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Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

Objective . The common spatial patterns (CSP) algorithm is an effective method to extract discriminatory features from electroencephalography (EEG) to be used by a brain-computer interface (BCI). However, informed selection of CSP filters typically requires oversight from a BCI expert to accept or reject filters based on the neurophysiological plausibility of their activation patterns. Our goal was to identify, analyze and automatically classify prototypical CSP patterns to enhance the prediction of motor imagery states in a BCI. Approach . A data-driven approach that used four publicly available EEG datasets was adopted. Cluster analysis revealed recurring, visually similar CSP patterns and a convolutional neural network was developed to distinguish between established CSP pattern classes. Furthermore, adaptive spatial filtering schemes that utilize the categorization of CSP patterns were proposed and evaluated. Main results . Classes of common neurophysiologically probable and improbable CSP patterns were established. Analysis of the relationship between these categories of CSP patterns and classification performance revealed discarding neurophysiologically improbable filters can decrease decoder performance. Further analysis revealed that the spatial orientation of EEG modulations can evolve over time, and that the features extracted from the original CSP filters can become inseparable. Importantly, it was shown through a novel adaptive CSP technique that adaptation in response to these emerging patterns can restore feature separability. Significance . These findings highlight the importance of considering and reporting on spatial filter activation patterns in both online and offline studies. They also emphasize to researchers in the field the importance of spatial filter adaptation in BCI decoder design, particularly for online studies with a focus on training users to develop stable and suitable brain patterns., (© 2021 IOP Publishing Ltd.)

Background: Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival., Methods: Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay., Results: Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity., Conclusion: This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients., Level of Evidence: Diagnostic Test, level III.

Every patient is different and has the potential to respond unfavorably to anesthetic and surgical intervention. Preparation is the key to optimizing patient outcome., (Copyright © 2017 Elsevier Inc. All rights reserved.)

An OMS office is a complex environment. Within such an environment, a diverse scope of complex surgical procedures is performed with different levels of anesthesia, ranging from local anesthesia to general anesthesia, on patients with varying comorbidities. Optimal patient outcomes require a functional surgical and anesthetic team, who are familiar with both standard operational principles and emergency recognition and management. Offices with high volume and time pressure add further stress and potential risk to the office environment. Creating and maintaining a functional surgical and anesthetic team that is competent with a culture of patient safety and risk reduction is a significant challenge that requires time, commitment, planning, and dedication. This article focuses on the role of simulation training in office training and preparation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Dental procedures are often performed on patients who present with some level of medical fragility. In many dental schools, the exercise of taking a medical history is all too often a transcription of information to the dental chart, with little emphasis on the presurgical risk assessment and the development of a treatment plan appropriate to the medical status of the dental patient. Changes in dentistry, driven by an increasingly medically complex population of dental patients, combined with treatment advances rooted in the biomedical sciences necessitate the adaptation of our dental education to include a stronger background in systemic health. Many predoctoral educators in the American Association of Oral and Maxillofacial Surgeons (AAOMS) have expressed concern about the medical preparedness of our dental students; therefore, the AAOMS and its Committee on Predoctoral Education and Training have provided recommendations for improving the medical curriculum in predoctoral dental education, including a strengthening of training in clinical medicine and biomedical sciences, with specific recommendations for improved training of our dental students and dental faculty., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

There are multiple systemic diseases that have an impact on coagulation, of which oral and maxillofacial surgeons must be cognizant. Recent evidence has supported the potential for both hypocoagulable and hypercoagulable states in patients with liver and kidney disease with an even less understood impact on prolonged bleeding in the oral cavity. These systemic diseases are not limited to diseases affecting the liver, kidney, and bone marrow; however, these diseases are common among the patient population and surgeons must be capable of making appropriate judgment and modifying care appropriately., (Published by Elsevier Inc.)

Platelet abnormalities result from a wide range of congenital and acquired conditions, which may be known or unknown to patients presenting for oral maxillofacial surgery. It is critical to obtain a thorough history, including discussion of any episodes of bleeding or easy bruising, to potentially discern patients with an underlying platelet disorder. If patients indicate a positive history, preoperative laboratory studies are indicated, with potential referral or consultation with a hematologist. Appropriate preoperative planning may reduce the risk of bleeding associated with platelet dysfunction, potentially avoiding serious perioperative and postoperative complications., (Published by Elsevier Inc.)

