SNOT-22). Cronbach α was used to measure the internal consistency of Fr-sQOD. The reliability and the external validity of Fr-sQOD were assessed through a test-retest approach and by correlating Fr-sQOD with SNOT-22 scores, respectively. The external validity was assessed by correlation analysis between Fr-sQOD and the result of an assessment of the severity of OD on a visual analog scale., Results: Eighty patients completed the evaluations. The internal consistency was adequate (Cronbach α .96), and the test-retest reliability was high in the entire cohort (r s = 0.877, P < .001). The correlation between Fr-sQOD total scores and the severity of OD was moderate but significant (r s = -0.431; P = .001) supporting an acceptable external validity. Patients with OD had a significantly higher score of Fr-sQOD than healthy individuals ( P < .001), indicating a high internal validity., Conclusion: The Fr-sQOD is a reliable and valid self-administered tool in the evaluation of the impact of OD on quality of life of French-speaking patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Extra-gastrointestinal stromal tumor is a rare subtype of soft tissue sarcomas with significantly variable presentation, management, and prognosis. This makes it crucial to report the different institutional experiences of encountering extra-gastrointestinal stromal tumors (EGIST)., Case Presentation: We report 3 cases of EGIST diagnosis at American University of Beirut Medical Center for 2 males and 1 female in the 5th, 6th, and 7th decades of life, respectively. For the first case, the tumor was initially suspected to be ovarian cancer, but biopsy revealed a diagnosis of EGIST, and the patient was started on neoadjuvant therapy. In the second case, the tumor was retro-gastric and prelim diagnosis was gastric cancer but again biopsy revealed an EGIST histopathology, and the patient underwent surgery and adjuvant treatment. For the third case, a previous history of testicular cancer prompted an initial suspicion of recurrence with metastasis but biopsy and immunohistochemistry staining revealed EGIST with related markers. The patient underwent treatment at a different institution in his home country., Conclusion: This report sheds light on the importance of keeping EGIST amongst any differential list for abdominal and pelvic tumors. It also shows that EGIST-focused studies are needed to assess the effectiveness of the different treatment modalities available when utilized specifically for EGIST. This would allow for better oncological outcomes and improved quality of life., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Type 1 Arnold Chiari is a neurological malformation that may be associated with vocal cord paralysis in Children. In most cases, the vocal cord paralysis is related to protrusion of medulla and cerebellum in the foramen magnum, which led to compression on the vagus nerve. Case report: A 12-year-old child underwent suboccipital decompression and C1 laminectomy for a symptomatic type 1 Arnold Chiari malformation. After the surgery, patient reported severe dyspnea, aphonia, and dysphagia. The videolaryngostroboscopy and neurological examinations reported a postoperative bilateral vocal cord abduction paralysis due to bilateral IX and X cranial nerve paralyzes and a bilateral paralysis of the tongue. Discussion: The type 1 Arnold Chiari malformation clinical picture may present with unilateral or bilateral vocal cord paralysis, which may resolve with an adequate management of the disease. However, the neurosurgical decompression and C1 laminectomy may result in bilateral lesion of the IX, X, and XII cranial nerves, and related severe swallowing, aspiration and vocal cord disorders. Conclusion: We reported the first case of bilateral vocal cord abduction paralysis occurring post-neurosurgical decompression and C1 laminectomy in a child with type 1 Arnold Chiari malformation. This case highlights the importance of surgical steps of the procedure in front of the C1 vertebrae where there are IX, X, and XII cranial nerves., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Gram-negative bacillary meningitis remains a rare occurrence, even in patients with human immunodeficiency virus. Current literature only describes anecdotal cases of spontaneous nosocomial Proteus mirabilis meningitis. This report describes the clinical manifestations and management of a patient with healthcare-associated spontaneous Gram-negative bacillary meningitis in a patient with advanced human immunodeficiency virus disease., Case Presentation: A 23-year-old Congolese female was hospitalized in a human immunodeficiency virus specialized center for ongoing weight loss, chronic abdominal pain, and vomiting 9 months after initiation of treatment for tuberculosis meningitis. Hospitalization was complicated by healthcare-associated Gram-negative bacillary meningitis on day 18. Blood and cerebrospinal fluid cultures confirmed Proteus mirabilis. Antibiotic susceptibility testing showed extended spectrum beta-lactamase resistant to common antibiotics, and sensitive to meropenem. Despite initiation of high-dose meropenem by intravenous infusion (2 g every 8 hours), the patient did not improve, and died after 4 days of meropenem treatment. Gram-negative bacillary meningitis remains rare and is associated with an unfavorable prognosis., Conclusions: This case report highlights the importance of microbiological identification of pathogens in resource-limited settings. As Gram-negative bacillary meningitis does not present with pleocytosis in patients with advanced human immunodeficiency virus, a negative lumbar puncture cannot exclude this diagnosis. Access to clinical bacteriology in resource-limited settings is essential to enable correct antibiotic treatment and avoid overuse of antibiotics to which there is already resistance. It further plays an essential role in public health by identifying antibiotic susceptibilities. Infection prevention and control measures must be reinforced in order to protect patients from such avoidable healthcare-associated infections., (© 2023. The Author(s).)

Introduction and Importance: Hepatocellular carcinoma (HCC) constitutes most of primary liver cancers. HCC invading the gastrointestinal tract (GIT) is considered a rare entity with limited reports in the literature. Management can either be palliative or curative such as transarterial chemoembolization (TACE) followed by definitive resection. Here, we present a case of direct HCC invasion of the GIT that was managed by surgical resection., Case Presentation: A 74-year-old male with a history of a liver mass, found to have HCC. Admitted for medical optimization prior to definitive resection, however his stay was complicated by hemorrhagic shock, with imaging findings of hemoperitoneum suggestive of spontaneous rupture of the mass. TACE was done to stabilize the patient prior to resection. Patient was taken immediately to the operating room for definitive resection., Clinical Discussion: Most cases of direct HCC invasion into the GI tract present mainly with GI bleed. Some patients, present with abdominal pain without any warning signs of an occult GI bleed. Thus, absence of an occult GI bleeding does not exclude a GIT invasion. Management options are several, but in advanced stages, management is not limited to palliation., Conclusion: GIT invasion is a rare complication of HCC reported in scarcity in the literature. Most cases present with GI bleeding but with some rare cases, they present with more generalized symptoms like abdominal pain, weight loss or fatigue. Despite having a poor prognosis, complete surgical resection of the tumor may be a reassuring and life prolonging treatment option for these patients., (Copyright © 2022. Published by Elsevier Ltd.)

