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Introduction: Video teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature., Purpose: To develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection., Methods: This prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system., Results: In total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease., Conclusion: HDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.

Extracellular vesicles have emerged as important mediators of intercellular communication in cancer, including by conveying tumor-promoting microRNAs between cells, but their regulation is poorly understood. In this study, we report the findings of a comparative microRNA profiling and functional analysis in human glioblastoma that identifies miR-1 as an orchestrator of extracellular vesicle function and glioblastoma growth and invasion. Ectopic expression of miR-1 in glioblastoma cells blocked in vivo growth, neovascularization, and invasiveness. These effects were associated with a role for miR-1 in intercellular communication in the microenvironment mediated by extracellular vesicles released by cancer stem-like glioblastoma cells. An extracellular vesicle-dependent phenotype defined by glioblastoma invasion, neurosphere growth, and endothelial tube formation was mitigated by loading miR-1 into glioblastoma-derived extracellular vesicles. Protein cargo in extracellular vesicles was characterized to learn how miR-1 directed extracellular vesicle function. The mRNA encoding Annexin A2 (ANXA2), one of the most abundant proteins in glioblastoma-derived extracellular vesicles, was found to be a direct target of miR-1 control. In addition, extracellular vesicle-derived miR-1 along with other ANXA2 extracellular vesicle networking partners targeted multiple pro-oncogenic signals in cells within the glioblastoma microenvironment. Together, our results showed how extracellular vesicle signaling promotes the malignant character of glioblastoma and how ectopic expression of miR-1 can mitigate this character, with possible implications for how to develop a unique miRNA-based therapy for glioblastoma management.

Background: the ageing demographic means that increasing numbers of older people will be attending emergency departments (EDs). Little previous research has focused on the needs of older people in ED and there have been no evaluations of comprehensive geriatric assessment (CGA) embedded within the ED setting., Methods: a pre-post cohort study of the impact of embedding CGA within a large ED in the East Midlands, UK. The primary outcome was admission avoidance from the ED, with readmissions, length of stay and bed-day use as secondary outcomes., Results: attendances to ED increased in older people over the study period, whereas the ED conversion rate fell from 69.6 to 61.2% in people aged 85+, and readmission rates in this group fell from 26.0% at 90 days to 19.9%. In-patient bed-day use increased slightly, as did the mean length of stay., Discussion: it is possible to embed CGA within EDs, which is associated with improvements in operational outcomes.

Free-living marine nematode diversity was analyzed between Avicennia marina and Rhizophora mucronata mangrove covers of the Vellar Estuary (southeast coast of India). A total of 4,976 specimens of free-living marine nematodes were collected in 56 species. Comparatively, a higher species richness was obtained for A. marina (52 species) than for R. mucronata (44 species), whereas 40 species commonly existed in both mangrove covers. A higher density of nematodes was found in sediments of sandy nature, whereas there was lower total organic carbon compared to silt/clay composition; epigrowth feeders were dominant over the other feeding groups based on organic enrichment in surface sediments. Principal component analysis clearly explained the relationship between the environmental parameters of various months. Higher R values of analysis of similarities revealed significant differences in nematode assemblages between months, and it was quite evident by non-metric multidimensional scaling. Diversity indices showed higher values in the dry months. RELATE analysis explained serial changes in nematode species composition between months, and a relationship between biotic and abiotic variables was clarified using the BIO-ENV procedure. Viscosia spp., Metachromadora spp., Theristus spp., and Sphaerolaimus spp. were candidate species of A. marina leaf interaction by observation.

Objective: The purpose of this study is to evaluate the efficacy of a multisensory teaching approach in imparting the knowledge, skills, and confidence to manage epistaxis in a cohort of fourth year medical students., Methods: One hundred and thirty four fourth year medical students were recruited into the study from Aug 2011 to February 2012 in four groups. Students listened to an audio presentation (PODcast) about epistaxis and viewed a video presentation on the technical skills (VODcast). Following this, students completed a 5-minute Individual Readiness Assessment Test (IRAT) to test knowledge accrued from the PODcast and VODcast. Next, students observed a 10-minute expert demonstration of the technical skills on a human cadaver and spent half an hour practicing these techniques on cadaver simulators with expert guidance. The students' confidence was assessed with Confidence Level Questionnaires (CLQs) before and after their laboratory session. The skill level of a subset of students was also assessed with a pre- and post-laboratory Objective Structured Assessment of Technical Skills (OSATS)., Results: Eighty two percent of the participants achieved a score of at least 80% on the IRAT. The CLQ instrument was validated in the study. There was a statistically significant improvement between the pre- and post-laboratory CLQ scores (p<0.01) and also between pre- and post-laboratory OSATS scores (p<0.01). Qualitative feedback suggested a student preference for this teaching approach., Conclusions: This study provides further evidence that a multisensory teaching intervention effectively imparts the necessary knowledge, skill and confidence in fourth year medical students to manage epistaxis.

