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Aim: The purpose of this study was to evaluate presurgical comorbidities, perioperative and postoperative complications, and postsurgical outcomes of minimally invasive bariatric surgery in patients aged 55 years and older to determine if age should be used as a selection criteria for bariatric surgery. Methods: A total of 750 patients underwent sleeve gastrectomy or robotic-assisted Roux-en-Y gastric bypass from January 2008 to June 2014. Patients were divided into three groups according to age

Introduction: Few studies have reported the prevalence and consequences of infection with Helicobacter pylori among obese patients undergoing sleeve gastrectomy. This study reviewed whether infection with H. pylori has any association with postoperative complications. This study also examined whether there was any difference in postoperative percent excess weight loss (%EWL). Materials and Methods: In this retrospective study, the pathology reports of 400 patients who underwent sleeve gastrectomy between 2008 and 2013 at the authors' institution were reviewed. Data examined included the demographics, perioperative and postoperative complications, and %EWL in the follow-up period. Results: In 68 of 400 patients (17%), H. pylori was positive in the specimen. In the H. pylori negative group, 332 patients were eligible for follow-up. No perioperative and postoperative (30 days) complications were registered in the H. pylori positive group. There was one postoperative leak in the H. pylori negative group. No o...

We describe a case of anomalous left coronary artery from the pulmonary artery in association with total anomalous pulmonary venous return. The infant was diagnosed with total anomalous pulmonary venous return at 6 weeks of age and underwent successful surgical repair. On routine follow-up, he was found to have an anomalous left coronary artery from the pulmonary artery without evidence of mitral regurgitation or left ventricular dysfunction. The presence of the left-to-right shunt and secondary elevation in pulmonary artery pressures likely masked the usual findings associated with this coronary anomaly.

Graft-versus-host disease (GvHD) results from the recognition of the hematopoietic stem cell transplantation (HSCT) recipient’s tissues as being foreign by immunocompetent donor T cells. GvHD remains a major cause of HSCT-related morbidity and mortality. Historically, acute GvHD is defined as GvHD that is evident prior to day 100 post-HSCT. However, acute GvHD can occur after this arbitrary HSCT milestone, and the diagnosis of acute GvHD is made based on the clinical presentation and other factors and not necessarily on the timing. The incidence of acute GvHD has been reported from 20% to 70%. Acute GvHD most commonly affects the skin ranging from mild erythema confined to the palms and soles to full-body erythroderma with bullae. The GI tract and liver are common target organs of acute GvHD but are rarely affected without skin involvement. Because acute GvHD is associated with high morbidity and mortality rates, patients receive GvHD prophylaxis during the peri-HSCT period in an effort to prevent, or at least ameliorate, acute GvHD. The choice of medications for GvHD prophylaxis is based on the type of HSCT, the degree of histoincompatibility between the donor and the recipient, the hematopoietic stem cell (HSC) source, and the age of the donor and recipient at the time of HSCT. The diagnosis is most often made on a clinical basis and treated with immunosuppression. Mortality risk corresponds to the stage and grade of acute GvHD. The identification of biomarkers of acute GvHD is an active area of investigation. This chapter addresses the risk factors, clinical features, diagnostic studies, and management of acute GvHD as well as strategies for GvHD prophylaxis. Chapter 19 focuses on chronic GvHD.

Diagnosis and proper management of pain is a critical part of the necessary supportive care for patients undergoing HSCT but can be a significant clinical challenge for the healthcare team due to the multifactorial nature of pain in the HSCT setting. This chapter details the many causes of pain in HSCT. HSCT-associated pain is often due to the conditioning regimen (which consists of high-dose chemotherapy and/or total body irradiation) and graft-versus-host disease (GvHD) prophylaxis regimens as well as potential post-HSCT complications. Given that mucositis is one of the largest sources of pain and infection in patients undergoing HSCT, special attention is paid to mucositis-specific strategies. These strategies include oral care and topical therapies such as glutamine and palifermin which are under investigation. Systemic non-opioid pain medications are also discussed. The remainder of this chapter focuses on opioid options and discusses the principles of conversion between opioids, use of caregiver-/patient-controlled analgesia (which can facilitate better pain control and result in a lower total amount of opioids needed), management of opioid side effects, and guidelines for weaning opioids to avoid withdrawal symptoms.

The benefits of exercise for smokers attempting to quit are partially dependent on physical activity levels prior to cessation. Mood disturbances can manifest within 30 min of smoking a cigarette and contribute to negative reinforcement of smoking behavior over time, whereas a single bout of aerobic exercise can reduce negative mood states and improve affect on a similar timescale in non-smokers. The acute effects of exercise among non-abstaining smokers immediately after a cigarette are unknown but may have clinical implications for smokers considering cessation. The aim of this study was to examine the concurrent effects of exercise on mood disturbance and prefrontal brain hemodynamic response to emotionally arousing scenes 30 min after smoking a cigarette and to test whether prefrontal brain hemodynamic response was correlated with affective ratings of the scenes. Fifteen cigarette smokers, averaging 47.6 cigarettes/week in the year prior to screening, served as participants. Functional near-infrared spectroscopy was used to measure hemodynamic status over the dorsolateral prefrontal cortex (DLPFC). Participants viewed pleasant, unpleasant, and neutral scenes prior to smoking a cigarette and 30 min later after seated rest or exercise at a preferred intensity. Mood disturbance was assessed by the Profile of Mood States-Brief Form four times: before smoking a cigarette, before and after exercise and rest, and after a post-condition (exercise/rest) exposure to emotionally arousing scenes. Compared to seated rest, cycling after a cigarette reduced mood disturbance (p = =.038) and DLPFC hemodynamic response to unpleasant (p = =.003) and pleasant (p = =.021) scenes relative to neutral scenes. DLPFC hemodynamic response was not related to affective ratings of scenes. We report that cycling for 20 min at a preferred intensity reduces mood disturbances which occur shortly after smoking a cigarette and blunts DLPFC hemodynamic response to emotionally arousing scenes. The findings encourage further investigation of exercise for smokers in the maintenance stage of smoking cessation.

