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Contains fulltext : 170611.pdf (Publisher’s version ) (Closed access) BACKGROUND: The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement. METHODS: Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user. RESULTS: eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement. CONCLUSIONS: The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.

Drugs that affect lipid metabolism are used with the aim to decrease negative outcomes such as cardiovascular-related morbidity and mortality. Six classes of lipid-lowering medications exist, and each has a variety of actual or potential side effects associated with their use. These medications are discussed in the following chapter with a focus on side effects as described in current literature. Evidence presented should be used in context and may aid clinical decision-making through identification of appropriate monitoring for actual or potential side effects of lipid-lowering medications.

The current standard of care for glioblastoma (GBM) is maximal surgical resection with adjuvant radiotherapy and temozolomide (TMZ). As the 5-year survival with GBM remains at a dismal

Pheochromocytomas of the spine are uncommon and require careful preoperative planning. The authors retrospectively reviewed the charts of 5 patients with metastatic spinal pheochromocytoma who had undergone surgical treatment over the past 10 years at their medical center. They reviewed patient age, history of pheochromocytoma resection, extent and location of metastases, history of alpha blockage, surgical level, surgical procedure, postoperative complications, tumor recurrence, and survival. Metastases involved the cervical (1 patient), thoracic (3 patients), and lumbar (2 patients) levels. Preoperative treatment included primary pheochromocytoma resection, chemotherapy, alpha blockade, embolization, and radiation. Three patients had tumor recurrence, and 2 underwent 2-stage reoperations for tumor extension. Hemodynamic complications were common: 2 patients developed pulseless electrical activity arrest within 4 months after surgery, 1 patient had profound postoperative tachycardia with fever and an elevated creatine kinase level, and 1 patient experienced transient postoperative hypotension and paraplegia. One patient died of complications related to disseminated cerebral and spinal disease. With careful preoperative and surgical management, patients with symptomatic metastatic spinal pheochromocytoma can benefit from aggressive surgical treatment. Postoperative cardiovascular complications are common even months after surgery, and patients should be closely monitored long term.

A strain designated as S85(T) was isolated from a seaweed collected from coastal area of Chuuk State in Micronesia. The strain was gram-negative, rod-shaped, and non-motile and formed yellow colonies on the SWY agar (0.2 % yeast extract and 1.5 % agar in seawater) and Marine agar 2216. The strain grew at pH 5-9 (optimum, pH 8), at 15-40 °C (optimum, 25-28 °C), and with 1-9 % (w/v) NaCl (optimum, 3 %). The phylogenetic analysis based on 16S rRNA gene sequence showed that strain S85(T) was related to Lutibacter litoralis CL-TF09(T) and Maritimimonas rapanae A31(T) with 91.4 % and with 90.5 % similarity, respectively. The dominant fatty acids were iso-C15:0, iso-C15:0 3-OH and iso-C17:0 3-OH, C16:0 3-OH and summed feature 3 (C16:1 ω7c and/or iso-C15:0 2-OH). The major isoprenoid quinone was MK-6. The DNA G+C content of the type strain was 34.6 mol %. The major polar lipids were phosphatidylethanolamine, an unknown glycolipid and two unknown polar lipids. Based on this polyphasic taxonomic data, strain S85(T) stands for a novel species of a new genus, and we propose the name Ochrovirga pacifica gen. nov., sp. nov. The type strain of O. pacifica is S85(T) (=KCCM 90106 =JCM 18327(T)).

Traumatic brain injury (TBI) is characterized by an abrupt blow or exchange of force against the head and can be categorized as mild, moderate, and severe. The secondary cell death after TBI displays ischemic-like patterns including neuroinflammation. The scavenger receptor cluster of differentiation (CD) 36 is a lipid-associated protein capable of transducing intracellular signals to promote inflammatory mechanisms within different cell types. Expression and activation of CD36 is closely related to dyslipidemia secondary to diabetes. Diabetes mellitus (DM) has been documented as a co-morbidity factor in TBI, in that patients with a history of diabetes present with more severe brain damage and slower recovery from TBI than non-diabetic patients. Indeed, a strict regulation of blood serum glucose by the use of insulin promotes a better outcome for TBI patients. Based on these recent findings, we now advance the hypothesis that CD36 via DM insulin-associated pathways is closely involved in TBI chronic pathology.