Mixed lineage leukemias (MLLs) are human histone H3 lysine-4-specific methyl transferases that have critical roles in gene expression, epigenetics and cancer. Herein, we demonstrated that antisense-mediated knockdown of MLL1 induced cell-cycle arrest and apoptosis in cultured cells. Intriguingly, application of MLL1 antisense specifically knocked down MLL1 in vivo and suppressed the growth of xenografted cervical tumor implanted in nude mouse. MLL1 knockdown downregulated various growth and angiogenic factors, such as HIF1α, VEGF and CD31, in tumor tissue affecting tumor growth. MLL1 is overexpressed along the line of vascular network and localized adjacent to endothelial cell layer expressing CD31, indicating potential roles of MLL1 in vasculogenesis. MLL1 is also overexpressed in the hypoxic regions along with HIF1α. Overall, our studies demonstrated that MLL1 is a key factor in hypoxia signaling, vasculogenesis and tumor growth, and its depletion suppresses tumor growth in vivo, indicating its potential in novel cancer therapy.

A new design for a compact portable lab-on-a-chip instrument based on MCE and dual capacitively coupled contactless conductivity detection (dC(4) D) is described. The instrument is battery powered with total dimension of 14 × 25 × 8 cm(3) (w × l × h), and weighs 1.2 kg. The device consists of a front electrophoresis compartment which has the chip holder and the chip, the associated high-voltage electrodes for electrophoresis injection and separation and the detector. The detection cell is integrated into the device housing with an exchangeable plug-and-play cartridge format. The design of the dC(4) D cell has been optimized for maximum performance. The cartridge includes the top-bottom excitation and pick up electrodes incorporated into the cell and connected to push-pull self-latching pins that are insulated with plastic. The metal frame of the cartridge is grounded completely to eliminate electronic interferences. The cartridge is designed to clamp a thin fluidic chip at the detection point. The cartridges are replaceable whereby different cartridges have different detection electrode configurations to employ according to the sensitivity or resolution needed in the specific analytical application. The second compartment consists of all the electronics, data acquisition card, high-voltage modules of up to ±5 kV both polarity, and batteries for 10 h of operation. The improved detector performance is illustrated by the electrophoresis analysis of six cations (NH4 (+) , K(+) , Ca(2+) , Na(+) , Mg(2+) , Li(+) ) with a detection limit of approximately 5 μM and the analysis of the anions (Br(-) , Cl(-) , NO2 (-) , NO3 (-) , SO4 (2-) , F(-) ) with a detection limit of about 3 μM. Analytical capabilities of the instrument for food and medical applications were evaluated by simultaneous detection of organic and inorganic acids in fruit juice and inorganic cations and anions in rabbit blood samples and human urine samples are also demonstrated., (© 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objective: This study sought to evaluate the efficacy of a multisensory teaching approach in imparting the necessary knowledge, technical skills, and confidence to perform a cricothyrotomy to a cohort of fourth-year medical students., Methods: One hundred twenty students were recruited into the study. Subjects commenced by viewing an upper airway obstruction vodcast. Students subsequently observed an expert demonstration of cricothyrotomy on human cadavers. Following this, students were able to practice on cadaveric simulators guided by experts. The students' confidence was assessed with pre- and post-session confidence-level questionnaires. Thirty randomly selected students were then assessed with a post-session objective skill assessment test. Finally, a multiple choice examination was administered to test knowledge., Results: Ninety-five percent of student subjects achieved a score of at least 80% on the knowledge examination. All sampled students were considered competent to perform cricothyrotomy as judged by 2independent expert observers using the objective skill assessment test instrument. There was a statistically significant improvement between the pre- and post-CLQ scores (p<0.001). In keeping with current education theories on multisensory learning, qualitative feedback suggested a student preference for this teaching approach., Conclusion: This study provides further evidence that a multisensory teaching intervention effectively improves the knowledge, skill, and confidence of fourth-year medical students in performing cricothyrotomy., (Copyright © 2013 Association of Program Directors in Surgery. All rights reserved.)

Background: An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation., Aim: This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar., Setting and Design: This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting., Materials and Methods: Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life., Statistical Analysis: Crude differences in incidence rate assessed by χ(2) or Fisher exact test were applicable., Results: Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001)., Conclusion: These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

Total organic matter (TOM) content of sediment samples collected from various depths of continental shelf region of the southeast coast of India varied from 0.19% to 7.73%. Higher TOM content and lower median particle diameter could be attributed to the influence of higher riverine flow. Higher values were observed at 100 m depth and above (average 5.29%) and lower values in shallower depths below 100 m (average 3.07%). In the Principal Coordinate Analysis (PCO), the first two axes explained about 83.1% of the total variability. The direction of the vector representing total organic matter was towards 150 m depth. In the Canonical Analysis of Principal Coordinates (CAP) done to confirm the above pattern, the canonical correlation value obtained for the first axis was high (0.9999). The same for the second axis was 0.9995. The direction of the axis representing TOM in this analysis was towards the 100 m depth truly reflecting higher TOM level recorded here (average TOM at 100 m depth-5.81% and at 150 m depth-5.33%). The percentage of samples allocated to the correct group in CAP was 91.67% (33 out of the 36 samples). As the allocation success of samples is substantially greater around 92%, the CAP is explaining greater percentage of variability of TOM than PCO and was found to be quite useful for studies of this nature.