The contemporary treatment paradigm for jugular paraganglioma focuses on the preservation of neurologic function. For this reason, non-invasive means of achieving tumor control with minimal morbidity have been adopted as first line therapeutic options. Conventional radiation therapy is utilized for large, inoperable tumors but carries a small risk of local tissue injury and must be delivered over several weeks. In contrast, stereotactic radiosurgery and radiotherapy, with steep radiation falloff gradients, permits the delivery of a high dose of focused radiation in a single treatment or hypofractionated fashion to arrest tumor growth with reduced collateral injury. In the absence of prior treatment, these modalities achieve tumor control rates of greater than 90% in most series. Radiosurgery for recurrent disease, or in an adjuvant fashion following subtotal tumor resection, has been demonstrated to yield similar tumor control while avoiding cranial nerve damage that may occur with attempts at gross total tumor resection. Patients may experience an attendant decrease in symptoms such as pulsatile tinnitus, making this an attractive treatment option when the risk associated with surgery is high.

Currently, there is a paucity of literature evaluating hearing preservation outcomes in children following cochlear implantation. The objective of the current study is to report pediatric hearing preservation results following cochlear implantation with conventional full-length electrodes.Retrospective review (2000-2016).Tertiary referral center.All pediatric patients with a ≤ 75 dB preoperative low-frequency pure tone average (LFPTA; 250-500 Hz average), who underwent cochlear implantation with a conventional length electrode.Cochlear implantation.Complete, partial, minimal, or no hearing preservation following cochlear implantation (Skarzynski et al., 2013); maintenance of functional low frequency hearing (≤85 dB LFPTA).A total of 43 ears, in 35 pediatric patients, met inclusion criteria. The mean age at time of implantation was 8.6 years (range, 1.4-17.8 yr), 20 (57.1%) patients were female, and 25 (58.1%) cases were left-sided.The mean preoperative ipsilateral low frequency PTA and conventional four-frequency PTA (500, 1000, 2000, 3000 Hz average) were 54.2 dB (range, 15-75 dB) and 82.2 dB (range, 25-102.5 dB), respectively. The mean low frequency PTA and conventional four-frequency PTA shifts comparing the pre- and first postoperative audiogram were Δ25.2 dB (range, -5 to 92.5 dB) and Δ18.3 dB (range, -8.8 to 100 dB), respectively. Overall, 17 (39.5%) ears demonstrated complete hearing preservation, 19 (44.2%) ears partial hearing preservation, 0 minimal hearing preservation, and 7 (16.3%) exhibited no measurable acoustic hearing after surgery. In total, 28 (65.1%) ears maintained functional low-frequency hearing (i.e., ≤85 dB LFPTA) based on the initial postoperative audiogram. There was no statistically significant difference in the initial low frequency PTA shift comparing lateral wall and perimodiolar electrodes (Δ22.2 versus Δ28.1 respectively; p = 0.44), cochleostomy and round window insertions (Δ25.2 vs. Δ24.7 respectively; p = 0.95), or statistically significant association between age at implantation and low frequency PTA shift (r = 0.174; p = 0.26).In total, 22 ears in 19 patients had serial audiometric data available for review. Over a mean duration of 43.8 months (range, 2.6-108.3 mo) following surgery, the mean low frequency PTA and conventional four-frequency PTA shift comparing the initial postoperative and most recent postoperative audiogram was Δ9.7 dB (range, -27.5 to 57.5 dB) and Δ8.1 dB (range, -18.8 to 31.9 dB), respectively.Varying levels of hearing preservation with conventional length electrodes can be achieved in most pediatric subjects. In the current study, 82% of patients maintained detectable hearing thresholds and 65% maintained functional low-frequency acoustic hearing. These data may be used to guide preoperative counseling in pediatric patients with residual acoustic hearing. Additionally, the favorable rates of hearing preservation achieved in children provide further evidence for the expansion of pediatric cochlear implant candidacy to include patients with greater degrees of residual hearing.

Objective To describe a novel case of congenital profound bilateral sensorineural hearing loss in a patient with bilateral nodular internal auditory canal and labyrinthine enhancement and temporal bone dysplasia. Patients A 76-day-old female was referred to the authors' center for evaluation of congenital deafness. Behavioral observations and objective audiometric evaluation demonstrated bilateral profound sensorineural hearing loss and a comprehensive multidisciplinary evaluation identified compound heterozygous pathogenic variants in MYO7A, a gene associated with Usher Syndrome Type 1B or DFNB2. Computed tomography and contrast-enhanced magnetic resonance imaging studies demonstrated bilateral temporal bone anomalies with unique middle and inner ear malformations, as well as unique contrast enhancement in the membranous labyrinth, internal auditory canals, and cranial nerves, which have not been previously described with MYO7A variants. Interventions Given the potential risk for progressive bilateral labyrinthitis ossificans, bilateral simultaneous cochlear implantation was performed at 4 months of age. Main outcome measures Subsequent audiologic follow up after implantation shows significantly improved access to auditory information and increased vocalizations. At last testing, speech and language skills for both receptive and expressive language abilities were found to be commensurate with her chronological age. Conclusion We report a novel presentation and imaging findings of congenital bilateral profound sensorineural hearing loss in a patient with nodular internal auditory canal and labyrinthine enhancement and coexisting inner ear dysplasia. Despite the multiple radiologic abnormalities, the patient has demonstrated good benefit from cochlear implantation. Future study of rare variants of congenital deafness, such as this, is critical toward defining new disease processes and determining optimal treatment.