Introduction and Importance: Melanoma is a malignant skin neoplasm with a high metastatic potential. Several reports have shown that metastatic melanoma has a predilection to metastasize to the GI tract; however, diagnosing metastatic melanoma as a cause of intussusception has been reported in only few cases with variable presentations., Case Presentation: We present the case of a 48-year-old woman with a long history of metastatic melanoma who presented with recurrent enteric intussusception due to a melanoma lesion acting as a pathologic lead point despite immunotherapy treatment. We contribute the management plan, diagnostic modalities, and surgical approach of this rare form of adult intussusception in guidance of future management plans., Clinical Discussion: The variability in presentation of adult intussusception makes diagnosis difficult and the lack of consensus on management and surgical strategies poses challenging hurdles. A diagnostic laparoscopy followed by reduction and resection of the intussuscepted lesion in a small surgical field is an effective and beneficial palliative procedure with favorable outcomes. Our patient developed intussusception despite receiving a trial of dual immunotherapy after chemotherapy., Conclusion: It may be insufficient to control disease even with dual immunotherapy after chemotherapy. Further studies are needed to determine the optimal surgical and oncological management in treating gastrointestinal metastasis of malignant melanoma., (Copyright © 2022. Published by Elsevier Ltd.)

Introduction: To explore the prevalence of dysphonia in European patients with mild-to-moderate COVID-19 and the clinical features of dysphonic patients., Methods: The clinical and epidemiological data of 702 patients with mild-to-moderate COVID-19 were collected from 19 European Hospitals. The following data were extracted: age, sex, ethnicity, tobacco consumption, comorbidities, general, and otolaryngological symptoms. Dysphonia and otolaryngological symptoms were self-assessed through a 4-point scale. The prevalence of dysphonia, as part of the COVID-19 symptoms, was assessed. The outcomes were compared between dysphonic and nondysphonic patients. The association between dysphonia severity and outcomes was studied through Bayesian analysis., Results: A total of 188 patients were dysphonic, accounting for 26.8% of cases. Females developed more frequently dysphonia than males (P = 0.022). The proportion of smokers was significantly higher in the dysphonic group (P = 0.042). The prevalence of the following symptoms was higher in dysphonic patients compared with nondysphonic patients: cough, chest pain, sticky sputum, arthralgia, diarrhea, headache, fatigue, nausea, and vomiting. The severity of dyspnea, dysphagia, ear pain, face pain, throat pain, and nasal obstruction was higher in dysphonic group compared with nondysphonic group. There were significant associations between the severity of dysphonia, dysphagia, and cough., Conclusion: Dysphonia may be encountered in a quarter of patients with mild-to-moderate COVID-19 and should be considered as a symptom list of the infection. Dysphonic COVID-19 patients are more symptomatic than nondysphonic individuals. Future studies are needed to investigate the relevance of dysphonia in the COVID-19 clinical presentation., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Oxaliplatin remains an essential component of many chemotherapy protocols for gastrointestinal cancers; however, neurotoxicity and hepatotoxicity may be dose-limiting. The gold standard for the diagnosis of oxaliplatin-induced hepatotoxicity is liver biopsy, which is invasive and costly. Splenomegaly has also been used as a surrogate for liver biopsy in detecting oxaliplatin-induced sinusoidal obstruction syndrome (SOS), but splenic measurement is not routine and can be inaccurate and complex. We investigated the correlation between increased liver elasticity assessed by Fibroscan and the increase in spleen volume on cross-sectional imaging after oxaliplatin as a noninvasive technique to assess liver stiffness associated with oxaliplatin-induced SOS., Methods: Forty-six patients diagnosed with gastrointestinal cancers and planned to take oxaliplatin containing regimens were included in this prospective study at the American University of Beirut Medical Center (AUBMC). Measurement of spleen volume using cross-sectional imaging and of liver elasticity using Fibroscan was performed at baseline, 3 and 6 months after starting oxaliplatin. Mean liver elasticity measurements were compared between patients stratified by the development of splenomegaly using the Student t- test. Splenomegaly was defined as 50% increase in spleen size compared with baseline., Results: Patients who developed splenomegaly after oxaliplatin use had significantly higher mean elasticity measurements as reported by Fibroscan at 3 (16.2 vs. 7.8 kPa, P  = 0.036) and 6 (9.3 vs. 6.7 kPa, P  = 0.03) months., Conclusion: Measurement of elasticity using Fibroscan could be potentially used in the future as a noninvasive test for predicting oxaliplatin-induced hepatotoxicity., (© 2021 The Authors.)

Background: Human cystic echinococcosis (CE), most commonly caused by echinococcosis granulosis, is the most common presentation of hydatid disease of the liver and is considered endemic in the Middle East region. Patients and Methods: This study is a retrospective single-center analysis of all patients with hepatic hydatid disease presenting for surgical management from 2001 to 2019. Results: From 2001 to 2019, 100 patients (54 males, 46 females) were diagnosed with hydatid disease of the liver with a mean age of 45 years (range, 19-82). The most common presenting symptom was right upper quadrant abdominal pain followed by incidental finding of cyst on imaging. Thirteen patients (13%) presented with signs and symptoms of obstructive jaundice. Of the 100 patients, 39 underwent laparoscopic surgery and 61 underwent open surgery. The most common complications were as follows: 16 bile leaks (16%), 14 intra-abdominal fluid collections (14%), 8 wound infections (8%), and 3 patients had biliary strictures (3%). Of the 100, 8 patients(8%) had recurrence of their hepatic hydatid disease. Conclusions: Hydatid disease of the liver is not a common disease, and its management can include medical, surgical, and interventional radiology. The decision depends on the size and complexity of the cyst and its location. Bile leak is a common complication and should be managed conservatively or through intervention by radiology or endoscopic retrograde cholangiopancreatography (ERCP).