Background: Multiple factors contribute to muscle weakness and reduced muscle mass in chronic obstructive pulmonary disease (COPD) and this impacts patients' quality of life. One factor implicated in this process is systemic inflammation, an accompaniment of acute exacerbations. Recurrent exacerbations are associated with lower health status. This study examines the relationship between muscle weaknesses, health status and exacerbation frequency in a cohort of patients with COPD., Methods: This is an observational study of 188 (95 female) patients with COPD attending two hospital clinics in the northeast of England between 2004 and 2007. We measured spirometry, body mass index, health status (St George's Respiratory Questionnaire) and grip strength and recorded Medical Research Council dyspnoea scores and the frequency of exacerbations in the previous year., Results: Patients were aged 72.5±8.3 years (data expressed as mean±SD) with Medical Research Council score of 3.6±0.8, forced expiratory volume in one second (FEV(1)) of 49.2±21.5 per cent predicted and a total St George's Respiratory Questionnaire score of 72.2±15.5. Grip strength, expressed as per cent predicted, was 72.0±21.8 in men and 81.0±18.2 in women. Exacerbations ranged from zero to five in the previous year and there were associations of reduced grip strength with exacerbation frequency (χ(2)=9.634; p=0.0019) and lower health status (χ(2)=34.00; p<0.001)., Conclusion: Our data clearly demonstrate that reduction in grip strength occurs more frequently and to a greater extent in patients with a history of frequent exacerbations and is associated with reduced health status.

Background: The great auricular nerve (GAN) originates from the cervical plexus at the levels of C2 and C3, supplying sensation to the skin overlying the lower aspect of the pinna and angle of the mandible. The GAN can be injured during many procedures in the head and neck, resulting in a significant negative impact on the patient's quality of life. There are no reliable anatomic studies of GAN in the area where it is most likely to get injured., Objective: To determine the GAN relationship to the posterior border of the platysma and the external jugular vein (EJV)., Methods: Patients undergoing neck dissections were included in the study. Measurements were taken between the posterior border of the platysma relative to the nearest edge of the EJV and the GAN. The distance between the GAN and the EJV was also noted., Results: The posterior borders of the platysma and EJV are found, on average, 0.08 cm away from each other, and the free edge of the platysma was most often posterior to the EJV. The distance from the platysma to the GAN was, on average, 0.60 cm. The distance between the EJV and the GAN was 1.17 cm., Conclusion: We have added a safe, reliable, and surgically relevant technique to the head and neck surgeon's armamentarium for identifying the GAN and avoiding attendant injury with long-term debilitating neurologic sequelae.

Wound healing has always been among important and crucial subjects in medicine. Morphine dependency has also been a social and health problem in the Middle East. This study was aimed to investigate the effects of morphine dependency on pro-inflammatory and fibroblast cell recruitment, as well as re-epithelialization and the revascularization processes involved in secondary intention wound healing in rats. A full-thickness wound (2×2 cm in diameters) was created on the dorsum of two groups of rats, a control group and a second group consisted of morphine dependent rats. During the first 14 days of post wounding the wound was excised consecutively at priorly planned days with peripheral margins of normal skin. The specimens were evaluated by two pathologists, who were blind to the study design, and the cellular population, re-epithelialization and revascularization were reported by them. Histological examination of the wound tissue showed evidence of increased population of fibroblasts and a plateau or decreased recruitment of macrophage and neutrophile cells. In the dependent group re-epithelialization was observed to be enhanced significantly in comparison to the control group while having an inhibitory effect on revascularization. The present study demonstrates that morphine dependency enhances re-epithelialization as well as tissue recruitment of fibroblasts; thereby probably enhancing secondary intention wound healing.

Background: Measured reductions in lung function, as a result of COPD, use a measured current value and make comparisons to a determined 'normal' value arrived at using a regression equation based upon a patients height. Osteoporosis is a recognised co-morbidity in patients with chronic obstructive pulmonary disease (COPD) and may cause excessive height loss resulting in the 'normal' values and disease progression being under-estimated., Purpose: The aim of the study was to examine the height variation in a cohort of COPD patients and controls over a 7-8 years period and evaluate its impact on estimates of lung function and hence COPD progression., Methods: In 1999-2002 we studied a cohort of primary care patients in Sunderland, UK with and without COPD and reexamined 104 (56 male) during 2007-2009. We calculated FEV(1)% predicted for actual and estimated height (armspan/1.03 and armspan/1.01 in males and females respectively)., Results: In 1999-2002 the subjects were aged 62.6 ± 9.4 years, BMI was 26.4± 4.7 kg/m2, predicted FEV(1) was 59.0 ±16.0, and mean actual height was 167.3±8.9cm. The actual height changed significantly (p<0.001) by 2cms over time in both genders. Whilst the overall classifications of the cohort did not change significantly when armspan was used to determine height and hence normal lung volume, individual cases did move to a classification of higher severity., Conclusions: The study suggests that current measured height may underestimate the degree of impairment of FEV(1) and hence progression of COPD. The use of height, derived from armspan, may give a more accurate measure of 'normal' lung volumes and hence the degree of impairment.

Introduction: Several complications have been reported with inguinal hernias. Although hematuria and flank pain, either as the presentation or as a complication of inguinal hernia, are infrequent, this condition may lead to the development of obstructive uropathy, which can have diverse manifestations., Case Presentation: A 71-year-old Iranian man with Persian ethnicity presented with new onset episodes of gross hematuria and left-sided flank pain. A physical examination revealed a large and non-tender inguinal hernia on his left side. An initial workup included an abdominal ultrasound, an intravenous pyelogram and cystoscopy, which showed left hydronephrosis and a bulging on the left-side of his bladder wall. On further evaluation, computed tomography confirmed that his sigmoid colon was the source of the pressure effect on his bladder, resulting in hydroureteronephrosis and hematuria. No tumoral lesion was evident. Herniorrhaphy led to the resolution of his signs and symptoms., Conclusion: Our case illustrates a rare presentation of inguinal hernia responsible for gross hematuria and unilateral hydronephrosis. Urologic signs and symptoms can be caused by the content of inguinal hernias. They can also present as complications of inguinal hernias.