OBJECTIVEThe morbidity of gross-total resection of jugular paraganglioma (JP) is often unacceptable due to the potential for irreversible lower cranial neuropathy. Stereotactic radiosurgery (SRS) has been used at the authors’ institution since 1990 for the treatment of JP and other benign intracranial tumors. Conventional means of assessing tumor progression using linear measurements or elliptical approximations are imprecise due to the irregular shape and insinuating growth pattern of JP. The objective of this study was to assess long-term tumor control in these patients by using slice-by-slice 3D volumetric segmentation of serial MRI data.METHODSRadiographic data and clinical records were reviewed retrospectively at a single, tertiary-care academic referral center for patients treated from 1990 to 2017. Volumetric analyses by integration of consecutive tumor cross-sectional areas (tumor segmentation) of serial MRI data were performed. Tumor progression was defined as volumetric growth of 15% or greater over the imaging interval. Primary outcomes analyzed included survival free of radiographic and clinical progression. Secondary outcomes included new or worsened cranial neuropathy.RESULTSA total of 85 patients were treated with Gamma Knife radiosurgery (GKRS) for JP at the authors’ institution over the last 27 years. Sixty patients had pretreatment and serial posttreatment contrast-enhanced MRI follow-up suitable for volumetric analysis. A total of 214 MR images were analyzed to segment tumor images in a slice-by-slice fashion to calculate integral tumor volume. The median follow-up duration was 66 months (range 7–202 months). At 5 years the tumor progression-free survival rate was 98%. Three tumors exhibited progression more than 10 years after GKRS. Estimated survival free of radiographic progression rates (95% confidence interval [CI]; n = number still at risk) at 5, 10, and 15 years following radiosurgery were 98% (95% CI 94%–100%; n = 34), 94% (95% CI 85%–100%; n = 16), and 74% (95% CI 56%–98%; n = 6), respectively. One patient with tumor progression required treatment intervention using external beam radiation therapy, constituting the only case of clinical progression. Two patients (3%) without preexisting lower cranial nerve dysfunction developed new ipsilateral vocal fold paralysis following radiosurgery.CONCLUSIONSSRS achieves excellent long-term tumor control for JP without a high risk for new or worsened cranial neuropathy when used in primary, combined modality, or recurrent settings. Long-term follow-up is critical due to the potential for late radiographic progression (i.e., more than 10 years after SRS). As none of the patients with late progression have required salvage therapy, the clinical implications of this degree of tumor growth have yet to be determined.

The past several years have demonstrated an increased recognition of operative videos as an important adjunct for resident education. Currently lacking, however, are effective methods to record video for the purposes of illustrating the techniques of minimally invasive (MIS) and complex spine surgery. We describe here our experiences developing and using a shoulder-mounted camera system for recording surgical video. Our requirements for an effective camera system included wireless portability to allow for movement around the operating room, camera mount location for comfort and loupes/headlight usage, battery life for long operative days, and sterile control of on/off recording. With this in mind, we created a shoulder-mounted camera system utilizing a GoPro™ HERO3+, its Smart Remote (GoPro, Inc., San Mateo, California), a high-capacity external battery pack, and a commercially available shoulder-mount harness. This shoulder-mounted system was more comfortable to wear for long periods of time in comparison to existing head-mounted and loupe-mounted systems. Without requiring any wired connections, the surgeon was free to move around the room as needed. Over the past several years, we have recorded numerous MIS and complex spine surgeries for the purposes of surgical video creation for resident education. Surgical videos serve as a platform to distribute important operative nuances in rich multimedia. Effective and practical camera system setups are needed to encourage the continued creation of videos to illustrate the surgical maneuvers in minimally invasive and complex spinal surgery. We describe here a novel portable shoulder-mounted camera system setup specifically designed to be worn and used for long periods of time in the operating room.

Objective To determine the sensitivity and specificity of ocular and cervical vestibular evoked myogenic potentials (VEMPs) in the diagnosis of superior semicircular canal dehiscence (SCD) and to describe the VEMP response characteristics that are most sensitive to SCD and compare the findings to previous reports. Study Design Case series with chart review. Setting Two tertiary neurotologic referral centers. Subjects and Methods Cervical and ocular VEMP peak-to-peak amplitudes and thresholds from 39 adult patients older than 18 years with surgically confirmed SCD were compared with 84 age-matched controls. Results Using receiver operating characteristic (ROC) curves, cervical VEMP (cVEMP) amplitudes, cVEMP thresholds, and ocular VEMP (oVEMP) amplitudes had areas under the curve of 0.731, 0.912, and 0.856, respectively, all of which were statistically significant ( P.0001). For cVEMP thresholds, at the clinical equivalent ≤85-dB normalized hearing level (nHL) threshold, the sensitivity and specificity were 97.3% and 31.3%, respectively. At the ≤70-dB nHL threshold, the sensitivity and specificity were 73.0% and 94.0%, respectively. For oVEMP amplitudes12.0 µV, the sensitivity and specificity were 78.6% and 81.7%, respectively. Conclusion Data from this multicenter study suggest that both cVEMP thresholds and oVEMP amplitudes remain good diagnostic tests for identifying SCD, with each test dependent on a number of factors. The sensitivity and specificity of these individual tests may vary slightly between centers depending on testing parameters used.

AOSpine masters series. , AOSpine masters series. , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

Background Thumb epiphyses cannot be visualized on radiographs in infants with radial polydactyly, making it difficult to classify by Wassel type. The purpose of this study was to identify radiographic features that distinguish a separate epiphysis from a shared epiphysis. This may assist in operative planning and establishing prognosis. Methods The charts of 34 radial polydactyly patients treated with surgical reconstruction from 2008 through 2012 were retrospectively reviewed. Measurements of the most proximal bones involved in the duplication, including length, width at shaft, width at base, distance between radial and ulnar thumb, and angle between radial and ulnar thumb, were taken from PA radiographs of the thumb by four blinded individuals. The interclass correlation coefficient was calculated to determine inter-observer reliability. Operative notes were reviewed to distinguish between shared and separate epiphyses. Several indices were created from these measurements. Results Radiographic measurements showed high ***interobserver reliability. There were statistically significant differences between patients with separate and shared epiphyses for indices for the width shaft index, interspace distance, the angle×interspace distance, and the angle×interspace index. Conclusion Radiographic differences exist between children with separate and shared epiphyses. In patients with shared epiphyses, the radial thumb tends to be smaller, closer to the ulnar thumb, and less divergent. Threshold values were identified for predicting the status of the epiphysis based on the angle×interspace distance and the angle×interspace index. These values may be used to help determine in advance of surgery if a shared epiphysis exists.