Purpose: Video laryngoscopy (VL) is an innovation in tracheal intubation that could be beneficial in an emergency situation. However, the technique could be detrimental if it prolongs intubation performed by an inexperienced physician. The purpose of this study was to compare direct laryngoscopy (DL) with VL skill for oral and maxillofacial surgery (OMS) residents and practitioners to assess the practicality of recommending the inclusion of VL as a component of OMS emergency airway management., Materials and Methods: To address the research purpose, the authors designed and implemented a randomized crossover study investigating the performance of OMS residents and practitioners to intubate a mannequin using DL versus VL. The predictor variables were the experience level of the participants and their ability to intubate with DL and with VL. The outcome variables were time to view cords, the Cormack-Lehane glottis view achieved, the time to intubate the mannequin, and the total time for performing laryngoscopy and intubation. Comparisons of laryngoscopy and intubation and resident and practitioner experiences were compared using Cox proportional hazards survival analysis., Results: Data from 22 OMS residents and 26 practitioners were assessed. The comparison outcomes between DL and VL showed that the time to view cords was shorter for VL, the Cormack-Lehane glottis view was better for VL, the time to intubate was shorter for DL, and the total time between techniques was not statistically different. OMS practitioners showed better times than OMS residents and showed adeptness with VL that was comparable to DL., Conclusion: The combined findings with OMS residents and practitioners showed comparable total intubating times between DL and VL, which is consistent with what has previously been reported with other medical colleagues., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists., Methods: The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics., Results: Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month., Conclusions: Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care., Practical Implications: Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management., (Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: When the future status of dentistry is considered, scholarship in the profession plays a key role. It is by scholarship that dentistry distinguishes itself as a learned and esteemed profession, and this position paper aims to explore and promote this vital core value., Methods: As Fellows of the American Dental Education Association's selective Leadership Institute, the authors spent over a year critically examining the role of scholarship in dentistry, which was identified as a critical issue for the profession. A review of the health care literature was conducted to inform this paper's position., Results: Scholarship is clearly the trait that distinguishes a profession from a trade, as evidenced by trends in other health care professions, as well as dentistry. Although dentistry is a learned profession rightly meriting that distinction, there are a few notable areas that can be improved., Conclusions: Because scholarship defines a profession, dentists as doctors and the leaders in oral health should demonstrate the highest scholarship; absence of scholarship risks perception of dentistry as a trade. All dentists can consistently manifest scholarship by integrating basic science, as well as by incorporating the dental evidence-base, into daily practice., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This article presents an overview of the role of an acute care nurse practitioner (ACNP) in an acute care setting caring for patients with cardiovascular issues. Discussion includes the evolution of the ACNP role, the consensus model for advanced practice registered nurse regulation, and a case study highlighting the role of the ACNP while caring for a hemodynamically unstable patient. The case study articulates the ACNP's role as liaison between the patient, family members, collaborating physicians, and nurses., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Induction of a T cell mediated immune response is critical for the eradication of viral infections and tumours. Soluble peptide-loaded major histocompatibility complex-Ig ((pep-)MHC-Ig) have been shown to bind their cognate ligands, T cell receptor, with high affinity, and are successfully used to visualize antigen-specific T cells. Furthermore, immobilized (pep-)MHC-Ig can activate and expand antigen-specific T cells in vitro and in vivo. In this study, we investigate the use of (pep-)MHC-Ig as a potential strategy to modulate antigen specific T cell immune responses in vivo. (SIY-)K(b)-Ig immunization, together with the pre-activation by an anti-CD40 monoclonal antibody, is able to stimulate a strong expansion of adoptively transferred 2C transgenic T cells and the formation of long term antigen-specific memory T cells. In addition, mechanistic studies show that the (pep-)MHC-Ig molecules directly activate T cells in vivo without requiring uptake and reprocessing by antigen-presenting cells. Furthermore, B6 mice immunized with (pep-)MHC-Ig molecules inhibit tumour growth in a B16-SIY melanoma prevention model. Thus, soluble (pep-)MHC-Ig molecules represent a powerful tool for active immunotherapy.