A series of polyethylenimine (PEI) and γ-polyglutamic acid (PGA) nanocomposites (PPGA) was prepared and evaluated in terms of their cell viability and transfection efficiency in vitro and in vivo. On complexion with pDNA, the positively charged PPGA/DNA nanocomposites resulted in a higher level of in vitro reporter gene transfection (2.7-7.9-fold) as compared to native PEI, and selected commercial reagents and >95% cell viability in HEK293, HeLa and HepG2 cell lines. Further, PPGA-5 nanocomposite (the best working system in terms of transfection efficiency among the series) was found to efficiently transfect primary mouse keratinocytes up to 22% above the control level. PPGA-5, when tested for in vivo cytotoxicity in Drosophila, did not induce any stress in the exposed larvae in comparison with control. In vivo gene expression using PPGA-5 showed the highest transfection efficiency in spleen of mouse closely followed by heart tissues after intravenous injection through tail vein. Besides, these nanocomposites also delivered siRNA efficiently into mammalian cells, resulting in ∼ 80% suppression of EGFP expression. These results together demonstrated the potential of the projected nanocomposites for in vivo gene delivery., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Branched Polyethylenimine, 25 kDa (PEI), was blended with gellan gum, an anionic heteropolysaccharide, for partial neutralization of its excess positive charge to form gellan gum-polyethylenimine (GP) nanocomposites (NCs). Subsequently, we manipulated the amount of gellan gum for obtaining a series of NCs and characterized them for their size, charge and morphology. Among all the NCs, one member, named GP3, showed the best transfection efficiency in tested cell lines in comparison with the rest of the series, PEI, Lipofectamine and other commercial transfection agents and also exhibited minimum cytotoxicity. It was found to transfect primary cells of mouse skin with better efficiency than PEI and Lipofectamine and was able to protect the plasmid DNA from nucleases and serum proteins present in the blood. GP3 exhibited efficient intracellular delivery of plasmid as revealed by confocal studies while its intracellular presence was also confirmed by the knockdown of GFP expression (using GFP specific siRNA) and JNKII by quantifying proteins in cell lysates and by western blotting and hybridization, respectively. In vivo cytotoxicity studies in Drosophila showed lack of induction of stress response in the exposed organisms. Further, exposed organisms did not show any developmental delay or mortality and no morphological defects were observed in the emerged flies. In vivo gene expression studies in Balb/c mice revealed maximum expression of luciferase enzyme in spleen. The study suggests that GP3 may act as an efficient non-viral gene carrier with diverse biomedical applications., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: To compare complication rates after use of intermaxillary fixation (IMF) bone screws for anterior (ie, symphyseal/parasymphyseal) and posterior (ie, body and angle) mandible fractures., Methods: A retrospective analysis of isolated mandible fractures treated with intraoperative IMF bone screws at 2 major level 1 trauma centers within the Department of Otolaryngology-Head and Neck Surgery at the University of Minnesota. From January 1, 2003, through January 31, 2006, we accrued 53 patients with 67 isolated mandible fractures treated with intraoperative IMF bone screws. These patients had at least 6 weeks of follow-up., Results: Twenty-one patients had anterior mandible fractures and 32 had posterior mandible fractures. In the anterior group, there was 1 incident of wound dehiscence, resulting in a total complication rate of 5%. In the posterior fracture group, there was 1 infection (3%), 4 malunions/malocclusions (12%), and 1 nonunion (3%), for an overall complication rate of 19%. The difference between groups for malocclusion rates (12% vs 0%) was significant (P < .001)., Conclusions: The IMF bone screw system has a superior speed and safety profile. It produces better occlusion results in anterior mandible fractures and might have a lower overall complication rate compared with arch bars. Given this, IMF bone screws are the preferred modality of intermaxillary fixation in properly selected mandible fractures.

Background: Evidence-based medicine has increasingly become an integral part of clinical research and practice. The purpose of this study was to assess the trends in the level of evidence in leading facial plastic surgery journals in recent years., Methods: All scientific articles within the field of facial plastic surgery published in The Laryngoscope, Archives of Facial Plastic Surgery, Otolaryngology-Head and Neck Surgery, Journal of Plastic Surgery, and Plastic and Reconstructive Surgery from 1999, 2002, 2005, and 2008 were rated for level of evidence. The presence of p values and confidence intervals was also noted., Results: Of 975 articles reviewed, 88 percent were clinical and 88 percent were therapy articles. Overall, there was an increase in the average level of evidence of articles published from 1999 to 2008. There was also a significant increase in the proportion of articles reporting p values and confidence intervals. However, the number of articles containing level 1 or 2 evidence remains low., Conclusions: With the increased demand for evidence-based medicine, facial plastic surgery literature has seen an overall increase in the quantity of higher level evidence research published. However, articles representing level 1 and 2 evidence remain rare.