Signal transducer and activator of transcription 3 (STAT3) is a potent regulator of gliomagenesis through its induction of angiogenesis, host immunosuppression, and tumor invasion. Gain of function mutations result in constitutive activation of STAT3 in glioma cells, making STAT3 an attractive target for inhibition in cancer therapy. Nevertheless, some studies show that STAT3 also participates in terminal differentiation and apoptosis of various cell lines and in glioma with phosphatase and tensin homolog (PTEN)-deficient genetic backgrounds. In light of these findings, the utility of STAT3 as a prognostic indicator and as a target of drug therapies will be contingent on a more nuanced understanding of its pro- and anti-tumorigenic effects.

The immunosuppressive effects of chemotherapy present a challenge for designing effective cancer immunotherapy strategies. We hypothesized that although systemic chemotherapy (SC) exhibits negative immunologic effects, local chemotherapy (LC) can potentiate an antitumor immune response. We show that LC combined with anti–programmed cell death protein 1 (PD-1) facilitates an antitumor immune response and improves survival (P < 0.001) in glioblastoma. LC-treated mice had increased infiltration of tumor-associated dendritic cells and clonal expansion of antigen-specific T effector cells. In comparison, SC resulted in systemic and intratumoral lymphodepletion, with decreased immune memory in long-term survivors. Furthermore, adoptive transfer of CD8+ cells from LC-treated mice partially rescued SC-treated mice after tumor rechallenge. Last, the timing of chemo- and immunotherapy had differential effects on anti–PD-1 efficacy. This study suggests that both mode of delivery and timing have distinct effects on the efficacy of anti–PD-1. The results of this work could help guide the selection and scheduling of combination treatment for patients with glioblastoma and other tumor types.

Automation is a critical and timely source of job displacement, but little is known about how observers react to automation-driven layoffs. In a series of six studies, we contrast reactions to auto...

Background: Our aim was to review the published literature evaluating treatment approaches for chronic heart failure (HF), notably as it relates to African American patients. Method: We undertook a comprehensive database search (1986–2017) of PubMed, EMBASE, and Ovid/MEDLINE utilizing terms ‘African American’, ‘black’, ‘chronic heart failure’, ‘heart failure’, ‘medication’, ‘chronic therapy’, and ‘clinical trials’. Additional notable studies were obtained from ClinicalTrials.gov . Studies published in English that examine treatment modalities of chronic HF in African American and non-African American patients were included. Results: Examples of current gaps worthy of investigation include whether to maximize thiazides and calcium-channel blockers prior to adding renin–angiotensin system (RAS) inhibitors or beta blockers in HF with preserved ejection fraction; whether hydralazine/isosorbide dinitrate (ISDN) should be initiated during earlier HF stages; whether to prioritize hydralazine/ISDN over other agents such as RAS inhibitors; varying response of African Americans to different agents within drug classes; and the role of mineralocorticoid receptor antagonists. Conclusion: Further studies are needed in order for consensus guidelines to clarify how best to treat this population.

CM Kercsmar, AF Beck, H Sauers-Ford JAMA Pediatr. 2017;171(11):1072–1080 To reduce asthma health care use for Medicaid pediatric patients residing in the county surrounding Cincinnati, Ohio. An estimated 36 000 children ages 2 to 17 years who resided in Hamilton County, had a diagnosis of asthma, and were Medicaid insured were studied over a 6-year period. Approximately 13 000 were Medicaid insured. From January 1, 2010, through December 31, 2015, a multidisciplinary team used an integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating risks related to adverse exposures, and augmenting self-management and collaborative relationships between the family and …

C Roduit, R Frei, M Depner; PASTURE Study Group. JAMA Pediatr. 2017;171(7):655–662 To identify different phenotypes of atopic dermatitis (AD) by using a definition based on symptoms before age 6 years and to determine whether some subtypes are more at risk for developing other allergic diseases. The Protection Against Allergy Study in Rural Environments is a European birth cohort. Pregnant women were recruited between August 2002 and March 2005 and divided into 2 groups depending on whether they lived on a farm. Children from this cohort with data on AD from birth to 6 years of age were included. Questionnaires were administered to the mothers; reports of AD symptoms were assessed at …

Autonomic dysfunction is a well-known complication of Guillain-Barré syndrome (GBS) and may manifest as hemodynamic fluctuations. Posterior reversible encephalopathy syndrome (PRES) is commonly associated with acute hypertension, but is rarely reported to occur in association with GBS. We describe a patient with GBS who developed PRES in the setting of autonomic dysfunction and review the clinical features of all 12 previously reported patients with co-occurrence of GBS and PRES. Almost all cases have occurred in women over the age of 55, raising the possibility of increased sensitivity to dysautonomia in this patient group.