Author(s): Kuan, Edward C; Kennedy, William P; Patel, Neil N; Kohanski, Michael A; Tong, Charles C; Kennedy, David W; Palmer, James; Adappa, Nithin D; Bosso, John V

Although catheter-based intervention is generally accepted as the treatment of choice for branch pulmonary artery (PA) stenosis, there are no data directly comparing both the need for reintervention and time to reintervention in patients undergoing transcatheter stenting versus surgical arterioplasty. We compared children who underwent surgical branch pulmonary arterioplasty and branch PA stent placement between January 2008 and May 2012 at a single tertiary center. Need for reintervention and mean time to reintervention were assessed using chi-square and independent sample Student t test. Thirty-seven patients were included (surgery n = 18, stent n = 19). Mean weight at initial intervention was 11.3 ± 8.8 kg for surgical and 20.1 ± 15.5 kg for stent (p = 0.041). Intervention was performed on the left PA in 17 patients, the right PA in 12 patients, and both PAs in 8 patients. Five patients had undergone previous intervention. On mean follow-up of 807 ± 415 days, 50 % (9 of 18) of the surgery cohort and 5.3 % (1 of 19) of the stent cohort required reintervention (p = 0.002). In all but one case reintervention was catheter-based. Mean time to reintervention for the surgery cohort was 272 ± 162 days and for the single stent cohort it was 150 days. When comparable age and weight groups were analyzed, reintervention was still more common in the surgery cohort (p = 0.007). Children undergoing surgical branch pulmonary arterioplasty are more likely to require reintervention than those undergoing stent placement.

Metabolic profiling of urine and fecal extracts, histological investigation of intestinal ilea, and fecal metagenomics analyses were used to investigate effects of prolonged antibiotic use in mice. The study provides insight into the effects of extended empiric antibiotic therapy in humans. Mice were administered a broad-spectrum antibiotic for four consecutive days followed by oral gavage with Clostridium butyricum, an opportunistic gram-positive pathogenic bacteria commonly isolated in fecal and blood cultures of necrotizing enterocolitis patients. Metagenomics data indicated loss of bacterial diversity after 4 days on antibiotics that was restored after removing antibiotic pressure. Histological analyses indicated damage to ileal villi after antibiotic treatment that underwent repair after lifting antibiotic pressure. Metabolic profiling confirmed intestinal injury in antibiotic-treated mice indicated by increased urinary trans-4-hydroxy-l-proline, a breakdown product of collagen present in connective tissue of ileal villi that may serve as a biomarker for antibiotic-induced injury in at risk populations.

There has been a conscious effort to address osteoporosis in the aging population. As bisphosphonate and intermittent parathyroid hormone (PTH) therapy become more widely prescribed to treat osteoporosis, it is important to understand their effects on other physiologic processes, particularly the impact on spinal fusion. Despite early animal model studies and more recent clinical studies, the impact of these medications on spinal fusion is not fully understood. Previous animal studies suggest that bisphosphonate therapy resulted in inhibition of fusion mass with impeded maturity and an unknown effect on biomechanical strength. Prior animal studies demonstrate an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. The purpose of this study was to determine if bisphosphonates and intermittent PTH treatment have impact on human spinal fusion. A systematic review of the literature published between 1980 and 2015 was conducted using major electronic databases. Studies reporting outcomes of human subjects undergoing 1, 2, or 3-level spinal fusion while receiving bisphosphonates and/or intermittent PTH treatment were included. The results of relevant human studies were analyzed for consensus on the effects of these medications in regards to spinal fusion. There were nine human studies evaluating the impact of these medications on spinal fusion. Improved fusion rates were noted in patients receiving bisphosphonates compared to control groups, and greater fusion rates in patients receiving PTH compared to control groups. Prior studies involving animal models found an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. No significant complications were demonstrated in any study included in the analysis. Bisphosphonate use in humans may not be a deterrent to spinal fusion. Intermittent parathyroid use has shown early promise to increase fusion mass in both animal and human studies but further studies are needed to support routine use.

Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery.The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques.The study is set in a fresh tissue dissection laboratory.The sample includes eight fresh human cadavers.A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines.Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage.Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p.01) when compared with mean pressures without the hydrogel sealant.We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.

Study design Retrospective analysis of national insurance billing database. Objective To examine trends in reoperation after single-level lumbar discectomy. Summary of background data Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy caused by disc herniation. Randomized clinical trials have demonstrated the advantage of discectomy over nonsurgical treatment options, allowing for a more rapid reduction in symptoms. However, population-level data regarding reoperation after single level discectomy is limited. Methods Data were collected using the commercially available PearlDiver software for patients billed with the Current Procedural Terminology code for our index procedure, hemilaminotomy and removal of disc material, between January 2007 and September 2014. The index group was then followed for up to 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Results Analysis of data obtained from 13,654 patient records revealed a rate of additional lumbar surgeries after single-level discectomy of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.9% (370/6274) of patients within 4 years. Patients who received a re-exploration discectomy within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years after the re-exploration discectomy. The average additional cost of lumbar reoperation, as measured by insurance reimbursement, was approximately $11,161 per-patient per year. Conclusion We report an overall 4-year reoperation rate of 12.2% after single-level discectomy. In addition, we report a rate of progression to lumbar fusion following re-exploration discectomy of 38.4% within 4 years of reoperation. Further studies are needed regarding the best treatment algorithm in patients with reherniation or iatrogenic instability after lumbar discectomy. This study should enhance the shared decision making process by providing surgeons and patients with valuable data regarding the frequency and nature of reoperations after discectomy. Level of evidence 3.

Demonstrate the association of radiographic dural enhancement with increased tumor adherence at the porus acusticus, which may influence completeness of resection and facial nerve outcome.Case series with chart review.Academic referral center.A total of 205 consecutive patients with histopathologically confirmed vestibular schwannoma (VS) were evaluated. Patients with tumors exhibiting dural enhancement on postgadolinium T1-weighted magnetic resonance imaging were identified and compared with matched controls. Completeness of resection, intraoperative details, and facial nerve outcomes were analyzed.Excluding strictly intracanalicular tumors (n = 32, 16%) and those with NF2 (n = 10, 4.9%), the presence of dural enhancement was radiographically confirmed in 16 (9.8%) cases. Paired analysis did not reveal significant baseline differences between cases and controls. Subtotal resection was performed in 5 (31%) of the 16 patients with tumors exhibiting dural enhancement, in contrast to 1 (3%) of the matched controls (P = .01). Four (25%) demonstrated increased tumor adherence at the porus acusticus intraoperatively, compared with 1 control (3%, P = .04). Long-term facial nerve function was similar between cases and controls (81% vs 84% House-Brackmann I-II function, P = 1.00).Dural enhancement is present in approximately 10% of extracanalicular VS. Dural enhancement at the porus acusticus may represent hypervascularity, dural reaction, or infiltration, and portends increased tumor adherence and greater likelihood of subtotal resection to preserve facial nerve function. To our knowledge, this is the first series that reports the prevalence of this phenomenon in VS and the potential surgical implications. Recognition preoperatively may be valuable toward patient counseling.