Background: Mandibular reconstruction is challenging for experienced and resident surgeons. Three-dimensional (3D) biomodeling creates accurate physical models of patients' craniofacial skeletons, which can potentially assist reconstruction. However, this capacity has not been objectively examined., Objective: The purpose of this study was to assess 3D biomodels in performing and learning mandibular reconstruction through surgical simulation., Design: Prospective cohort study., Setting: Tertiary care academic referral centre., Methods: Ten experienced and 10 naive resident surgeons were asked to bend and fixate a titanium reconstruction plate, for a standardized anterior hemimandibular defect, on a 3D biomodel by freehand or 3D biomodel-assisted means. Participants were randomized to which technique was performed first. Twenty-four to 48 hours later, participants performed the opposite technique., Main Outcome Measures: Accuracy was measured by anterior mental projection and intercondylar and interangular splay. The results per technique were compared to a complete (control) mandible. The time of reconstruction and usability of each technique, as per an International Standards Organization-based questionnaire, were also determined., Results: Three-dimensional biomodel-assisted reconstruction led to plates with statistically indifferent projection and splay compared to the control (p < .05) for both groups. Conversely, freehand constructs significantly deviated in projection and splay for either group (p < .05). No difference in reconstruction time by technique was found (p < .05). Usability favoured 3D biomodel-assisted bending, with significantly higher ratings in either group (p < .05)., Conclusions: Three-dimensional biomodels provide a usable and accurate means of mandibular reconstruction for experienced surgeons. Moreover, when used in surgical simulation, they provide an effective tool for teaching residents.

Objective: To compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting., Study Design: This was a double-blind trial including consecutive infants aged <18 months treated in an urban urgent care setting. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal) saline with epinephrine every 4 hours. The primary efficacy outcome was bronchiolitis severity score improvement at 48 hours (chi2 analysis). Scores and oxygen saturation immediately before and after each treatment were recorded to assess safety., Results: A total of 187 previously healthy infants (median age, 3.1 months) diagnosed with bronchiolitis were enrolled. Positivity for respiratory syncytial virus was similar in the 3 treatment groups (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69+/-1.09, and that for the 0.9% saline group was 4.12+/-1.11 (P=.04; difference, 0.43, 95% confidence interval for the difference, 0.02-0.88). The mean severity score for the 3% saline group was intermediate at 4.00+/-1.22. Revisit rates after discharge were similar in the 3 treatment groups. No adverse reactions or other safety concerns were identified., Conclusions: Nebulization with 5% hypertonic saline is safe, can be widely generalizable, and may be superior to current treatment for early outpatient treatment of bronchiolitis., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Vitamin D deficiency can develop very early in infancy, and be characterized by severe hypocalcemic symptoms. This study was done to determine the relation between symptomatic hypocalcemia and vitamin D deficiency in newborn infants and their mothers in the state of Qatar. This is a retrospective study for all newborns presented to the Pediatric Emergency Centers in Qatar with symptomatic hypocalcemia from 1 January 2006 to 31 December 2007. Nineteen newborn infants during the study period presented with symptomatic hypocalcemia. Vitamin D deficiency with or without relative hypoparathyroidism was the attributed cause. Vitamin D deficiency in newborn infants secondary to maternal vitamin D deficiency leading to hypocalcemic symptoms is not uncommon in the state of Qatar. Therefore, vitamin D supplementation in pregnant and lactating mothers in the state of Qatar should be considered after proper screening.

Some derivatives of benzimidazole were synthesized by nucleophilic substitution of 2-substituted-1H-benzimidazole. The resulting ethyl (2-substituted-1H-benzimidazol-1-yl) acetate on treatment with hydrazine hydrate yielded 2-(2-substituted-1H-benzimidazol-1-yl) acetohydrazide, which on further reaction with one equivalent of different aliphatic or aromatic carboxylic acids in the presence of phosphoryl chloride afforded the corresponding target compounds, 2-substituted-1-[{(5-substituted alkyl/aryl)-1,3,4-oxadiazol-2-yl} methyl]-1H-benzimidazole. The structures of the synthesized compounds were evaluated by spectral and elemental methods of analyses. All the synthesized compounds were screened for their antimicrobial activities. All of the derivatives showed good activity towards Gram-positive bacteria and negligible activity towards Gram-negative bacteria. Some of the synthesized compounds showed moderate activity against tested fungi.

The efficient synthesis of novel azetidin-2-ones 6 has been established. Thus, condensation of 5-[(2-methyl-1H-benzimidazol-1-yl)methyl]-1,3,4-thiadiazol-2-amine 4 with various aromatic aldehydes afforded 5-[(2-methyl-1H-benzimidazol-1-yl)methyl]-N-[(substituted) phenylmethylidene]-1,3,4-thiadiazol-2-amine 5 which on cycloaddition with chloroacetyl chloride in the presence of triethylamine catalyst yielded 3-chloro-1-{5-[(2-methyl-1H-benzimidazol-1-yl)methyl]-1,3,4-thiadiazol-2-yl}-4-(substituted) phenylazetidin-2-one 6. Structures of the synthesized compounds have been elucidated on the basis of their elemental analyses and spectral data. All the synthesized compounds were screened for their antimicrobial activity.

Background: Head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure with the preservation of function when deciding the patient's best treatment protocol. This task is especially difficult in cancer of the base of tongue. The purpose of this manuscript is to describe the beavertail modification of the radial forearm-free flap in base of tongue reconstruction., Methods: Thirty-one consecutive patients treated for base of tongue cancer with primary surgery were followed prospectively. The technique of the beavertail modification is described. Swallowing and speech function were assessed preoperatively and postoperatively., Results: All the flaps survived. Thirty (97%) patients started consuming oral diet within 1 year, and all had normal speech intelligibility., Conclusions: The beavertail modification of the radial forearm arm flap seems to provide the reconstructive elements that allow patients with large base of tongue extirpations to develop functional swallowing and speech production postoperatively.