Background and Purpose: The aim was to evaluate potential predictive factors of smell recovery in a clinical series of 288 patients presenting olfactory dysfunction (OD) related to coronavirus disease 2019 (COVID-19). Potential correlations were sought between epidemiological, clinical and immunological characteristics of patients and the persistence of OD at 60 days., Methods: COVID-19 positive patients presenting OD were prospectively recruited from three European hospitals. Baseline clinical and olfactory evaluations were performed within the first 2 weeks after OD onset and repeated at 30 and 60 days. In a subgroup of patients, anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies were measured in serum, saliva and nasal secretions at 60 days., Results: A total of 288 COVID-19 patients with OD were included in the study. Two weeks after the onset of the loss of smell, 52.4% of patients had OD on psychophysical tests, including 113 cases (39.2%) of anosmia and 38 cases (13.2%) of hyposmia. At 60-day follow-up, 25.4% of the patients presented persistent OD. There was no significant correlation between sex, age, viral load on nasopharyngeal swab or COVID-19 severity and poor olfactory outcome. In a subgroup of 63 patients, it was demonstrated that patients with poor olfactory outcomes at 60 days had lower levels of salivary and nasal immunoglobulin G (IgG) and IgG1, but similar levels of antibodies in the serum., Conclusions: No clinical markers predicted the evolution of OD at 60 days. Patients with poor olfactory outcome at 60 days had lower saliva and nasal antibodies, suggesting a role for local immune responses in the persistence of COVID-19 related OD., (© 2021 European Academy of Neurology.)

Background : The objective of this study was to investigate the efficacy and safety of early administration of oral corticosteroids (OC) or nasal corticosteroids (NC) as an add-on to olfactory training (OT) versus OT alone in patients with olfactory dysfunction (OD) related to coronavirus disease 2019 (COVID-19). Methods : Patients with a positive diagnosis of COVID-19 and OD were prospectively recruited from March 22 to December 15, 2020 from 4 European hospitals. Patients had confirmed OD on psychophysical testing. All patients undertook OT, with add-on 10 days of OC (group 1: OC + OT), or 1 month of NC (group 2: NC + OT) or olfactory training alone (group 3: OT). Olfactory evaluations (Sniffin'Sticks tests) were carried out at the time of inclusion, 1 and 2 months after the start of the therapeutic course. Results : A total of 152 hyposmic or anosmic patients completed the study. Group 1, 2 and 3 included 59, 22 and 71 patients, respectively and all patient groups were comparable regarding baseline Sniffin'Sticks tests. The median Sniffin'Sticks test values significantly improved from pre- to post-intervention in all groups. The increase of Sniffin'Sticks test values was higher in group 1 (OC + OT) compared with groups 2 and 3 ( p < 0.001) at one month after treatment but did not remain so at 2 months. Groups 1, 2 and 3, respectively, presented parosmia in 20/71 (28.2%), 9/22 (40.9%) and 42/71 (59.2%) patients. This difference was statistically significant between group 1 and 3 ( p < 0.001). There were no patients with a worsening of the disease or an increase of the severity of the COVID-19 symptoms. Conclusions : The use of OCs in patients with OD related to mild COVID-19 is generally well-tolerated without any case of deterioration of symptoms. OC is associated with greater improvement in psychophysical olfactory evaluations at 1-month post-treatment but there was no difference at 2 months. Parosmia may be reduced following treatment with OC and NC. On the basis of these preliminary results, it is possible to state that considering the 2 months efficacy of OC and NC with respect to the OT alone and the risk-benefit ratio, the benefit to start a specific treatment of COVID-19 related OD cannot be demonstrated and there is a need for a randomised controlled trial to assess this further.

Introduction: Sleep disturbances are more common in cancer patients than in the general population; however, there is limited research pertaining to the occurrence of such disturbances that subsequently impact patients' quality of life. The aim of our study is to describe the prevalence of insomnia among pancreatic cancer patients who have recently undergone recent pancreaticoduodenectomy., Methods: We performed a 6-year (2014-2020) retrospective cohort analysis of all adult patients aged 18 and above with pancreatic cancer who underwent pancreaticoduodenectomy at our institution. Insomnia was characterized using the Pittsburgh Sleep Quality Index (PSQI). Symptoms of insomnia and the impact caused by these symptoms on daily lives were assessed with the Insomnia Severity Index (ISI), and patients were divided into mild insomnia (ISI 8-14) or moderate to severe insomnia (ISI ≥ 15)., Results: Out of forty patients with pancreatic cancer that have undergone pancreaticoduodenectomy, 19 (47.2%) reported that their sleep disturbances had a significant effect on their quality of life. A total of 22 (55.0%) patients reported insomnia, with 63.2% reporting mild insomnia. Chemotherapy was found to significantly increase the risk of moderate to severe insomnia. The mean ISI score was 7.2 ± 6.9, and the mean PSQI score was 7.0 ± 5.1. ISI and PSQI showed a strong positive correlation ( r = 0.78, p < 0.01)., Conclusion: Sleep disturbances such as insomnia following pancreatic cancer surgery are highly prevalent. Treating physicians and surgeons should recognize and routinely screen for sleep disorders through the management of a multidisciplinary team in order to alleviate some of the burden on the patients' mental well-being., Competing Interests: No potential competing interest was reported by the authors., (Copyright © 2021 Sabine Chalhoub et al.)

Background: The objective evaluation of the olfactory function of coronavirus disease 2019 patients is difficult because of logistical and operator-safety problems. For this reason, in the literature, the data obtained from psychophysical tests are few and based on small case series., Methods: A multicenter, cohort study conducted in seven European hospitals between March 22 and August 20, 2020. The Sniffin-Sticks test and the Connecticut Chemosensory Clinical Research Center orthonasal olfaction test were used to objectively evaluate the olfactory function., Results: This study included 774 patients, of these 481 (62.1%) presented olfactory dysfunction (OD): 280 were hyposmic and 201 were anosmic. There was a significant difference between self-reported anosmia/hyposmia and psychophysical test results ( p = 0.006). Patients with gastroesophageal disorders reported a significantly higher probability of presenting hyposmia (OR 1.86; p = 0.015) and anosmia (OR 2.425; p < 0.001). Fever, chest pain, and phlegm significantly increased the likelihood of having hyposmia but not anosmia or an olfactory disturbance. In contrast, patients with dyspnea, dysphonia, and severe-to-critical COVID-19 were significantly more likely to have no anosmia, while these symptoms had no effect on the risk of developing hyposmia or an OD., Conclusions: Psychophysical assessment represents a significantly more accurate assessment tool for olfactory function than patient self-reported clinical outcomes. Olfactory disturbances appear to be largely independent from the epidemiological and clinical characteristics of the patients. The non-association with rhinitis symptoms and the high prevalence as a presenting symptom make olfactory disturbances an important symptom in the differential diagnosis between COVID-19 and common flu.