Background Neuroblastoma is a pediatric malignancy, and most tumor cells express the norepinephrine transporter (NET) enabling uptake of NET ligands. Meta-iodobenzylguanidine (MIBG) is a NET-specific ligand used as a highly specific imaging agent and targeted radiotherapeutic. Patients with neuroblastoma frequently require sedation during targeted radiotherapy. Dexmedetomidine has been increasingly used to achieve efficacious sedation. There are theoretical concerns that this highly selective alpha-2 adrenergic receptor agonist may interfere with active uptake of MIBG through the NET transporter. In this study, we analyzed the impact of [125-iodine]-labeled MIBG ([125 I]MIBG) uptake in the presence of dexmedetomidine in human neuroblastoma-derived cellular models. Procedure Carrier-free [125 I]MIBG was synthesized using UltraTrace® resin (Molecular Insight Pharmaceuticals, Inc., Tarrytown, NY) through radioiododestannylation from a tin precursor bound by a solid-state polymer. NET (SLC6A2) protein expression was determined in human neuroblastoma cell lines (BE2C, SKNSH and IMR5). [125 I]MIBG internalization studies were performed using [125 I]MIBG alone or in combination with either desipramine or dexmedetomidine. Dexmedetomidine and desipramine competitive inhibition studies were performed and concentration at 50% maximal inhibition was calculated. Finally, NET inhibitor dissociation studies were performed in which after pre-incubation with either desipramine or dexmedetomidine, cells were washed and [125 I]MIBG was added. Results We show dose-dependent inhibition of [125 I]MIBG uptake by dexmedetomidine, but at several logs lower potency than the known NET inhibitor desipramine. A review of pediatric dexmedetomidine pharmacokinetic data shows that the concentrations achieved in the serum are much lower than those required to block MIBG uptake. Conclusion We conclude that dexmedetomidine will not interfere with therapeutic [131 I]MIBG efficacy.

The National Heart, Lung, and Blood Institute recommends that children older than 3 years seen in the medical setting have their blood pressure (BP) measured. The authors aimed to determine whether BPs are measured at well-child visits and whether elevated readings are recognized. A retrospective chart review of 3- to 18-year-old children seen for well-child visits was performed. Age, sex, weight, height, BP, extremity measured, and type of intervention were collected. BP was measured in 777 of 805 patients (97%). BP was elevated in 158 patients (20%). A total of 95 patients (60%) did not receive any intervention. Not recognizing elevated BP was associated with increased daily patient load (17.9±6.5 vs 12.6±5.5, P=.001). Higher body mass index was associated with elevated BP (P=.0008) but was not associated with improved recognition. Findings show that BP is almost always measured at well-child visits but is not being measured appropriately, and general pediatric clinics are not consistently following BP management recommendations.

Objective To elucidate the long-term clinical behavior, treatment, and outcomes of sporadic facial nerve schwannoma (FNS) in a large cohort of patients managed in the post–magnetic resonance imaging era. Patients and Methods Retrospective review at a single tertiary health care system (January 1, 1990, through December 31, 2015), evaluating 80 consecutive patients with sporadic FNS. Results Ninety-eight patients with FNS were identified; 10 with incomplete data and 8 with neurofibromatosis type 2 were excluded. The remaining 80 patients (median age, 47 years; 58% women) were analyzed. Forty-three (54%) patients presented with asymmetrical hearing loss, 33 (41%) reported facial paresis, and 21 (26%) reported facial spasm. Seventeen (21%) exhibited radiologic features mimicking vestibular schwannoma, 14 (18%) presented as a parotid mass, and 5 (6%) were discovered incidentally. Factors predictive of facial nerve paresis or spasm before treatment were female sex and tumor involvement of the labyrinthine/geniculate and tympanic facial nerve segments. The median growth rate among growing FNS was 2.0 mm/y. Details regarding clinical outcome according to treatment modality are described. Conclusion In patients with FNS, female sex and involvement of the labyrinthine/geniculate and tympanic segments of the facial nerve predict a higher probability of facial paresis or spasm. When isolated to the posterior fossa or parotid gland, establishing a preoperative diagnosis of FNS is challenging. Treatment should be tailored according to tumor location and size, existing facial nerve function, patient priorities, and age. A management algorithm is presented, prioritizing long-term facial nerve function.

The thyroglossal duct cyst is one of the more common congenital anterior neck masses. In rare cases, carcinoma has been detected within one of these cysts on histopathologic analysis of resected tissue. Since the incidence of thyroglossal duct cyst carcinoma is low, the appropriate management of the thyroid gland proper is not algorithmic. We present 2 cases of papillary thyroid carcinoma that were discovered in a thyroglossal duct cyst, and we describe the diagnostic and therapeutic measures taken in each case. Particular attention is paid to two points: (1) fine-needle aspiration biopsy may not be sufficient to rule out carcinoma and (2) removal of the thyroid gland may be advisable in selected situations.

Proximal junctional kyphosis is an increasingly recognized complication following long-segment posterior spinal fusion for adult spinal deformity. The authors describe a novel technique for interspinous ligament reinforcement at the proximal adjacent levels using a cadaveric semitendinosus tendon graft secured with an Ethibond No. 2 double filament (Ethicon, Somerville, New Jersey) via the Krackow suture weave. A retrospective review identified 4 patients who had received this graft. No proximal junctional kyphosis was seen at a mean short-term follow-up of 5.5 months. Interspinous ligament reinforcement at the proximal adjacent level with a cadaveric semitendinosus tendon graft is a feasible strategy for preventing proximal junctional kyphosis. [ Orthopedics. 2017; 40(1):e206–e210.]