Aim: Hepatobiliary scintigraphy is an integral part in the diagnostic work-up of the neonatal cholestasis syndrome. However, less than optimal specificity is its major disadvantage. Differentiation between biliary atresia and neonatal hepatitis is nearly impossible in some cases with poor hepatocellular function. 99mTc sestamibi (MIBI) is a cationic lipophilic agent which is a substrate of P-glycoprotein. This glycoprotein is normally expressed in biliary canalicular surfaces of hepatocytes. This property provides a hepatic excretory mechanism which is different from bilirubin excretion. In this study we evaluated the value of 99mTc MIBI in differential diagnosis of neonatal cholestasis., Patients, Methods: 20 infants with a mean age of 2.41 months (range, 0.1-5 months) were included in the study. Ten infants turned out to have extrahepatic biliary atresia and the other ten had neonatal hepatitis. Hepatobiliary (with 99mTc BrIDA) and 99mTc MIBI scintigraphy were performed for all the patients., Results: 99mTc MIBI scintigraphy has shown bowel activity in all patients, including the patients with biliary atresia. Hepatobiliary scintigraphy revealed bowel activity only in five patients with neonatal hepatitis., Conclusion: Bowel visualization with 99mTc MIBI may be seen in patients with biliary atresia and 99mTc MIBI has limited value in differential diagnosis of neonatal cholestasis.

Background: Dysfunction of the soft palate is devastating to the patient's quality of life, resulting in unintelligible speech and poor swallowing. Reconstruction of the soft palate is complex because the dynamic fibromuscular structure cannot be duplicated. The efficacy of soft palate reconstruction has therefore been called into question. The purpose of this article is: (1) to describe our comprehensive surgical paradigm for soft palate reconstruction, (2) to provide details of the surgical techniques used, and (3) to report on patient functional outcomes., Methods: Fifty-two patients spanning 3 different size-based categories of soft palate reconstruction were included in the final analysis. Using videofluoroscopic studies of swallowing, the presence of nasopharyngeal reflux and any instance of aspiration of a bolus into the airway was noted. In addition, a simple diet survey was completed, and the use of a g-tube was noted., Results: The results revealed that our protocol for soft palate reconstruction provided the majority of our patients with separation of the oropharynx and nasopharynx, while maintaining nasal patency. Restoration of swallowing function was timely, with 91% of the patients returning to an oral diet at the early postoperative visit and only 14% of patients demonstrating mild nasopharyngeal reflux., Conclusion: We have developed a comprehensive reconstructive protocol that provides patients with separation of the oropharynx and nasopharynx, while maintaining nasal patency. Restoration of function is timely, with reestablishment of normal intelligibility and resonance of speech as well as safe and efficient swallowing function., ((c) 2008 Wiley Periodicals, Inc.)

In this study, the use of medications for analgesia and/or sedation for incarcerated inguinal hernia reductions in the emergency department was analyzed. A retrospective chart review was conducted for all patients presenting to a pediatric emergency department with incarcerated inguinal hernia from 2002 to 2005. A total of 99 children presented with incarcerated hernias during the study period. The median age was 11 months. Forty-four percent of children received medication for the procedure, of them 75% received parenteral and 25% oral or intranasal medications. Forty-five percent of children who received medication went through at least 1 hernia reduction attempt initially without medications. More than half the children with incarcerated inguinal hernias did not receive any medication for pain and/or sedation prior to hernia reduction. Guidelines for medication use for children with incarcerated inguinal hernias need to be developed.

Objective: The purpose of this article is to review and document the differing methods of functional outcome measurements following treatment for oral and oropharyngeal carcinoma., Study Design: Literature review., Methods: Articles were identified using the MEDLINE database search engine. The "Methods" sections of relevant articles were then reviewed, and functional outcomes assessment methods were tabulated., Results: We identified 60 articles published in the last 7 years (2000-2007) that reported on functional outcomes following treatment for oral or oropharyngeal cancer. Twenty-three studies used quality of life questionnaires and 12 used clinical observations to describe function. Swallowing was assessed objectively in 29 studies, with videofluoroscopic swallowing studies as the primary method of assessment. Speech was assessed in only 10 articles, with perceptual analysis used as the primary assessment modality., Conclusions: Preserving good speech and swallowing function following treatment for oral and oropharyngeal cancer remains an extremely important aspect of cancer care. Nevertheless, there is a clear lack of uniform methods for assessing functional outcomes. We propose that functional outcome studies should include both objective and subjective assessments of swallowing and speech to gain sufficient information on posttreatment function.