Objective: To assess the usefulness of orofacial strength and voice quality as assessment of response to levodopa challenge test (LCT) used in the diagnosis of early idiopathic Parkinson disease (IPD)., Study Design: Controlled Prospective Study., Methods: From January 2014 to April 2019, patients with early IPD and healthy individuals were recruited and evaluated for clinical findings (Hoehn and Yahr scale; Unified Parkinson's Disease Rating Scale); Voice Handicap Index (VHI); grade of dysphonia, roughness, breathiness, asthenia, and strain and instability (GRBASI); maximal phonation time; phonation quotient; acoustic parameters; and orofacial muscle strength Oral Performance Instrument (IOPI; IOPI Medical, Woodinville, WA, USA) t) at baseline and 45 minutes after the levodopa intake (LCT)., Results: A total of 32 IPD patients and 20 healthy individuals completed the study. Healthy individuals exhibited better VHI, grade of dysphonia, breathiness, asthenia, strain, instability, and acoustic measurements (noise-related, tremor, F0 short- and mid-term and intensity short-term parameters) than healthy subjects. The mean values of muscle strength of lips, cheeks, fundamental frequency (F0), highest F0, and shimmer significantly improved from pre- to post-LCT in IPD patients. Healthy individuals did not exhibit significant changes of orofacial strength and voice quality assessment from pre- to post-LCT. Significant associations were found between clinical, orofacial strength, and some aerodynamic and acoustic measurements., Conclusion: Orofacial strength and acoustic voice quality measurements may be used as objective outcomes of the LCT responsiveness in patients with early IPD., Level of Evidence: 3A. Laryngoscope, 2020., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To investigate the coronavirus disease 2019 (COVID-19) status of patients with initial sudden olfactory anosmia (ISOA) through nasopharyngeal swabs for reverse transcription-polymerase chain reaction (RT-PCR) analysis and to explore their olfactory dysfunctions with psychophysical olfactory evaluation., Methods: A total of 78 ISOA patients were recruited from April 6, 2020, to April 10, 2020, through a public call of University of Mons (Mons, Belgium). Patients benefited from nasopharyngeal swabs and fulfilled the patient-reported outcome questionnaire. Among them, 46 patients performed psychophysical olfactory evaluation using olfactory identification testing. Based on the duration of the ISOA, 2 groups of patients were compared: patients with olfactory dysfunction duration ≤12 days (group 1) and those with duration >12 days (group 2)., Results: In group 1, 42 patients (87.5%) had a positive viral load determined by RT-PCR and 6 patients (12.5%) were negative. In group 2, 7 patients (23%) had a positive viral load and 23 patients (77%) were negative. The psychophysical olfactory evaluation reported that anosmia and hyposmia occurred in 24 (52%) and 11 (24%) patients, respectively. Eleven patients were normosmic. The viral load was significantly higher in patients of group 1 compared with those of group 2., Conclusions: Coronavirus disease 2019 was detected in a high proportion of ISOA patients, especially over the first 12 days of olfactory dysfunction. Anosmia is an important symptom to consider in the detection of COVID-19 infection.

Background & Aims: Liver fibrosis is a metabolic disease associated with several factors, mainly age, gender, immune suppression, viral hepatitis, alcohol and metabolic diseases. Here, we are assessing the gender impact on liver status in NAFLD patients younger than 50 years., Methods: All males younger than 50 years and premenopausal females diagnosed with NAFLD were included in this study. Fibroscan results, demographics and clinical data were collected and analyzed by SPSS software. Patients were stratified based on fibrosis scores as mild or no fibrosis for F0-F1-F2 and severe fibrosis for F3 and F4. Data was analyzed and compared based on gender., Results: A total of 221 patients 134 males and 80 premenopausal females were included. Factors that affected liver fibrosis scores were different between males and females, where only body-mass index (BMI), white blood cells (WBC) count, and glucose level were associated with severe liver fibrosis in females. Also, liver fibrosis scores were associated with severe liver fibrosis in males only, no difference in these scores was observed in premenopausal females with severe or mild liver fibrosis., Conclusions: Gender differences are prominent in NAFLD and different factors are associated with liver status in males as compared to females. Besides, fibrosis score could predict liver status in males but not in females. Further larger-scale studies are necessary to verify gender impact on liver fibrosis development., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To investigate the occurrence of olfactory and gustatory dysfunctions in patients with laboratory-confirmed COVID-19 infection., Methods: Patients with laboratory-confirmed COVID-19 infection were recruited from 12 European hospitals. The following epidemiological and clinical outcomes have been studied: age, sex, ethnicity, comorbidities, and general and otolaryngological symptoms. Patients completed olfactory and gustatory questionnaires based on the smell and taste component of the National Health and Nutrition Examination Survey, and the short version of the Questionnaire of Olfactory Disorders-Negative Statements (sQOD-NS)., Results: A total of 417 mild-to-moderate COVID-19 patients completed the study (263 females). The most prevalent general symptoms consisted of cough, myalgia, and loss of appetite. Face pain and nasal obstruction were the most disease-related otolaryngological symptoms. 85.6% and 88.0% of patients reported olfactory and gustatory dysfunctions, respectively. There was a significant association between both disorders (p < 0.001). Olfactory dysfunction (OD) appeared before the other symptoms in 11.8% of cases. The sQO-NS scores were significantly lower in patients with anosmia compared with normosmic or hyposmic individuals (p = 0.001). Among the 18.2% of patients without nasal obstruction or rhinorrhea, 79.7% were hyposmic or anosmic. The early olfactory recovery rate was 44.0%. Females were significantly more affected by olfactory and gustatory dysfunctions than males (p = 0.001)., Conclusion: Olfactory and gustatory disorders are prevalent symptoms in European COVID-19 patients, who may not have nasal symptoms. The sudden anosmia or ageusia need to be recognized by the international scientific community as important symptoms of the COVID-19 infection.