The Dynesys dynamic stabilization system is an alternative to rigid instrumentation and fusion for the treatment of lumbar degenerative disease. Although many outcomes studies have shown good results, currently lacking is a comprehensive report on complications associated with this system, especially in terms of how it compares with reported complication rates of fusion. For the present study, the authors reviewed the literature to find all studies involving the Dynesys dynamic stabilization system that reported complications or adverse events. Twenty-one studies were included for a total of 1166 patients with a mean age of 55.5 years (range 39–71 years) and a mean follow-up period of 33.7 months (range 12.0–81.6 months). Analysis of these studies demonstrated a surgical-site infection rate of 4.3%, pedicle screw loosening rate of 11.7%, pedicle screw fracture rate of 1.6%, and adjacent-segment disease (ASD) rate of 7.0%. Of studies reporting revision surgeries, 11.3% of patients underwent a reoperation. Of patients who developed ASD, 40.6% underwent a reoperation for treatment. The Dynesys dynamic stabilization system appears to have a fairly similar complication-rate profile compared with published literature on lumbar fusion, and is associated with a slightly lower incidence of ASD.

Normal cell growth consists of two distinct phases, quiescence and proliferation. Quiescence, or G(0), is a reversible growth arrest in which cells retain the ability to reenter the proliferative cycle (G(1), S, G(2), and M). Although not actively dividing, quiescent cells are metabolically active and quiescence is actively maintained. Our results from microRNA PCR arrays and Taqman PCR assays showed a significant decrease (4-fold) in miR-302 levels during quiescence compared to proliferating normal human fibroblasts, suggesting that miR-302 could regulate cellular proliferation. Results from a Q-RT-PCR and dual-luciferase-3'-UTR reporter assays identified ARID4a (AT-rich interacting domain 4a, also known as RBP1) and CCL5 (C-C motif ligand 5) as targets for miR-302. Ionizing radiation decreased miR-302 levels, which was associated with an increase in its target mRNA levels, ARID4a and CCL5. Such an inverse correlation was also observed in cells treated with hydrogen peroxide as well as SOD2-overexpressing cells. Overexpression of miR-302 suppresses ARID4a and CCL5 mRNA levels, and increased the percentage of S-phase cells. These results identified miR-302 as an ROS-sensitive regulator of ARID4a and CCL5 mRNAs as well as demonstrate a regulatory role of miR-302 during quiescence and proliferation.

Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P =0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P P Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.

Purpose: The purpose of this study was to evaluate the change in corneal wavefront aberrations in young adults who have been fit with multifocal soft contact lenses for myopia progression control. Findings have been analyzed for statistical significance and clinical relevance and compared to reportedly successful Orthokeratology outcomes. Methods: The dominant eye of 40 participants (27 women, 13 men; mean age 27.3 ± 3.2 years; range 23 to 39 years) was fit with Proclear Multifocal center distance lenses (Coopervision, Pleasanton, USA) having a variety of distance powers and reading additions. Refractive errors were limited to a range of –6.00 D up to +1.00 D of sphere, and no greater than –1.00 D of cylinder. Corneal wavefront measurements were performed over 6 mm diameters with a Zeiss Atlas 9000 corneal topographer (Zeiss Meditec, Dublin, USA) prior to, and following lens fitting. Data were converted into rectangular Fourier optics terms M, J0, J45 and RMS values for each reading addition were statistically analyzed. Following evaluation of statistical significance and clinical relevance, results were compared to published data from successful Orthokeratology treatments. Results: Statistically significant changes in higher order aberrations were detected for lenses of all reading additions. Lens groups with higher Add-powers demonstrated stronger changes with increased significance. Final RMS values relating to 2nd, 3rd and 4th Zernike Orders reached clinical significance with a wavefront error of 0.10 μm, the equivalent of 0.25D. Moreover, as Add-powers increased, 3rd and 4th order aberrations likewise showed an increase. Pre-fitting astigmatism values accounted for the highest recorded aberrations and remained predominantly unchanged. Conclusion: Proclear Multifocal center-distance contact lenses were found to increase higher order wavefront aberrations in a manner dependent on their Add-power. In comparison to successful Orthokeratology outcomes, the amounts of resulting aberrations are notably different.

Accurate assessment of brain-implantable microdevice bio-integration remains a formidable challenge. Prevailing histological methods require device extraction prior to tissue processing, often disrupting and removing the tissue of interest which had been surrounding the device. The Device-Capture Histology method, presented here, overcomes many limitations of the conventional Device-Explant Histology method, by collecting the device and surrounding tissue intact for subsequent labeling. With the implant remaining in situ, accurate and precise imaging of the morphologically preserved tissue at the brain/microdevice interface can then be collected and quantified. First, this article presents the Device-Capture Histology method for obtaining and processing the intact, undisturbed microdevice-tissue interface, and imaging using fluorescent labeling and confocal microscopy. Second, this article gives examples of how to quantify features found in the captured peridevice tissue. We also share histological data capturing (1) the impact of microdevice implantation on tissue, (2) the effects of an experimental anti-inflammatory coating, (3) a dense grouping of cell nuclei encapsulating a long-term implant, and (4) atypical oligodendrocyte organization neighboring a long term implant. Data sets collected using the Device-Capture Histology method are presented to demonstrate the significant advantages of processing the intact microdevice-tissue interface, and to underscore the utility of the method in understanding the effects of the brain-implantable microdevices on nearby tissue.

Objectives: Indications for surgical treatment of bladder diverticula include tumor, lower urinary tract symptoms refractory to medical treatment, renal dysfunction or recurrent urinary tract infections. We describe the technique and report the outcomes of robotic bladder diverticulectomy at our institution. Methods: A chart review of patients who underwent robotic bladder diverticulectomy at our institution from 2007 to 2010 was carried out. Indications for the procedure were: lower urinary tract symptoms (LUTS) not responding to medical treatment (2 patients), ureteral obstruction (1 patient), tumor arising in a diverticulum (2 patients) and diverticulum secondary to neurogenic bladder (1 patient). One patient also had renal dysfunction associated with ureteral insertion into the diverticulum and therefore underwent ipsilateral ureteroneocystostomy. Other additional procedures included transurethral resection of the prostate (1 patient) and bilateral pelvic lymph node dissection (1 patient). Perioperative and postoperative outcomes were analyzed. Results: Six patients (median age 61.5 years, range 19–75) underwent da Vinci diverticulectomy using a transperitoneal approach without the need for open conversion. Median operative time was 232 min (135–360 min.). Median estimated blood loss was 100 mL (50–150 mL). The Foley catheter was removed after a negative cystogram and median time to catheter removal was 7 days (7–12 days). Median hospital stay was 3 days (2–5 days). The only complication was a urinary tract infection managed with antibiotics. Conclusions: Robotic surgery represents a reasonable minimally invasive treatment option for resection of bladder diverticula when indicated.