Object The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome. Methods The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery. Results The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period. Conclusions Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.

In this study we compared effects of practice time reading aloud to an adult on improvement in reading rate and comprehension. Eighty-one poor readers in 2nd and 4th grade, including 38 English Learner students (ELs), served as their own controls by participating in two practice conditions, each 3 times per week for 7 weeks: (a) 10 min reading aloud one-to-one to an adult listener and (b) 20 min reading aloud one-to-one. Repeated measures analysis of variance showed that 20 min of practice was better than 10 min for 4th graders, but not for 2nd graders, and gains in rate accelerated across the 14 weeks of practice. We found no differences in rate gains across conditions between ELs and native English speakers. After controlling for pretests, reading rate at posttest, along with vocabulary, contributed significant variance to reading comprehension outcomes.

The relationship between recollection-mediated recognition memory and behavioral pattern separation is poorly understood. In two separate experiments, we modified a well-validated object discrimination task with previously demonstrated sensitivity to neural pattern separation with instructions to assess recollection and familiarity. In the first experiment, we included a Remember/Know (R/K) judgment, and in the second we included a source memory judgment. We found that both “Remember” and correct source judgments were higher for lures labeled “similar” (where pattern separation is engaged) but also higher on lures called “old” (where pattern separation is absent), suggesting that false alarms in pattern separation tasks are frequently mediated by recollection. As one might expect, “Remember” judgments and correct source decisions increased with greater dissimilarity for “similar” responses and increased with greater similarity for “old” responses. This suggests that recollection can occur in the presence and in the absence of pattern separation and that false alarms to similar lures are not simply driven by familiarity.

The authors discuss the ophthalmologic manifestations of facial nerve paralysis and propose a surgical algorithm for their managment. Surgical techniques for canthoplasty, tarsorrhaphy, and suborbicularlis oculi fat pad lift (SOOF lift) are discussed.

Rehabilitation of the paralyzed face requires consideration of the functional, esthetic, and psychological concerns of the afflicted patient. Lack of spontaneous facial animation significantly impairs the capacity to interact socially and convey emotion. With the advent of microneurovascular free tissue transfer, a new era of dynamic reconstruction was introduced, and symmetry with movement became a clinical reality. Although the gracilis is highly touted as the workhorse flap in facial reanimation surgery, a better understanding of flap physiology and neurovascular anatomy has contributed to the increased versatility in flap design while minimizing donor site morbidity. The purpose of this manuscript is to explore alternative donor muscle groups used in the surgical management of chronic facial paralysis and describe their operative technique, namely, the extensor digitorum brevis, serratus anterior, and anterolateral thigh flaps.

There are more surgical and medical options for treating patients with facial nerve injury than ever before. However, little high-quality outcomes research has been performed comparing these different interventions. Fortunately, there are a number of well-validated outcomes measures available to evaluate patients with facial nerve injury. This manuscript categorizes and summarizes these tools.

Chronic facial paralysis is a challenging clinical entity. One of the primary goals is re-establishment of a dynamic smile, which is so important to everyday social interaction. When the facial muscles are denervated for longer than approximately 2 years, they atrophy and fibrose making nerve transfer procedures ineffective. In these cases, regional or free muscle transfer is necessary to achieve dynamic facial movement. Over the past decade, orthodromic temporalis tendon transfer has become a favored facial reanimative procedure. The surgical technique, and important pre- and postoperative factors, are discussed.

Selective chemodenervation is an important adjunct in the management of several aspects of facial nerve paralysis and paresis. Herein, the authors describe the utility of chemodenervation in the treatment of the synkinesis and contralateral hyperkinesis often associated with facial nerve injury.

The use of free tissue for dynamic reconstruction of the paralyzed face has allowed for the development of novel flaps aimed at maximizing the functional and cosmetic results. While the gracilis free-tissue transfer is highly popularized and well described, other donor sites are available for versatile pedicle length and soft-tissue adjuncts with minimal donor site morbidity. This article's aim is describe the surgical technique of other free-tissue options for dynamic reconstruction of the paralyzed face, specifically the latissimus dorsi, the pectoralis minor, and the rectus abdominis free-tissue transfer.