Objective: We investigate the prevalence of the self-reported and objective sudden loss of smell (SLS) in patients with severe coronavirus disease 2019 (COVID-19)., Methods: Severe COVID-19 patients with self-reported SLS were recruited at hospitalization discharge. Epidemiological and clinical data were collected. The Sino-nasal Outcome Test-22 (SNOT-22) was used to evaluate rhinological complaints. Subjective olfactory and gustatory functions were assessed with the National Health and Nutrition Examination Survey (NHNES). Objective SLS was evaluated using psychophysical tests. Potential associations between olfactory evaluation and the clinical outcomes (duration of hospitalization; admission biology; one month serology (IgG), and chest computed tomography findings) were studied., Results: Forty-seven patients completed the study (25 females). Subjectively, eighteen (38.3%) individuals self-reported subjective partial or total SLS. Among them, only three and four were anosmic and hyposmic, respectively (38.9%). Considering the objective evaluation in the entire cohort, the prevalence of SLS was 21.3%. Elderly patients and those with diabetes had lower objective olfactory evaluation results than young and non-diabetic individuals., Conclusions: The prevalence of SLS in severe COVID-19 patients appears to be lower than previously estimated in mild-to-moderate COVID-19 forms. Future comparative studies are needed to explore the predictive value of SLS for COVID-19 severity.

Background: Liver diseases is a worldwide etiology causing high morbidity and mortality. Fibroscan is a quick, painless examination performed in clinic or at the patient's bedside. It is used to evaluate liver status for patients with suspected liver disease prognosis. This study aims at describing the spectrum of liver diseases among patients performing Fibroscan at a tertiary care center in Lebanon., Methods: This is a retrospective data collection study on patients who underwent Fibroscan at the American University of Beirut hepatobiliary unit between 2015 and 2018. Medical charts of all patients were reviewed. Data were collected and analyzed using SPSS 25 software., Results: A total of 620 patients presented to the hepatobiliary unit for Fibroscan, of which 419 (67.5%) were males. The mean age was 47.8 ± 13.4 (range 18-84). 362(58.3%) had NAFLD, 89 (14.3%) had Hepatitis-B, 69 (11.1%) had Hepatitis-C, 48 (7.7%) had ALD, 20 (3.3%) had DILI, and 13 (2.9%) had autoimmune hepatitis. 190 (30.6%) were overweight (BMI over 25), 128 (20.6%) had diabetes. Liver stiffness corresponding to the diagnosis of F4 liver fibrosis stage on Fibroscan was mostly reported in 6 (46.5%) autoimmune hepatitis, 101 (27.9%) NAFLD, and 18 (26.1%) HCV patients. 141 (45.5%) patients who had one or more metabolic risk factors suffered from severe stage steatosis compared with 78 (28.9%) who had not any risk factors with P -value 0.04., Conclusions: Based on our sample , NAFLD is emerging as a predominant etiology of CLD, followed by, HBV, and HCV. This is the first study that reports CLD status in Lebanon, further studies that describe the prevalence and incidence of the disease at a larger scale are needed., Competing Interests: None of the authors have any competing interests. The authors alone are responsible for the content and writing of the article. No conflict of interest is declared., (© 2020 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.)

Background: Wound complications following midline laparotomies are common and the main source of postoperative morbidity including superficial or deep wound infection, skin dehiscence, fascia dehiscence, and incisional hernia. Abdominal closure complications are strongly associated with suture technique and material, in addition to other factors related to the patient and type of surgery performed. The traditional technique is to place the fascia sutures 1 cm apart and at least 1 cm away from the fascia edge. A Swedish study described a new technique of placing the sutures 5 mm apart and 5 mm away from the fascia edge, resulting in lower rates of abdominal wound complications. This study has a number of limitations. There is a need for improved quality evidence to convince the surgical community to change the closure technique of abdominal wounds aiming to reduce morbidity, which is exemplified in incisional hernias and other various postop complications., Methods: This is a 1:1 randomized, controlled, patient- and assessor-blinded, parallel design, superiority trial, with a primary endpoint of incisional hernia at 1 year. The study will be conducted at AUBMC over a 3-year period. Patients planned for a non-emergent midline laparotomy for general surgery or vascular procedure will be randomized to either fascia closure technique. In order to detect a drop of 12% in the incidence of incisional hernia, with 80% power and an alpha of 0.05, we will need to recruit 114 patients per arm. After adjusting for loss to follow-up, target recruitment is 274 subjects. We will compare both arms for the primary, secondary, and exploratory outcomes, using chi-square or t test as appropriate. Univariate and multivariate logistic regression will be done., Discussion: This trial will assess postop complications following abdominal midline wound closures via two different suturing techniques. This trial will generate evidence-based conclusions that will allow surgeons to assess the role of a new abdominal closure technique in decreasing short- and long-term postoperative complications, for a commonly performed procedure., Trial Registration: ClinicalTrials.gov NCT03527433 . Registered on 17 May 2018 before starting participant enrollment.

Objective: To investigate olfactory dysfunction (OD) in patients with mild coronavirus disease 2019 (COVID-19) through patient-reported outcome questionnaires and objective psychophysical testing., Methods: COVID-19 patients with self-reported sudden-onset OD were recruited. Epidemiological and clinical data were collected. Nasal complaints were evaluated with the sinonasal outcome-22. Subjective olfactory and gustatory status was evaluated with the National Health and Nutrition Examination Survey. Objective OD was evaluated using psychophysical tests., Results: Eighty-six patients completed the study. The most common symptoms were fatigue (72.9%), headache (60.0%), nasal obstruction (58.6%), and postnasal drip (48.6%). Total loss of smell was self-reported by 61.4% of patients. Objective olfactory testings identified 41 anosmic (47.7%), 12 hyposmic (14.0%), and 33 normosmic (38.3%) patients. There was no correlation between the objective test results and subjective reports of nasal obstruction or postnasal drip., Conclusion: A significant proportion of COVID-19 patients reporting OD do not have OD on objective testing., (© 2020 Wiley Periodicals, Inc.)

