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Key Points: Question: Does the benefit from endovascular thrombectomy for patients with large ischemic strokes caused by large vessel occlusion vary by the extent of presenting ischemic injury? Findings: In an exploratory analysis of a randomized clinical trial that included 336 participants, while functional outcomes worsened as baseline ischemic core volumes increased, endovascular thrombectomy was associated with better clinical outcomes across a wide spectrum of ischemic changes and penumbra profiles on various imaging modalities compared with medical management. Meaning: Endovascular thrombectomy, compared with medical management, improved clinical outcomes across a wide spectrum of ischemic core volumes and penumbral profiles; however, large ischemic core volume is an important prognostic factor to consider when individualizing treatment decisions. Importance: Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. Objective: To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. Design, Setting, and Participants: An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. Intervention: EVT vs MM. Main Outcomes and Measures: Primary outcome was functional outcome—90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Results: Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. Conclusion and Relevance: In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. Trial Registration: ClinicalTrials.gov Identifier: NCT03876457 This exploratory analysis of the SELECT2 trial assesses the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and the association of mismatch with clinical outcomes and endovascular treatment effect in adult patients with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery and large ischemic core in 31 global centers between October 2019 and September 2022. [ABSTRACT FROM AUTHOR]

Four strategies for reasserting the primacy of education are suggested to address the deficiencies of graduate medical education (GME) in the US. Achieving the objectives would require regulatory reform, adequate funding, and institutional competency in the use of education resources.

Tips are provided for medical schools that want to encourage industry sponsorship of medical research. This can lead to conflicts of interest if the medical school or any of its faculty actually own stock in the company that develops products based on the research. And this in turn can cause the public to lose faith in doctors and the health care system.

Retinopathy of prematurity (ROP, formerly called retrolental fibroplasia), an eye disorder in premature infants that can lead to blindness, has been thought to result from increased arterial oxygen tension (among other causes); this relationship, however, has not been unequivocally confirmed. Infants with cyanotic congenital heart disease (CCHD, inadequate heart activity such that the infant turns blue from lack of circulation) have low arterial oxygen tension (a measure of the amount of oxygen dissolved in the blood), and are believed to rarely develop ROP. This may not be the case, however. To learn more concerning the relationship between the two conditions, the records of six premature infants with CCHD who weighed between 1,100 and 2,050 grams were reviewed. All had undergone ophthalmologic examination at regular intervals after birth. The infants had been born at gestational ages ranging from 26 to 34 weeks; all had required mechanical ventilation (breathing with the aid of a machine). Three developed ROP; however, the abnormalities resolved within the first months of age in all cases. No differences were noted in the arterial oxygen tensions of the infants with or without ROP, or in the length of time oxygen was administered. A brief review is presented of the medical literature concerning the relationship between oxygen tension and ROP; the fact that infants with CCHD can also develop ROP, however, indicates that elevated oxygen tension is only one factor associated with the latter disease. Infants with CCHD should not be assumed to be free from ROP, and should be examined for symptoms as any other premature infant. (Consumer Summary produced by Reliance Medical Information, Inc.)

Octylcyanoacrylate tissue adhesive appears to be faster and less painful than sutures when treating skin lacerations. This was the conclusion of a study in which 130 patients with lacerations were randomly assigned to receive suturing or octylcyanoacrylate tissue adhesive. Wound healing was similar in both groups, but treatment with octylcyanoacrylate tissue adhesive took about one-fourth as much time as suturing. The patients treated with adhesive reported much less pain., Objective. -- To assess the effectiveness of a new tissue adhesive for laceration closure. Design. -- A prospective, randomized controlled trial. Setting. -- An adult teaching hospital. Participants. -- One hundred thirty patients with 136 lacerations who consented to enrollment during a 5-month period. The lacerations included all eligible nonmucosal facial lacerations, as well as selected extremity and torso lacerations (not on hands, feet, or joints). One hundred six lacerations were available for early follow-up, and 98 were available for 3-month evaluation. Interventions. -- Lacerations were randomly allocated to have skin closure with octylcyanoacrylate adhesive or monofilament suture. Main Outcome Measure. -- A 3-month photograph of the wound was assigned a cosmesis score on a previously validated 100-mm visual analog cosmesis scale by a plastic surgeon who was unaware of the method of wound closure. Results. -- There were no differences in the mean visual analog cosmesis scores (67 mm for octylcyanoacrylate vs 68 mm for sutures; P=.65). Similarly, there was no difference in the percentage of early (80% vs 82%; P=.80) or late (72% vs 75%; P=.74) optimal wound evaluation scores. The tissue adhesive was a faster method of wound repair (3.6 vs 12.4 minutes; P [is less than] .001) as well as being less painful (visual analog pain scores, 7.2 vs 18.0 mm; P [is less than] .001). Conclusions. -- Octylcyanoacrylate tissue adhesive effectively closes selected lacerations. This relatively painless and fast method of wound repair can replace the need for suturing several million lacerations each year.