This report and images describe a case of atrial flutter with 2:1 conduction pattern in a 3 year-old male with d-TGA, ASD, and VSD status-post repair, which was demonstrated by M-mode echocardiography.

•To compare laparoendoscopic single-site (LESS) and standard laparoscopic pyeloplasty procedures with the aim of defining whether perioperative, recovery or health-related quality of life (HRQL) benefits exist for the LESS procedure. PATIENTS AND METHODS • From November 2007 to August 2008, sixteen patients underwent LESS pyeloplasty at a tertiary care referral centre. These patients were compared with a matched cohort of patients undergoing standard laparoscopic pyeloplasty. • Matching criteria included gender and age (within 10 years), as well as preoperative degree of obstruction (T 1/2 within 15 min) and differential renal function (within 10% ipsilaterally) based on diuretic radionuclide scanning. Mean follow-up was 13 ± 4 months for the LESS group and 17 ± 3 months for the standard laparoscopic group. • LESS pyeloplasty procedures were all performed using a single-port device in the umbilicus and suturing was assisted with a 2-mm grasping instrument. Perioperative variables, successful relief of obstruction and HRQL measurements were compared between the two groups. RESULTS • Except for a lower body mass index in the LESS group (23 ± 6 kg/m 2 vs 30 ± 7 kg/m 2 , P=0.002), no difference was noted for perioperative variables between the two cohorts, including hospital stay and analgesic requirement. • No significant HRQL advantage was noted for either group based on a six-item non-validated questionnaire. • All patients in both groups experienced clinical resolution of their symptoms. A patient in the standard laparoscopy group and two patients in the LESS group had T 1/2 > 20 min (0.063% vs 0.125%, P= 1.00) on diuretic radionuclide scanning. • Limitations include the retrospective nature of the present study, as well as the relatively small study population and short follow-up. CONCLUSIONS • No benefit was noted for LESS pyeloplasty over the standard laparoscopic procedure beyond aesthetic advantages. • Further comparisons are needed to determine whether these results are generalizable to other LESS procedures.

Understanding changes in the properties of semiconductor materials after immobilization of biomolecules on the surface is essential for the fabrication of well-tuned and programmable devices. The work examines changes in the properties of gallium phosphide (GaP) after modification with an organic linker, a single stranded DNA, and its complementary strand. We investigated changes in surface potential with Kelvin probe force microscopy (KPFM). Analysis revealed that a more ordered adlayer of ssDNA was present when a lower concentration of linker molecule was used. KPFM data combined with coverage data obtained from X-ray photoelectron spectroscopy (XPS) further confirmed this result. Successful hybridization with the complementary strand was confirmed by both KPFM and Raman spectroscopy. The results indicate that one can control the amount of DNA on the surface by changing the initial concentration of the organic linker, and thus modulate the surface potential of the semiconductor material.

Treatment of glioblastoma multiforme remains a major challenge despite advances in standard therapy, including surgery, radiation, and chemotherapy. The field of nanomedicine is expected to have a major impact on the treatment and management of brain tumors. Over the past decade, significant efforts have been made in using nanoparticles for diagnosis and treatment of brain tumors. One class of nanoparticles, liposomes, have received considerable attention for use as nanocarriers for delivery of therapeutics and contrast agents. The purpose of this article is to present the advances in the design and functional characteristics of liposomes for applications in brain tumor imaging.

Bitter (T2R) and sweet (T1R) taste receptors are expressed in the upper airway, where they play key roles in antimicrobial innate immune defense. Bitter bacterial products are detected by taste receptors on ciliated cells and solitary chemosensory cells, resulting in downstream nitric oxide and antimicrobial peptide release, respectively. Genetic polymorphisms in taste receptors contribute to variations in T1R and T2R functionality, and phenotypic differences correlate with disease status and disease severity in chronic rhinosinusitis (CRS). Correspondingly, there are also subjective bitter and sweet taste differences between patients with CRS and individuals without CRS across a number of compounds. The ability to capture these differences with a simple and inexpensive taste test provides a potentially useful diagnostic tool, while bitter compounds themselves could potentially serve as therapeutic agents. The present review examines the physiology of airway taste receptors and the recent literature elucidating the role taste receptors play in rhinologic disease.

Energy drinks have increased in popularity in adolescents and young adults; however, concerns have been raised regarding the ingredients in energy drinks and their potential negative effects on health. Caffeine, the most physiologically active ingredient in energy drinks, is generally considered safe by the US Food and Drug Administration (FDA), although adverse effects can occur at varying amounts. Guarana, which contains caffeine in addition to small amounts of theobromine, theophylline, and tannins, is also recognized as safe by the FDA, although it may lead to caffeine toxicity when combined with caffeine. The amount of ginseng in energy drinks is typically far below the amount used as a dietary supplement, and is generally considered safe. Taurine, an intracellular amino acid, has been reported to have positive inotropic effects; however, this claim is not supported by research. Most energy drinks also contain sugar in an amount that exceeds the maximum recommended daily amount. Young athletes are increasingly using energy drinks because of the ergogenic effects of caffeine and the other ingredients found in these beverages. Energy drinks combined with alcohol are also gaining popularity in young adults, which poses significant concerns about health risks. Other health concerns related to consumption of energy drinks include case reports of seizures and cardiac arrest following energy drink consumption and dental enamel erosion resulting from the acidity of energy drinks.