Purpose: To study the usefulness of voice quality as therapeutic outcome in laryngopharyngeal reflux disease., Material and Methods: A total of 80 patients with reflux finding score (RFS) > 7 and reflux symptom index (RSI) > 13 were treated with pantoprazole, diet, and lifestyle recommendations for 3 months. The therapeutic effectiveness was assessed with RSI; RFS; Voice Handicap Index; blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability (GRBASI); aerodynamic and a panel of acoustic measurements before and after treatment. A correlation analysis between symptoms, videolaryngostroboscopic signs, and acoustic measurements was conducted., Results: Compared to baseline, means of RSI, RFS, Voice Handicap Index, perceptual dysphonia, and roughness significantly decreased. Significant improvements of phonatory quotient, percent jitter, percent shimmer, Relative Average Perturbation, Pitch Perturbation Quotient, Phonatory F0 Range, Amplitude Perturbation Quotient, smooth Amplitude Perturbation Quotient, and Peak-to-Peak Amplitude Variation were found at the end of treatment. Studies of correlation did not identify relevant correlation between videolaryngostroboscopic signs, especially vocal folds edema, and objective voice quality evaluations., Conclusion: Voice quality assessments can help to better understand voice disorders and can be used as indicators of the treatment effectiveness in patients with laryngopharyngeal reflux-related symptoms., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To compare symptoms, signs, and acoustical voice quality changes throughout the 6-month course of empirical treatment between laryngopharyngeal reflux (LPR) males and females., Materials and Methods: Forty clinically diagnosed LPR females and 40 males with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were treated with pantoprazole and diet recommendations during 3 or 6 months according to their evolution. RSI, RFS, and acoustic parameters were assessed at baseline and 3 and 6 months posttreatment. A correlation analysis between videolaryngostroboscopic findings and acoustic measurements was performed., Results: RSI, RFS, and many acoustic measurements (i.e., percent jitter, percent shimmer, phonatory fundamental frequency range, fundamental frequency variation, and peak-to-peak amplitude variation) significantly improved from baseline to 3 months posttreatment in male group. In female group, RSI and RFS total score significantly improved along the 3 first months of treatment. However, some clinical outcomes (i.e., RSI total score, hoarseness, cough, and globus) continued to improve from 3 to 6 months of treatment. We did not identify significant improvement of acoustic measurements in female group. The correlation study did not reveal significant correlation between videolaryngostroboscopic findings and acoustic measurements., Conclusion: This preliminary study suggests the occurrence of gender-related differences in the LPR therapeutic response. Further studies need to clarify whether females require a longer course of therapy than males., (© 2019 S. Karger AG, Basel.)

Background: Fibroscan is an effective and noninvasive tool to quantify fibrosis and steatosis in liver diseases including nonalcoholic fatty liver disease (NAFLD). Type-2-diabetes is a known risk factor for worse prognosis in NAFLD. In this study, we compare liver status in NAFDL diabetic and nondiabetic patients, identify potential risk factors, and determine the usefulness of Fibroscan in this population., Patients and Methods: The charts of all patients with NAFLD who underwent Fibroscan at our institution were reviewed. Fibroscan results, demographics, and clinical data were collected and analyzed using SPSS software., Results: Of the 248 NAFLD patients, 73 (29.4%) were diabetic and 175 (70.6%) were nondiabetic. As detected by the NAFLD' liver stiffness measure, 35 (47.94%) diabetic patients had severe liver fibrosis (F4) in contrast to only 46 (26.3%) nondiabetics. Diabetic patients also presented more with hypertension, dyslipidemia, coronary artery disease, and chronic kidney disease. Liver steatosis, liver function tests, and noninvasive scores did not vary significantly between the two groups, except for γ-glutamyltransferase, prothrombin time-international normalized ratio, and BMI-alanine aminotransferase ratio-diabetes score. Diabetic patients had significantly lower high-density lipoproteins and low-density lipoproteins., Conclusion: Fibroscan results and low-density lipoprotein are potential diagnostic factors of liver fibrosis in diabetic patients with NAFLD. Further studies are necessary to verify liver fibrosis diagnostic tools and prognostic and genetic markers in diabetic patients.

Objective: To investigate the usefulness of voice quality assessment as a treatment outcome in responder and nonresponder patients with laryngopharyngeal reflux (LPR)., Material and Methods: Eighty clinically diagnosed LPR patients with reflux finding score (RFS) > 7 and reflux symptom index (RSI) > 13 were treated with pantoprazole, lifestyle changes, and diet recommendations for three months. RSI; RFS; Voice Handicap Index; blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability; aerodynamic and acoustic measurements were assessed at baseline and after treatment. These data were analyzed and compared with regard to the clinical evolution of patients (responder versus nonresponder). Patients who significantly improved RSI ≤ 13 and RFS ≤ 7 after treatment were considered as responder. Nonresponders were defined as patients with RSI > 13 and/or RFS > 7 at the end of treatment. Studies of correlation between the adherence to the diet regimen and the evolution of both signs and symptoms and between videolaryngostroboscopic signs; blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability; and acoustic measurements were conducted., Results: Significant improvements in RSI, RFS, Voice Handicap Index, perceptual voice quality (dysphonia and roughness), and some fundamental frequency and intensity perturbation cues (phonatory fundamental frequency range, percent jitter, pitch perturbation quotient, relative average perturbation, percent shimmer, smoothed amplitude perturbation quotient, amplitude perturbation quotient, and peak-to-peak amplitude variation) were mainly identified after treatment in responder patients. The clinical and voice quality improvements of nonresponder patients were lower; highlighting a similar evolution of symptoms, signs, and voice quality. The correlation analysis revealed significant relationships between the adherence to lifestyle changes and diet recommendations and the improvement of symptoms and substantial correlations between breathiness and fundamental frequency perturbation parameters., Conclusion: Voice quality assessments can be used as indicators of the treatment effectiveness in patients with LPR. Voice quality improvement seems to be consistently associated with clinical improvement., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: With the advancement in surgical expertise at high-volume centers and advances in perioperative management, pancreaticoduodenectomy is becoming safer and remains the gold standard for treating periampullary pathologies. We describe our experience in optimizing perioperative management in order to avoid admission to the intensive care unit and improve outcomes., Method: Retrospective data were collected on 370 surgical patients who underwent a pancreaticoduodenectomy between the years 1994 and 2016., Results: Of the 370 patients, 200 operated between 2009 and 2016 did not require intensive care admission, blood transfusion, or central line insertion. The results were compared between different time intervals: before the year 1998, between the years 1998 and 2008, and between the years 2009 and 2016. The median blood loss dropped from 800 to 400 to 300 mL, respectively. The median operative time also dropped from 360 to 335 to 215 min, respectively. In addition, the median length of hospital stay decreased from 25 to 16 to 7 days, respectively., Conclusion: With the centralization of pancreaticoduodenectomy in high-volume centers and with specialized surgeons performing the surgery, there is a significant decrease in the onset of postoperative complications with a lesser need for blood transfusions and, subsequently, better recovery of patients without the need for intensive care unit admission., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2019 by S. Karger AG, Basel.)