Background Glioblastoma (GBM) is a poorly immunogenic neoplasm treated with focused radiation. Immunotherapy has demonstrated synergistic survival effects with stereotactic radiosurgery (SRS) in murine GBM. GITR is a co-stimulatory molecule expressed constitutively on regulatory T-cells and by effector T-cells upon activation. We tested the hypothesis that anti-GITR monoclonal antibody (mAb) and SRS together would confer an immune-mediated survival benefit in glioma using the orthotopic GL261 glioma model. Methods Mice received SRS and anti-GITR 10 days after implantation. The anti-GITR mAbs tested were formatted as mouse IgG1 D265A (anti-GITR (1)) and IgG2a (anti-GITR (2a)) isotypes. Mice were randomized to four treatment groups: (1) control; (2) SRS; (3) anti-GITR; (4) anti-GITR/SRS. SRS was delivered to the tumor in one fraction, and mice were treated with mAb thrice. Mice were euthanized on day 21 to analyze the immunologic profile of tumor, spleen, and tumor draining lymph nodes. Results Anti-GITR (1)/SRS significantly improved survival over either treatment alone (p

Purpose: Checkpoint molecules like programmed death-1 (PD-1) and T-cell immunoglobulin mucin-3 (TIM-3) are negative immune regulators that may be upregulated in the setting of glioblastoma multiforme. Combined PD-1 blockade and stereotactic radiosurgery (SRS) have been shown to improve antitumor immunity and produce long-term survivors in a murine glioma model. However, tumor-infiltrating lymphocytes (TIL) can express multiple checkpoints, and expression of ≥2 checkpoints corresponds to a more exhausted T-cell phenotype. We investigate TIM-3 expression in a glioma model and the antitumor efficacy of TIM-3 blockade alone and in combination with anti-PD-1 and SRS.Experimental Design: C57BL/6 mice were implanted with murine glioma cell line GL261-luc2 and randomized into 8 treatment arms: (i) control, (ii) SRS, (iii) anti-PD-1 antibody, (iv) anti-TIM-3 antibody, (v) anti-PD-1 + SRS, (vi) anti-TIM-3 + SRS, (vii) anti-PD-1 + anti-TIM-3, and (viii) anti-PD-1 + anti-TIM-3 + SRS. Survival and immune activation were assessed.Results: Dual therapy with anti-TIM-3 antibody + SRS or anti-TIM-3 + anti-PD-1 improved survival compared with anti-TIM-3 antibody alone. Triple therapy resulted in 100% overall survival (P < 0.05), a significant improvement compared with other arms. Long-term survivors demonstrated increased immune cell infiltration and activity and immune memory. Finally, positive staining for TIM-3 was detected in 7 of 8 human GBM samples.Conclusions: This is the first preclinical investigation on the effects of dual PD-1 and TIM-3 blockade with radiation. We also demonstrate the presence of TIM-3 in human glioblastoma multiforme and provide preclinical evidence for a novel treatment combination that can potentially result in long-term glioma survival and constitutes a novel immunotherapeutic strategy for the treatment of glioblastoma multiforme. Clin Cancer Res; 23(1); 124–36. ©2016 AACR.

Glioblastoma (GBM) is a poorly immunogenic neoplasm treated with focused radiation. Immunotherapy has demonstrated synergistic survival effects with stereotactic radiosurgery (SRS) in murine GBM. GITR is a co-stimulatory molecule expressed constitutively on regulatory T-cells and by effector T-cells upon activation. We tested the hypothesis that anti-GITR monoclonal antibody (mAb) and SRS together would confer an immune-mediated survival benefit in glioma using the orthotopic GL261 glioma model. Mice received SRS and anti-GITR 10 days after implantation. The anti-GITR mAbs tested were formatted as mouse IgG1 D265A (anti-GITR (1)) and IgG2a (anti-GITR (2a)) isotypes. Mice were randomized to four treatment groups: (1) control; (2) SRS; (3) anti-GITR; (4) anti-GITR/SRS. SRS was delivered to the tumor in one fraction, and mice were treated with mAb thrice. Mice were euthanized on day 21 to analyze the immunologic profile of tumor, spleen, and tumor draining lymph nodes. Anti-GITR (1)/SRS significantly improved survival over either treatment alone (p

Traditional medical fundraising charities have been relying on third-party watchdogs and carefully crafting their reputation over time to signal their credibility to potential donors. As medical fundraising campaigns migrate to online platforms in the form of crowdfunding, potential donors can no longer rely on the organization's traditional methods for achieving credibility. Individual fundraisers must establish credibility on their own. Potential donors, therefore, seek new factors to assess the credibility of crowdfunding campaigns. In this paper, we investigate current practices in assessing the credibility of online medical crowdfunding campaigns. We report results from a mixed-methods study that analyzed data from social media and semi-structured interviews. We discovered eleven factors associated with the perceived credibility of medical crowdfunding. Of these, three communicative/emotional factors were unique to medical crowdfunding. We also found a distinctive validation practice, the collective endorsement. Close-connections' online presence and external online communities come together to form this collective endorsement in online medical fundraising campaigns. We conclude by describing how fundraisers can leverage collective endorsements to improve their campaigns' perceived credibility.