To assess the risk for venous thrombo-embolism (VTE) and the utilisation of VTE prophylaxis in an open medical-surgical intensive care unit (ICU), patients were admitted and enrolled to the ICU at a multispecialty, tertiary care teaching hospital in Mumbai, for an observational study during a 3-month period. Risk factors for VTE and methods of VTE prophylaxis used were noted. Risk stratification was done, and the consultants attending the ICUs filled a questionnaire about VTE awareness, preferences and usage of VTE prophylaxis methods and reasons for not using thromboprophylaxis. Of 580 admissions, 488 were included in the study. As per the risk stratification, thromboprophylaxis was indicated in 466 (95%). The study group had an average VTE risk of 5.74, with a mean risk of 6.48 in medical patients and 5.0 in surgical patients. The most common risk factors in medical patients were bed rest >72 hours (56%), age >60 years (49.6%) and age 40-60 years (38.4%). Among surgical patients, the most common risk factors were major surgery (80.25%), central venous access (59.24%) and age 40-60 years (46.6%). Overall, VTE prophylaxis was used in 229 patients (47%), with 127 (55%) medical and 102 (45%) surgical patients. The most common methods of VTE prophylaxis used were elastic stockings (24.2%), low molecular weight heparin (15%) and low molecular weight heparin and stockings both (9.6%). Fear of bleeding was the commonest reason cited for the underutilisation of VTE prophylaxis. Almost half of all high-risk patients admitted to the ICU didn't receive any thromboprophylaxis. Consistent practice patterns of ICUs, and continuing medical education programmes addressing VTE prophylaxis will help improve the usage of VTE prophylaxis.

Background: Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures., Objectives: The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture., Methods: This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (

Squamous cell carcinoma of the head and neck is a rare cause of humoral hypercalcemia of malignancy. This paraneoplastic syndrome is usually one of the presenting symptoms of the disease. We report a case of squamous cell carcinoma of the oral cavity that presumably elaborated parathyroid hormone-related peptide (PTH-rP) and caused hypercalcemia only after radiotherapy and chemotherapy.

Introduction: Frontal sinus obliteration continues to be the gold standard for frontal disease control and is often employed as a last resort of treatment after more conservative therapies fail. Different methods of sinus mapping have been previously reported and include (1) 6-foot Caldwell radiography, (2) sinus probing, and (3) sinus transillumination. Image-guided technology was recently introduced to clinical practice, but its utility in frontal sinus mapping has not been evaluated., Objective: To assess the accuracy and safety of the previously reported methods of frontal sinus mapping and compare them with image-guided mapping., Study Design: Five cadaveric heads were used. The four mapping methods were applied to each head along five different axes of the frontal bone: 0, 45, 90, 135, and 180 degrees. The true frontal sinus margin was ascertained. Measurements were made from the true sinus limits to the margin points estimated by the four frontal sinus mapping methods., Results: The image-guided mapping method provided was the most accurate when compared with the other mapping methods (p < .01). The image-guided mapping method was also the least likely to overshoot the real margin compared with the other mapping methods (p < .001). The template method was the least accurate and least safe method., Conclusions: Image-guided mapping is the most accurate and safest method of mapping the frontal sinus margins.

We investigated the effects of pertussis toxin treatment on acetylcholine-induced desensitization of the muscarinic contractile response in guinea pig ileum. Incubation of the isolated ileum with acetylcholine (30 microM) for 20 min caused a decrease in the sensitivity of the ileum to the contractile action of the muscarinic agonist oxotremorine-M. This desensitization was characterized by an increase in the EC(50) value of oxotremorine-M without a change in its maximal effect. A maximal 4- to 5-fold increase in the EC(50) value of oxotremorine-M was measured at the earliest time investigated after acetylcholine treatment (5 min), and normal sensitivity recovered within approximately 20 min after washout of acetylcholine. Treatment of the ileum with pertussis toxin caused a small increase in the contractile response to oxotremorine-M when measured without prior exposure to acetylcholine. After exposure to acetylcholine, little desensitization was observed in ilea that had been treated with pertussis toxin. Pertussis toxin-treatment caused a small increase in oxotremorine-M-mediated phosphoinositide hydrolysis and a large decrease in oxotremorine-M-mediated inhibition of forskolin-stimulated cAMP accumulation in slices of the longitudinal muscle of the ileum. Exposure of the ileum to acetylcholine had no desensitizing effect on the ability of oxotremorine-M to elicit phosphoinositide hydrolysis, indicating that the mechanism for desensitization of the contractile response occurs at a level downstream from the receptor and phosphoinositide hydrolysis. Our results suggest that activation of muscarinic receptors coupled to pertussis toxin-sensitive G(i) and G(o) is required for most of the desensitization observed in this study.

We have studied the role of M(2) and M(3) muscarinic receptors in acetylcholine-mediated desensitization of the contractile response to histamine in the guinea pig ileum. Treatment of the isolated ileum with acetylcholine (30 microM) for 20 min caused a marked desensitization of the contractile response to histamine. When measured 5 min after washout of acetylcholine, the EC(50) value of histamine increased 5.8-fold compared with that estimated before acetylcholine treatment, whereas the maximal response was unaffected. This shift in the EC(50) value of histamine was maximal at the earliest time measured after acetylcholine treatment (5 min), and normal sensitivity recovered in approximately 20 min. Acetylcholine-induced desensitization was prevented by uncoupling of M(2) receptors from G(i) with pertussis toxin or by selective inactivation of M(3) receptors with N-2-chloroethyl-4-piperidinyl diphenylacetate (4-DAMP mustard). The shifts in the EC(50) values of histamine measured 5 min after acetylcholine treatment were only 2.0- and 1.8-fold in pertussis toxin- and 4-DAMP mustard-treated ilea, respectively. Both pertussis toxin- and 4-DAMP mustard-treatment had little or no effect on histamine-induced contractions in control ileum. Measurement of histamine-stimulated inositol phosphate accumulation in the longitudinal muscle of the ileum showed little or no inhibitory effect of prior exposure to acetylcholine, indicating that the majority of the heterologous desensitization occurs downstream from phospholipase Cbeta activation. Collectively, our results suggest that activation of both M(2) and M(3) receptors is required for heterologous desensitization of histamine-mediated contractions in the guinea pig ileum.