Background: Pancreaticoduodenectomy is a challenging surgical intervention that remains the cornerstone in the treatment of localized peri‑ampullary pathologies. The concept of treatment standardization has been well-established in many high-volume centers in the world. Here, we present our experience in pancreaticoduodenectomy from 1994 to 2015., Methods: We performed a retrospective review of the medical charts of patients who underwent pancreaticoduodenectomy at our institution. Data was entered to SPSS statistical software and analyzed. The Mann-Whitney U and Fisher's exact tests were used to report statistical differences between groups., Results: Of the 370 patients who underwent pacreaticoduodenectomy, 300 were analyzed. The 1-, 3-, 5- and 10-year survival rates were 85%, 35%, 15%, and 7%, respectively with a 30-day mortality rate of 5.0% (15 patients). The median age of the patients was 61 (13-84) years, with 193 (64.3%) males and 107 (35.7%) females. The median operative time was 300 (130-570) min. The median postoperative length of hospital stay was 12 (5-76) days. Thirty-two patients required re-laparotomies; 10 for pancreatic leak, 7 for biliary leak and 15 for control of bleeding. Seventy-five (25.0%) patients developed pancreatic fistulae. Delayed gastric emptying was present in 31 (10.3%) patients. A significant improvement in surgical outcome was observed in cases done after 2008 which indicates the important role of specialized team in surgical management., Conclusions: The number of patients undergoing pancreaticoduodenectomy has been increasing annually over the past twenty-two years in our institution with results comparable to published series from high-volume centers. Through standardization of surgical techniques and perioperative management carried out by a specialist team, our results continue to improve despite the increasing complexity of cases referred to our unit., (Copyright © 2019 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Laryngopharyngeal reflux (LPR) is an inflammatory condition suspected to be associated with dysphonia. In this study, we investigated multidimensional perceptual, aerodynamic, and acoustic voice changes in patients with clinically diagnosed LPR compared to healthy participants. We prospectively included 80 outpatients with Reflux Finding Score (RFS) >7 and Reflux Symptom Index (RSI) >13 from September 2013 to April 2016 and we compared clinical and voice quality assessments of these patients with 80 healthy participants. Statistically significant differences were found between groups with regard to Voice Handicap Index, perceptual voice quality (grades of dysphonia, roughness, strain, breathiness, asthenia, and instability), phonatory quotient, percentage jitter, percentage shimmer, peak-to-peak amplitude variation, standard deviation of fundamental frequency, and noise to harmonic ratio. Granulation score of RFS was found to affect the highest number of acoustic parameters. We did not identify significant correlation between vocal fold edema and objective voice quality measurements. This study supports that patients with LPR have significant deterioration of both subjective and objective voice quality compared to healthy participants.

Background: Septic arthritis is a common rheumatologic condition with myriad microbiological causative agents. Moraxella is one of the very rare causes of septic arthritis. We hereby present the third case of Moraxella nonliquefaciens septic arthritis and the first case in a hematopoietic stem cell transplant patient (HSCT) along with a brief review of the literature., Methods: We used PubMed with google search engine to search the literature for reported cases of moraxella septic arthritis., Results: Information on 19 other cases of moraxella infectious arthritis was found. M. catarrhalis was the most common species isolated. Only 2 reports on M. nonliquefaciens were found; the first one in a multiple myeloma patient and the second one in a diabetic patient on hemodialysis. Predisposing conditions included inflammatory arthritis, prosthetic joints, diabetes, Human Immunodeficiency Virus (HIV) infection, Hepatitis C, hemodialysis, esophageal cancer, valve replacements, alcoholism and Intravenous (IV) drug use. The age group of the reported cases ranged from 3 months to 78 years., Conclusion: Infectious arthritis with Moraxella spp. is a very rare entity which can occur in any age group and in the setting of various underlying medical conditions., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To investigate the voice quality impairments in patients with laryngopharyngeal reflux (LPR) according to the gender., Design: Controlled multi-center study., Materials and Methods: 80 LPR patients (40 males and 40 females) with reflux finding score (RFS) > 7 and reflux symptom index (RSI) > 13 were included and clinically compared according to gender. To be considered as LPR patients, subjects responded to an empiric therapeutic trial based on pantoprazole intake and diet recommendations for 3 months or had positive pH/Impedance metry. Voice Handicap Index (VHI); Short Form Healthy Survey 36 (SF36), blinded Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI); aerodynamic and acoustic measurements were assessed in all patients and compared with 80 healthy controls (40 males and 40 females) according to gender., Results: The most common reasons for the consultation were, respectively, globus sensation in males (22.5%) and dysphonia (27.5%) in female who complained more of breathing difficulties and choking episodes related to LPR than males (p = 0.024). From a quality of life standpoint, female had increased significant impact of LPR disease on vitality and mental health than male. Compared to healthy subjects, both LPR male and female patients had stronger values of G, R, B, S, I, VHI, percent jitter, percent shimmer, and soft palate index than controls. In addition, LPR female had stronger values of lowest fundamental frequency and all aerodynamic measurements than controls., Conclusion: As showed in many other laryngeal conditions, voice quality of female could be more impaired by LPR than male. Some anatomical, histological and functional factors can be suspected and need additional future researches.