There is a need for enabling non-viral nanobiotechnology to allow safe and effective gene therapy and cell therapy, which can be utilized to treat devastating diseases such as brain cancer. Human adipose-derived mesenchymal stem cells (hAMSCs) display high anti-glioma tropism and represent a promising delivery vehicle for targeted brain tumor therapy. In this study, we demonstrate that non-viral, biodegradable polymeric nanoparticles (NPs) can be used to engineer hAMSCs with higher efficacy (75% of cells) than leading commercially available reagents and high cell viability. To accomplish this, we engineered a poly(beta-amino ester) (PBAE) polymer structure to transfect hAMSCs with significantly higher efficacy than Lipofectamine™ 2000. We then assessed the ability of NP-engineered hAMSCs to deliver bone morphogenetic protein 4 (BMP4), which has been shown to have a novel therapeutic effect by targeting human brain tumor initiating cells (BTIC), a source of cancer recurrence, in a human primary malignant glioma model. We demonstrated that hAMSCs genetically engineered with polymeric nanoparticles containing BMP4 plasmid DNA (BMP4/NP-hAMSCs) secrete BMP4 growth factor while maintaining their multipotency and preserving their migration and invasion capacities. We also showed that this approach can overcome a central challenge for brain therapeutics, overcoming the blood brain barrier, by demonstrating that NP-engineered hAMSCs can migrate to the brain and penetrate the brain tumor after both intranasal and systemic intravenous administration. Critically, athymic rats bearing human primary BTIC-derived tumors and treated intranasally with BMP4/NP-hAMSCs showed significantly improved survival compared to those treated with control GFP/NP-hAMCSs. This study demonstrates that synthetic polymeric nanoparticles are a safe and effective approach for stem cell-based cancer-targeting therapies.

Summary Objectives The temporoparietal fascia flap (TPFF) is a versatile tool in head and neck reconstruction. This article aims to describe the spectrum of TPFF applications through a series of case studies and related review of the literature. Methods Medical records were reviewed to identify cases that represent major TPFF application categories. A literature review was performed to support the presentation and discussion of each case category. Results Seven cases were identified each representing a distinct application category. These included auricular reconstruction, hair-bearing tissue transfer, facial soft tissue augmentation, cutaneous and mucosal oncologic defect repair, reconstruction after salvage laryngectomy, skull base reconstruction, and orbital reconstruction. Conclusion The TPFF is a uniquely versatile tool in head and neck reconstructive surgery. Outstanding in its pliable, ultra-thin yet hardy and highly vascular form, the temporoparietal fascia flap is a workhorse for the creative head and neck reconstructive surgeon.

BACKGROUND Postoperative psychosocial distress is a critical aspect of surgery, particularly in aesthetically sensitive areas. In this study, the authors assess the level of psychosocial distress associated with nasal reconstruction. The authors also compare postoperative distress levels associated with different reconstructive techniques throughout the healing process. METHODS The authors conducted a prospective study of patients undergoing nasal reconstruction following excision of cutaneous malignancy. The main outcome measure was the Derriford Appearance Scale 24, a measure of psychosocial distress. The Derriford Appearance Scale was administered at preoperative assessment, 1 < x < 4 weeks, 4 ≤ x < 12 weeks, and x ≥ 12 weeks. The entire cohort was analyzed with respect to distress levels before and after surgery. Reconstructions were categorized as interpolated, local tissue, or full-thickness skin graft. Analyses were performed for reconstruction type, patient, and defect data. RESULTS Fifty-nine patients were enrolled. Reconstructions included 14 interpolated flaps, 17 local tissue flaps, and 28 full-thickness skin grafts. For the entire cohort, distress levels were significantly higher at the first postoperative visit (p < 0.05), with normalization at subsequent follow-up evaluations. At the first assessment, the interpolated flap group had significantly higher levels of distress in comparison with the full-thickness skin graft group (p < 0.05). At late follow-up, levels of distress were equivalent. CONCLUSIONS Nasal reconstruction is associated with short-term increases in psychosocial distress that corrects by approximately 12 weeks after surgery. Interpolated flaps cause significantly higher distress at early assessment. Distress levels at late follow-up appear to be equivalent to those following a full-thickness skin graft despite larger and deeper initial defects. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.