Use of the Ottawa ankle rules appears to be an effective means of reducing the number of X-rays performed for ankle injuries without missing any ankle fractures. The Ottawa ankle rules are designed to assist emergency room physicians in diagnosing ankle fractures without resorting to unnecessary X-rays. The number of X-rays requested by emergency room doctors, the amount of time the patient spent in the emergency room and the cost of the emergency room visit were compared between two hospitals both before and after introduction of the assessment system in one hospital. The use of X-rays for diagnosing ankle injuries dropped by 28% at the hospital using the ankle rules. Ankle X-rays increased by 2% at the hospital not using the rules. The number of foot X-rays dropped by 14% at the hospital using the rules and increased by 13% at the other hospital. Emergency room visits were shorter and costs were lower for patients who did not have X-rays. Follow-up of patients who did not have X-rays indicated that no fractures had been missed when the ankle rules were followed., Objective.--To assess the impact on clinical practice of implementing the Ottawa ankle rules. Design.--Nonrandomized, controlled trial with before-after and concurrent controls. Setting.--Emergency departments of a university (intervention) hospital and a community (control) hospital. Patients.--All 2342 adults seen with acute ankle injuries during 5-month periods before and after the intervention. Intervention.--The implementation of the Ottawa ankle rules by emergency department physicians. Main Outcome Measure.--Proportions of patients referred for standard ankle and foot radiographic series. Results.--There was a relative reduction in ankle radiography by 28% at the intervention hospital but an increase by 2% at the control hospital (P

Research in otolaryngology in 1993 focused on the prevention, care and treatment of head and neck cancer and hearing loss. Studies show that malignant mutations of tissue in the head and neck are similar to tobacco-related p53 squamous cell carcinomas (SCC) of the lungs. Early detection of SCC of the head and neck is difficult because p53 mutations manifest themselves after the onset of tumors. Smokeless or inhaled tobacco products should be avoided to prevent the onset of head or neck cancer. Isotretinoin appears to be effective in the short-term treatment of oral cancers but has no effect on the rate of remission of the primary cancer. Implantation of artificial cochlea or inner ear tubes continues to improve the hearing ability of the deaf. Additionally, a combination of lidocaine and oxymetazoline appears to be a more effective and less addictive anesthetic than cocaine for certain surgical procedures of the nasal cavity., p53 mutations are early events in the development of carcinoma of the head and neck.--Cochlear implantation continues to influence rehabilitation of the profoundly deaf.--Replacing cocaine with a combination of lidocaine and oxymetazoline for nasal procedures avoids potential abuse.

The application of genetic and molecular biology to upper digestive tract malignancies and advances in the treatment of deafness are developments in otolaryngology-head and neck surgery that are discussed. A mutation on gene p53 may be a biological indicator of tumors of the upper laryngeal tract. Chemotherapy and radiation therapy together may help patients with neck cancer avoid the loss of their larynx. Surgery may be necessary if there is no response to the initial chemotherapeutic treatment. Cochlear and auditory brain stem implants are helping deaf children to learn to communicate. The cochlea is a bone in the inner ear. Cochlear implants have helped children understand speech without lipreading. Visual attention deficits also seem to be aided by the implants. Auditory brain stem implants are used for profoundly deaf children to help them recognize sounds and lipread. Other topics discussed include the early detection of deafness in children, the association between pigmentary disorders and deafness and research into the regeneration of the hair cells of the inner ear.

The president of the American Board of Otolaryngology believes that all medical resident training programs should be restructured with a de-emphasis on the amount of time spent in the residency and an emphasis on what was learned and achieved. He also recommends the development of "general specialists", who would be trained for a certain specialty but would still be able to provide primary care within that specialty.

Faculty members at the Woodruff Health Sciences Center (WHSC) of Emory University discuss their experience in reshaping the medical center to ensure its survival. Academic medical centers are in trouble because they are losing financial support due to government cutbacks and the rise of the managed care industry. In 1996, WHSC's director began a comprehensive strategic assessment and planning process. The results of the process are described. This can serve as a model for other academic medical centers.

The article discusses the call that has been given by the U.S. President Barack Obama to all American citizens to volunteer their services in helping address serious national challenges. The first place where they could start is the National Health Service Corps (NHSC), the main aim of which is to provide scholarships and student loan repayments to physicians and clinicians agreeing to practice for some time in US unreserved communities.

Research has identified gene mutations on 10 different chromosomes that appear to be involved in head and neck cancer. Studies have shown that people who received nasopharyngeal irradiation for various conditions 30 to 50 years ago do not have an increased risk of cancer. Hearing impairment may be a sign of early dementia in elderly people. Lasers have been used to treat port-wine stain, but many of the lesions return. Questionnaires can be used to determine how many snorers are at risk for sleep apnea syndrome, which can be surgically treated.

Molecular techniques have been used to identify p53 mutations in tissue samples from patients who have had surgery for head and neck cancer. Some of the samples that had been negative for residual cancer cells under a microscope were positive using the molecular technique. Many of these tumors recurred. Tobacco use has long been associated with head and neck cancer but the mechanism has been unclear. Research shows that many tissue samples of squamous cell head and neck cancer have mutations in the p53 gene. Patients who smoked and drank alcohol were even more likely to have p53 mutations than those who smoke. A study found that autologous blood transfusion is costly and confers very little health benefit over blood transfusions from another person. A microcolpohysteroscope is an instrument that allows a physician to examine internal organs such as the larynx in microscopic detail. Multichannel hearing devices appear to be successful at a cost similar to that of other medical interventions.