Background: Liposuction is one of the most commonly performed aesthetic procedures. It is performed worldwide as an outpatient procedure. However, the complications are underestimated and underreported by caregivers. We present a case of delayed diagnosis of bilothorax secondary to liver and gallbladder injury after tumescent liposuction., Methods: A 26-year-old female patient was transferred to our emergency department from an aesthetic clinic with worsening dyspnea, tachypnea and fatigue. She had undergone extensive liposuction of the thighs, buttocks, back and abdomen 5 days prior to presentation., Results: A chest X-ray showed significant right-sided pleural effusion. Thoracentesis was performed and drained bilious fluid. CT scan of the abdomen revealed pleural, liver and gall bladder injury. An exploratory laparoscopy confirmed the findings, the collections were drained; cholecystectomy and intraoperative cholangiogram were performed. The patient did very well postoperatively and was discharged home in 2 days., Conclusion: Even though liposuction is considered a simple office-based procedure, its complications can be fatal. The lack of strict laws that exclusively place this procedure in the hands of medical professionals allow these procedures to still be done by less experienced hands and in outpatient-based settings. Our case serves to highlight yet another unique but potentially fatal complication of liposuction., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objectives: The study aimed to investigate the impact of chemoradiotherapy (CRT) on speech and voice quality according to the anatomic localization of the head and neck cancer., Methods: Thirty-four patients treated by CRT for advanced suprahyoid (N = 17) or infrahyoid (N = 17) cancer were assessed for speech function, videolaryngostroboscopy, Voice Handicap Index, blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability, acoustic measurements, and aerodynamic measurements. Quality of life was evaluated using the European Organization for Research and Treatment of Cancer Head and Neck 35 (EORTC QLQ-H&N35) questionnaire., Results: Patients treated for an infrahyoid tumor presented more severe values of Voice Handicap Index items, dysphonia, breathiness, asthenia, and some acoustic cues (Voice Turbulence Index, Soft Phonation Index, degree of unvoiced segments, and number of unvoiced segments) than patients treated for a suprahyoid tumor. The EORTC QLQ-H&N35 communication item was better in the suprahyoid patient group., Conclusions: Voice quality impairments associated with CRT are more severe in patients treated for advanced infrahyoid cancer, suggesting the need to develop specific posttherapy management of the dysphonia according to the tumor anatomical localization., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Benzalkonium chloride (BAC) is a bactericidal preservative excipient commonly found in steroid nasal sprays used to treat allergic rhinitis and nasal polyposis. In rare cases, BAC can be responsible for type I and type IV hypersensitivity reactions that can manifest as rhinorrhea, which a clinician might misinterpret as a lack of response to nasal spray therapy rather than a complication of it. We report 3 cases of type IV hypersensitivity reactions in patients who were being treated with mometasone nasal spray. We describe the epidemiology, clinical features, diagnosis, and treatment of these reactions.

The objective is to assess the differences in the severity of symptoms, signs, voice quality, and quality of life before and after treatment according to age in suspected laryngopharyngeal reflux (LPR) patients. The design used in this paper is prospective multi-center study. Eighty clinically diagnosed LPR patients with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were treated with pantoprazole and diet recommendations for 3 months. Patients were subdivided into three groups according their age: group 1 (18-39 years, N = 21), group 2 (40-59 years, N = 31), and group 3 (≥60 years, N = 28). RSI, RFS, Voice Handicap Index (VHI), Short Form 36 questionnaire (SF36), aerodynamic, and acoustic measurements were evaluated at baseline and after treatment. The response to the empiric treatment was also assessed. Significant improvements in RSI, RFS, and VHI were found in all patient groups. The elderly patients showed a significantly lower RSI score than younger subjects (p = 0.035) without RFS difference among groups. At baseline, the SF36 score was better in group 3 with respect to social functioning (p = 0.049). At the 3-month follow-up, we found significant improvement of acoustic parameters only in the younger age groups (group 1 and group 2). The rate of resistant patients to the empiric treatment was higher in the younger group than in the elderly patient group (42.9 versus 28.6%). Age appears to reduce the subjective LPR symptom perception, leading to a lower rate of uncured patients. The utilization of acoustic parameters as an indicator of treatment effectiveness seems less useful for elderly subjects, probably due to an overlap between an aging voice and LPR.

Objective: To develop a French version of the Reflux Symptom Index (Fr-RSI) and to assess its internal consistency, reliability, and clinical validity., Study Design: Controlled, prospective trial., Materials and Methods: Forty-four patients with a reflux finding score > 7 and an Fr-RSI > 13 were enrolled and treated with 20 mg of pantoprazole twice daily and diet changes for 3 months. Ninety asymptomatic subjects were also included in the study. To assess reliability, Fr-RSI was completed twice within a 7-day period. Validity was assessed by comparing Fr-RSI scores with scores from the Voice Handicap Index (VHI) in 24 of 44 patients, at baseline and at 3 months posttherapy., Results: The mean values of Fr-RSI at baseline and after 7 days were 20.17 ± 5.76 and 19.75 ± 7.08, respectively, for patients with laryngopharyngeal reflux (LPR) and 4.02 ± 3.49 and 3.71 ± 3.82, respectively, for controls. The test-retest reliability was high in patients with LPR (r BP  = 0.78) and in healthy subjects (r BP  = 0.80). Cronbach's alpha was 0.85, indicating high internal consistency. The mean Fr-RSI score significantly improved from a baseline of 20.17 ± 5.76 to 5.58 ± 3.65 after 3 months of treatment (P = 0.001), and the initial mean VHI total score significantly improved from 20.29 ± 19.62 to 12.87 ± 12.04 after treatment (P = 0.029), indicating validity of the results. However, of the subcategories of the VHI, only the mean physical score improved from a baseline of 11.19 ± 9.22 to 7.35 ± 5.96 after treatment (P = 0.016)., Conclusion: The Fr-RSI developed in this study demonstrated both reliability and validity. It can be easily administered to assist in diagnosing and monitoring of LPR in French-speaking patients., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.