Timely entry into HIV care is critical for early initiation of therapy, immunologic recovery and improved survival. However, undocumented Latinos are more likely to enter HIV care late in the disease course and with concurrent AIDS. We conducted a qualitative study to examine the circumstantial, situational and social factors that uniquely affect entry and retention in care for this population. Between June and August 2006, we conducted semi-structured, in-depth, individual interviews with 22 undocumented Latino immigrants living with HIV infection. The interviews were audiotaped, transcribed and reviewed for accuracy. Data was analyzed using a grounded theory approach. Word content was coded and sorted by themes using AnSWR software. Emergent themes related to health care barriers include (1) the challenges of dealing with HIV stigma and rejection from family and community; and (2) the experienced and perceived structural barriers of accessing care as an undocumented individual. Societal intolerance of HIV and stigma-related experiences result in feelings of secrecy and shame. In addition, the undocumented state complicates the situation even further. These unique barriers include fear of deportation, work restrictions, inadequate translation services and difficulties meeting paperwork requirements. This study offers insight into the unique sociocultural and structural barriers faced by undocumented Latinos with HIV infection. Understanding and addressing these barriers will prove vital in the development and implementation of strategies to promote early entry into HIV care.

Congenital diaphragmatic hernias are common, primarily occurring through the foramen of Bochdalek. However, in contrast, defects through the foramen of Morgagni are much more rare. When late presentations occur, patients may be asymptomatic or may be critically ill with respiratory and gastrointestinal symptoms. In this paper, we present a 9-year-old male who presented with recurrent, vague abdominal pain, and a previously normal abdominal CT scan. Initial investigation via an abdominal radiograph demonstrated an unexpected left lower lobe abnormality. Further evaluation and management revealed this abnormality to be an unusual left-sided congenital diaphragmatic hernia that appeared through the retrosternal foramen of Morgagni, a rare occurrence.

Chronic facial paralysis is a devastating condition with severe functional and emotional consequences. The current surgical armamentarium permits the predictable reestablishment of a protective blink as well as good resting symmetry. Yet the ultimate goal of symmetric, spontaneous emotional expression remains elusive despite significant progress in the areas of peripheral nerve grafting and free tissue transfer. This commentary explores the possibility of an implantable electrical prosthesis for facial reanimation. It reviews animal studies supporting this concept as well as recent human data suggesting that such an implant could rescue denervated facial musculature, thus overcoming a major hurdle for existing reanimation techniques.

The primary treatment of food allergy is to avoid the culprit foods. This is a complex undertaking that requires education about reading the labels of manufactured products, understanding how to avoid cross-contact with allergens during food preparation, and communicating effectively with persons who are providing allergen-safe meals including relatives and restaurant personnel. Successful avoidance also requires a knowledge of nuances such as appropriate cleaning practices, an understanding of the risks of ingestion compared to skin contact or inhalation, that exposure could occur through unanticipated means such as through sharing utensils or passionate kissing, and that food may be a component of substances that are not ingested such as cosmetics, bath products, vaccines and medications. The authors review the necessary tools of avoidance that physicians and medical practitioners can use to guide their patients through the complexities of food avoidance.

Parents of food-allergic children are responsible for risk assessment and management of their child's condition. Such practices are likely informed by parental knowledge, attitudes, and beliefs of food allergy. Our objective was to characterize food allergy knowledge and perceptions among parents with food-allergic children. Parents were recruited nationally between January 2008 and 2009 to complete the validated, web-based Chicago Food Allergy Research Survey for Parents of Children with Food Allergy. Findings were analyzed to provide composite/itemized knowledge scores, describe attitudes and beliefs, and examine the effects of participant characteristics on response. A sample of 2945 parents was obtained. Participants had an average knowledge score of 75% correct (range 19-100%). Strengths were observed in each content domain; e.g., 95% of participants accurately identified the signs of a milk-induced reaction. Weaknesses were limited to items assessing food allergy triggers/environmental risks and perceptions of susceptibility/prevalence; e.g., 52% of parents incorrectly believed young children are at higher risk for fatal anaphylaxis than adolescents. Parental attitudes/beliefs were diverse, although 85% agreed children should carry an EpiPen at school and 91% felt schools should have staff trained in food allergy. One in four parents reported food allergy caused a strain on their marriage/relationship, and 40% reported experiencing hostility from other parents when trying to accommodate their child's food allergy. In conclusion, parents in our study exhibited solid baseline knowledge although several important misconceptions were identified. While a broad spectrum of parental perceptions was observed, a large proportion of parents reported that their child's food allergy had an adverse impact on personal relationships and also agreed on certain policies to address food allergy in schools.