Ten patients, predicted to pose a difficult intubation of the trachea, underwent inhalational induction of anaesthesia using sevoflurane. In all 10 cases the airway was secured successfully and the patient proceeded to have the planned operation. In six of the cases the anaesthetist experienced a problem during the induction but in no case did this present any real difficulties or lead to a critical incident. We feel that sevoflurane has a place for inhalational induction in this challenging group of patients.

Free radicals are normally produced as a by-product of cellular metabolism. Free radicals are capable of killing bacteria, damage biomolecules, provoke immune response, activate oncogens, cause atherogenesis and enhance ageing process. However, in healthy conditions nature has endowed human body with enormous antioxidant potential. Subtle balance exists between free radical generation and antioxidant defence system to cope with oxidative stress by various enzymes and vitamins at cellular level which prevent the occurrence of disease. However, factors tilting the balance in favour of excess free radicals generation lead to widespread oxidative tissue damage and diseases. Therefore, trouble starts when there is an excess of free radicals and the defence mechanism lags behind. Overwhelming production of free radicals in response to exposure to toxic chemicals and ageing may necessitate judicious antioxidant supplement to help alleviate free radical mediated damage.

Analysis of the admission patterns in a leprosy referral hospital during the last 27 years (1966 through 1993) shows a decrease in the number of annual admissions since 1987. While there were 1550 admissions during 1981-1983, only 842 patients were admitted during 1991-1993. There was no great change in the reasons for admission, about 46% for reactions, 37% for ulcers, 5% for neuritis and about 12% for other problems. However, compared to the pre-MDT days, admissions for neuritis have increased. A case is made for the continuation of special leprosy referral hospital even beyond the year 2000 AD, i.e., even after elimination of leprosy as a public health problem.

The present study comprised 50 cases of normal vaginal delivery and 50 cases of caesarean section. The cord blood level of immunoglobulin G was significantly higher in normal vaginal delivery cases than in caesarean section cases (mean level is 1653.2 +/- 443.1 mg/dl and 898.3 +/- 415.6 mg/dl respectively). The immunoglobulin G was low in cord blood but had higher concentration in all the 7 cases in study group who had fever with rigor in antenatal period. Thus the babies delivered with caesarean section had lower immunoglobulin level than normal vaginal delivery.

Interaction of frusemide and digitalis on frog heart has been studied. It was found that like digitalis, frusemide did not have any effect on normal heart, but restored the normal myocardial contraction of the hypodynamic frog heart. Frusemide induced cardiac arrest when administered during digoxin infusion. It is suggested that interaction of frusemide and digoxin has additive effect.

The role of monoamine oxidase B (MAO-B) in R(-)-deprenyl-mediated rescue of rat facial motoneurons axotomized at postnatal day 14 (P14) was investigated using the (+)- and (-)-enantiomers of deprenyl [S(+)-deprenyl and R(-)-deprenyl]. Previously, doses of R(-)-deprenyl sufficient to inhibit MAO-B were shown to increase the survival of motoneurons following an apparent loss of target-derived trophic support caused by axotomy in P14 rats. In the present experiments, motoneuronal survival was measured 21 d after unilateral facial nerve transection at P14. The animals were treated with saline or doses of R(-)- or S(+)-deprenyl ranging from 0.001 to 10 mg/kg every 2 days (/2d). Frontal serial 10 microns sections were taken through the length of the facial nuclei ipsilaterally and contralaterally to the facial nerve transections. Every third section was immunoreacted for an antibody against ChAT to identify the motoneuron somata, while every adjacent third section was Nissl stained to assess motoneuronal survival. A second series of P14 rats was treated with similar doses of the two deprenyl enantiomers or saline and the brainstems removed for measurement of MAO-A and MAO-B activity at 4 hr after the treatments. Averages of 24% of the facial motoneurons survived axotomy with either saline treatment or 0.001 mg/kg/2d doses of R(-)-deprenyl. Doses of R(-)-deprenyl of 0.005, 0.01, and 10.0 mg/kg/2d increased the surviving facial motoneuron to 38%, 51%, and 48%, respectively, indicating an ED50 of about 0.005 mg/kg/2d. Doses of S(+)-deprenyl as high as 10 mg/kg/2d did not increase motoneuronal survival, revealing a stereospecificity for the increased survival of at least 2000-fold. The ED50 for MAO-B inhibition in the P14 brainstem was approximately 0.1 mg/kg for the (-)-enantiomer and 2.0 mg/kg for the (+)-enantiomer, revealing a 20-fold higher sensitivity of the enzyme toward the (-)-enantiomer in the P14 rat brainstem. A dose of 10 mg/kg of S(+)-deprenyl inhibited about 65% of brainstem MAO-B activity without increasing motoneuronal survival, whereas 0.005 and 0.01 mg/kg of R(-)-deprenyl increased motoneuronal survival without significant inhibition of brainstem MAO-B activity.(ABSTRACT TRUNCATED AT 400 WORDS)