Background Most patients with juvenile myelomonocytic leukemia (JMML) are curable only with allogeneic hematopoietic cell transplantation (HCT). However, the current standard conditioning regimen, busulfan-cyclophosphamide-melphalan (Bu-Cy-Mel), may be associated with higher risks of morbidity and mortality. ASCT1221 was designed to test whether the potentially less-toxic myeloablative conditioning regimen containing busulfan-fludarabine (Bu-Flu) would be associated with equivalent outcomes. Procedure Twenty-seven patients were enrolled on ASCT1221 from 2013 to 2015. Pre- and post-HCT (starting Day +30) mutant allele burden was measured in all and pre-HCT therapy was administered according to physician discretion. Results Fifteen patients were randomized (six to Bu-Cy-Mel and nine to Bu-Flu) after meeting diagnostic criteria for JMML. Pre-HCT low-dose chemotherapy did not appear to reduce pre-HCT disease burden. Two patients, however, received aggressive chemotherapy pre-HCT and achieved low disease-burden state; both are long-term survivors. All four patients with detectable mutant allele burden at Day +30 post-HCT eventually progressed compared to two of nine patients with unmeasurable allele burden (P = 0.04). The 18-month event-free survival of the entire cohort was 47% (95% CI, 21-69%), and was 83% (95% CI, 27-97%) and 22% (95% CI, 03-51%) for Bu-Cy-Mel and Bu-Flu, respectively (P = 0.04). ASCT1221 was terminated early due to concerns that the Bu-Flu arm had inferior outcomes. Conclusions The regimen of Bu-Flu is inadequate to provide disease control in patients with JMML who present to HCT with large burdens of disease. Advances in molecular testing may allow better characterization of biologic risk, pre-HCT responses to chemotherapy, and post-HCT management.

An intramural ventricular septal defect (IVSD) is a type of interventricular communication that can occur following biventricular repair of a conotruncal malformation. There have been no previous reports depicting the actual pathologic anatomy of this defect. We describe two cases of IVSDs with their clinical imaging and postmortem pathology.

Over the years the authors have evaluated a number of patients with vestibular schwannomas (VS) who have also been diagnosed with a pituitary adenoma (PA). No associations between these tumors have been established to date. The objective of the current study is to investigate the epidemiological association between VS and PA via a population-based study and to supplement these data with a retrospective case series of 12 patients who were evaluated at the authors' center over the past 15 years. An analysis of the Surveillance, Epidemiology, and End Results database including all patients identified with a diagnosis of VS and/or PA was performed. A comparison between the observed and expected annual incidence was calculated and population differences between those with VS + PA were compared with single tumor populations. 9888 patients with VS and 26,577 patients with PA were identified among 822.9 million person-years. Within these populations, 31 patients were diagnosed with both tumor types. Overall, 1 in every 319 patients with VS was also diagnosed with a PA. The average annual incidence for VS was 1.2 per 100,000 persons per year while the average PA rate was 3.2 per 100,000 persons per year. The observed rate of co-incident VS and PA was greater than what is expected by chance alone assuming independence. The cohort of patients with coexisting VS and PA were older and more commonly male compared to VS-only or PA-only groups. These data strongly suggest that a common environmental or genetic predisposition exists for VS and PA development. Further study of this population may help elucidate the cause of tumorigenesis in a subset of patients with seemingly sporadic tumors.

The primary aim of this study was to examine percent excess weight loss (%EWL) across and between racial groups at 6, 12, 24, and 36 months follow-up in patients who received sleeve gastrectomy (SG) or a Roux-en-Y gastric bypass (RYGB) operation. We hypothesized that ethnic minorities (blacks and Hispanics) would have a lower %EWL than whites at 6, 12, 24, and 36 months for both SG and RYGB operations. The secondary aim was to examine %EWL within racial groups at 6, 12, 24, and 36 months as a function of the type of bariatric operation. We hypothesized that whites, blacks, and Hispanics would have a greater %EWL with RYGB than with SG.A total of 749 patients who underwent an SG or an RYGB operation from January 2008 to June 2014 were included. Data were collected from patients' electronic medical records. Self-reported data on race/ethnicity were also obtained from the electronic medical record and were classified into the following categories: white, Hispanic/Latino, African American or black, or other.Results revealed overall differences in %EWL between blacks and whites (P .05) and no overall differences in %EWL between Hispanics and whites (P = .697). Follow-up analyses revealed that Hispanics differed from blacks in %EWL at 6, 12, 24, and 36 months (all P .01) and that whites differed from blacks at 6 months (P .05). There were no significant differences between whites and Hispanics during any follow-up period. Overall, the %EWL differed by operation type (P .01), with RYGB associated with greater %EWL than SG. When stratified by race, the only difference was found in blacks, who had a greater %EWL after RYGB compared with SG (P .01).Our primary hypothesis was partially supported, as blacks but not Hispanics had a lower %EWL compared to whites at 6 months. An interesting finding is that blacks had a lower %EWL than Hispanics at every time point. Moreover, our secondary hypothesis was partially supported. Results revealed that overall RYGB was related to greater %EWL compared with SG, and within racial groups, among blacks only, RYGB was associated with a greater %EWL compared with SG.

We sought to analyze key factors that influence the management of lateral skull base defects and implement an algorithm to improve outcomes of reconstruction.Retrospective chart review.Single tertiary academic referral center.Adults who underwent temporal bone resection were included. Variables included tumor characteristics, ablative procedure, reconstructive method, and wound complications.Seventy-one patients were studied. Lateral temporal bone resection was performed in 55 patients (77%), subtotal temporal bone resection in 14 (20%), and total petrosectomy in two (3%). Primary closure was achieved in 46 patients (35%), with rotational muscle flaps in 21 (46%). The pectoralis major myocutaneous flap (PMMF) was used in nine patients (13%) without major complications. Single-stage free tissue transfer was undertaken in 10 patients (14%) with no flap failures. Primary closure was achieved in 16 of 32 of previously untreated cases (50%) compared to nine of 39 cases of previously treated disease (23%) (P = 0.03). Pedicled or free flaps were used in 18 of 39 cases of previously treated disease (46%) compared to three of 32 previously untreated cases (9%) (P0.001). Pedicled or free flaps were used in 13 of 22 cases (59%) in which partial or total auriculectomy was performed, whereas primary closure was achieved in 39 of 49 cases (80%) in which the pinna was preserved (P0.001).Advanced tumors that require adjuvant therapy, revision cases for recurrent disease, and cases involving auriculectomy warrant free flap or PMMF reconstruction, with the latter preferred in poor free flap candidates.4. Laryngoscope, 126:1911-1917, 2016.