To discuss whether strict allergen avoidance is the most appropriate strategy for managing or preventing food allergy.The standard of care for the management of food allergy has been strict allergen avoidance. This advice is based upon the suppositions that exposure could result in allergic reactions and avoidance may speed recovery. Recent studies challenge these assumptions. Studies now demonstrate that most children with milk and egg allergy tolerate extensively heated forms of these foods. Moreover, clinical trials of oral immunotherapy show that oral exposure can lead to desensitization. Additionally, recent epidemiologic studies fail to support the notion that delaying introduction of highly allergenic foods to infants and young children prevents the development of food allergy. In fact, the data suggest that delays may increase risks.Recent data indicate that strict allergen avoidance is not always necessary for treatment, exposure may be therapeutic, and extended delay in introduction of food allergens to the diet of young children may increase allergy risks. However, in many circumstances strict avoidance is clearly necessary for treatment. Additional studies are needed to determine the risks and benefits of exposure to tolerated allergen, including identification of biomarkers to identify patients who may benefit.

Objective To identify demographic and psychological factors that predict satisfaction or dissatisfaction with outcomes among patients undergoing facial plastic surgery. Methods All patients presenting to the Center for Facial Cosmetic Surgery at the University of Michigan between January 1, 2007, and January 1, 2008, were asked to participate. Patients answered an initial baseline survey consisting of demographic information and an assessment of their baseline level of optimism/pessimism in addition to a surgery-specific outcome questionnaire both preoperatively and 4 to 6 months postoperatively. Results Fifty-one patients (mean [SD] age, 53 [13.0]; 69% female; 98% white) participated. Patients over the mean age of 53 years were more satisfied with their results than those under the mean age ( P = .01). Patients currently being treated for depression were more satisfied with surgical outcomes than those not being treated ( P = .05). No correlation was identified between baseline optimism/pessimism or other baseline factors and patients' perceived surgical outcomes. Surgeons were decidedly less positive in their assessment of the outcome than patients. Conclusion Despite a priori hypotheses that patients treated for depression might be more pessimistic and rate their satisfaction lower than other patients, patients treated for depression show a trend toward greater satisfaction from facial plastic surgical procedures than those not treated for depression.

Over the next twenty years the number of Americans diagnosed with dementia is expected to more than double (CDC 2007). It is, therefore, an important public health initiative to understand what factors contribute to the longevity of a healthy mind. Both default mode network (DMN) function and increased aerobic fitness have been associated with better cognitive performance and reduced incidence of Alzheimer’s disease among older adults. Here we examine the association between aerobic fitness, functional connectivity in the DMN, and cognitive performance. Results showed significant age-related deficits in functional connectivity in both local and distributed DMN pathways. However, in a group of healthy elderly adults, almost half of the age-related disconnections showed increased functional connectivity as a function of aerobic fitness level. Finally, we examine the hypothesis that functional connectivity in the DMN is one source of variance in the relationship between aerobic fitness and cognition. Results demonstrate instances of both specific and global DMN connectivity mediating the relationship between fitness and cognition. We provide the first evidence for functional connectivity as a source of variance in the association between aerobic fitness and cognition, and discuss results in the context of neurobiological theories of cognitive aging and disease.

C Mill, MN Primeau, E Medoff. JAMA Pediatr. 2016;170(6):e160033 To assess the accuracy and the negative predictive value of the provocation challenge in a cohort of children referred to a single center with suspected amoxicillin allergy. Children with suspected amoxicillin allergy who were referred to the Montreal Children’s Hospital in Quebec, Canada, between March 1, 2012, and April 1, 2015, were recruited. Exclusion criteria were any reactions compatible with either Stevens-Johnson syndrome or toxic epidermal necrolysis. Children with a prior history of rash while receiving …

Summary Background The atopic march is well documented, but the interrelationship of food allergy (FA) and asthma is not well understood. Objective The aim of this study was to examine the strength of the association and temporal relationships between FA and asthma. Methods This analysis included 271 children 6 years (older group) and 296 children

Models of selective attention predict that focused attention to spatially contiguous stimuli may result in enhanced activity in areas of cortex specialized for processing task-relevant and task-irrelevant information. We examined this hypothesis by localizing color-sensitive areas (CSA) and word and letter sensitive areas of cortex and then examining modulation of these regions during performance of a modified version of the Stroop task in which target and distractors are spatially coincident. We report that only the incongruent condition with the highest cognitive demand showed increased activity in CSA relative to other conditions, indicating an attentional enhancement in target processing areas. We also found an enhancement of activity in one region sensitive to word/letter processing during the most cognitively demanding incongruent condition indicating greater processing of the distractor dimension. Correlations with performance revealed that top-down modulation during the task was critical for effective filtering of irrelevant information in conflict conditions. These results support predictions made by models of selective attention and suggest an important mechanism of top-down attentional control in spatially contiguous stimuli.

Wedding ceremonies of the early modern period became newly invented wedding “traditions” in a nascent form of transculturalism as Christian, Buddhist, and other “modern” wedding ceremonies, collectively called sinsik gyeolhon (new-style weddings), first emerged in the 1890s and became commonplace by the early 1920s. Some of the most noticeable changes in wedding ceremonies were the ways in which they became hybridized invented traditions, selectively choosing aspects of both “old” and “new” weddings. Weddings also became commercialized affairs, an emblem of urban middle- and upperclass culture in colonial Korea. When we examine all these aspects, we can see that weddings reflected not only social trends, but also the anxieties of the times. In addition to more recent works on weddings, I rely on primary sources such as newspaper and magazine articles as well as photographs from the colonial period to see how Koreans negotiated transcultural influences to produce weddings as invented traditions and how wedding practices became commercialized. By looking at hybridity and commercialization as closely related processes, this paper examines ways in which wedding ceremonies transformed in form and symbolism from the late nineteenth century through the colonial period.

Food allergy and atopic dermatitis often occur in the same patients. Food-induced eczema may be perceived as a controversial topic because the immunologic mechanisms have yet to be fully elucidated. Nevertheless, published clinical studies have clearly demonstrated that foods can induce symptoms in a subset of patients with atopic dermatitis. Those at greatest risk are young children in whom eczematous lesions are severe or recalcitrant to therapy. Allergy testing can be helpful but must be applied judiciously. A medical history obtained by a skilled and knowledgeable health care provider is of paramount importance to interpret test results appropriately. Finally, the implementation of proper dietary avoidance can improve symptoms and provide safety from potentially fatal anaphylaxis. However, if inappropriate prescribed, elimination diets can have significant negative nutritional and social consequences.

Understanding culture's impact on mental health and its treatment is extremely important, especially in light of recent reports highlighting the realities of health disparities and unequal treatment. This article provides a conceptual paradigm for understanding how culture influences six mental health domains, including (a) the prevalence of mental illness, (b) etiology of disease, (c) phenomenology of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking pathways, and (f) treatment and intervention issues. Systematic interrelationships between each of these domains are highlighted and relevant literature is reviewed. Although no one model can adequately capture the complex facets of culture's influence on mental health, the Cultural Influences on Mental Health (CIMH) model serves as an important framework for understanding the complexities of these interrelationships. Implications for clinical research and practice are discussed.

The extent to which cortical plasticity is retained in old age remains an understudied question, despite large social and scientific implications of such a result. Neuroimaging research reports individual differences in age-related activation, thereby educing speculation that some degree of plasticity may remain throughout life. We conducted a randomized longitudinal dual-task training study to investigate if performance improvements (a) change the magnitude or pattern of fMRI activation, thereby suggesting some plasticity retention in old age and (b) result in a reduction in asymmetry and an increase in age differences in fMRI activation as a compensatory model of performance-related activation predicts. Performance improvements were correlated with an increase in hemispheric asymmetry and a reduction in age differences in ventral and dorsal prefrontal activation. These results provide evidence for plasticity in old age and are discussed in relation to an alternative argument for the role of reduced asymmetry in performance improvements.

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. Just as there are numerous etiologies of facial paresis, there are as many therapeutic options and variations of these options. The purpose of this article was to review the most current surgical options for neural reanimation of a damaged facial nerve, including recent advances in nerve repair, conduit technology, and nerve transfers, as well as emerging technology in translational research with biomedical engineering and tissue engineering.