Myasthenia gravis (MG) is an uncommon autoimmune disorder presenting with fluctuating, progressive muscle weakness. The typical initial presentation includes ocular symptoms of ptosis, diplopia, or both. In the literature, other late symptoms have been described. The inability to close the jaws or difficulty in closing the jaws is an uncommon symptom of muscle weakness. Studies have found that only 4% of patients with MG ever complain of, or demonstrate, masticatory muscular weakness with an inability to close the jaws or difficulty in closing the jaws. In the present case, although the patient may have manifested other symptoms, his primary complaint was the inability to masticate as a result of muscular weakness and the difficulty in closing the jaw. The symptoms had reportedly been present for several months. The case is interesting in that the patient presented with an uncommon symptom as the primary complaint. The patient's recall and communication of his medical history was poor, and it is unclear as to all the factors that may have delayed the diagnosis. However, it is important for dentists to recognize these atypical symptoms of MG so that they can either order the initial tests or make the appropriate referral., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Surgical education is in a period of significant change. Assessment of surgical competency is imprecise compared with cognitive knowledge and judgment. A surgical competency measurement tool may be useful for plastic surgery training programs and certification societies. We present a validation study of a novel measurement instrument for arch bar placement and dental wire handling., Methods: An Arch Bar Placement Assessment Scale (ABPAS) was created via consensus by 2 craniofacial and 2 maxillofacial surgeons. Residents and faculty members of plastic and maxillofacial surgery (n = 20) then placed an arch bar on the lower jaw of a skull model. Performances were video recorded without revealing identities. Two study groups were created based on subjects experience level: group 1 (n = 10) previously placed fewer than 25 arch bars; group 2 (n = 10) previously placed more than 25 arch bars. Two craniofacial surgeons used the ABPAS to blindly grade surgical performance., Results: The ABPAS consisted of a 48-point rating scale that included a 23-point task-specific work list and a 25-point global rating scale. Pearson coefficient showed limited intraobserver (P = 0.97) and interobserver (P = 0.95) variance of test scores. The ABPAS demonstrated superior performance in group 2 in the task-specific work list [12.6 (5.5) vs 17.6 (1.5), P = 0.02], global rating scale [17.4 (4.4) vs 22 (2.1), P = 0.01], and ABPAS score [30 (9.8) and 39.6 (3.2), P = 0.01]., Conclusions: The ABPAS is a novel measurement tool which assesses technical surgical skill and can identify surgical competency in arch bar placement and dental wire handling. This tool may have future use in residency training and continuing education.

Background: A significant number of individuals suffer from plantar heel pain (PHP) and many go on to have chronic symptoms and continued disability. Persistence of symptoms adds to the economic burden of PHP and cost-effective solutions are needed. Currently, there is a wide variation in treatment, cost, and outcomes of care for PHP with limited information on the cost-effectiveness and comparisons of common treatment approaches. Two practice guidelines and recent evidence of effective physical therapy intervention are available to direct treatment but the timing and influence of physical therapy intervention in the multidisciplinary management of PHP is unclear. The purpose of this investigation is to compare the outcomes and costs associated with early physical therapy intervention (ePT) following initial presentation to podiatry versus usual podiatric care (uPOD) in individuals with PHP., Methods: A parallel-group, block-randomized clinical trial will compare ePT and uPOD. Both groups will be seen initially by a podiatrist before allocation to a group that will receive physical therapy intervention consisting primarily of manual therapy, exercise, and modalities, or podiatric care consisting primarily of a stretching handout, medication, injections, and orthotics. Treatment in each group will be directed by practice guidelines and a procedural manual, yet the specific intervention for each participant will be selected by the treating provider. Between-group differences in the Foot and Ankle Ability Measure 6 months following the initial visit will be the primary outcome collected by an independent investigator. In addition, differences in the European Quality of Life--Five Dimensions, Numeric Pain Rating Scale, Global Rating of Change (GROC), health-related costs, and cost-effectiveness at 6 weeks, 6 months, and 1 year will be compared between groups. The association between successful outcomes based on GROC score and participant expectations of recovery generally, and specific to physical therapy and podiatry treatment, will also be analyzed., Discussion: This study will be the first pragmatic trial to investigate the clinical outcomes and cost-effectiveness of ePT and uPOD in individuals with PHP. The results will serve to inform clinical practice decisions and management guidelines of multiple disciplines., Trial Registration: ClinicalTrials.gov: NCT01865734.

Background Context: Dysphagia is common in the early postoperative period after anterior cervical discectomy and fusion (ACDF). Several mechanisms, including soft-tissue swelling, have been implicated as a cause of postoperative dysphagia., Purpose: To determine whether anterior soft-tissue swelling is greater in patients with postoperative dysphagia., Study Design: Prospective cohort study., Patient Sample: Forty-three patients., Outcome Measures: Validated dysphagia questionnaire, lateral cervical spine radiographs., Methods: Patients undergoing one- or two-level ACDF using allograft bone and anterior instrumentation were enrolled. Baseline patient demographic characteristics and history were recorded. A dysphagia questionnaire, including a dysphagia numeric rating scale (DNRS; range, 0-10), was administered preoperatively and 2 and 6 weeks postoperatively. Lateral cervical radiographs were obtained preoperatively and 2 and 6 weeks postoperatively. The anterior cervical soft-tissue shadow width was measured at each level. Patients were divided into groups based on the 2-week dysphagia questionnaire: Group 1 (no symptoms/mild dysphagia) and Group 2 (moderate/severe dysphagia). Anterior soft-tissue shadow width at each level was compared between groups. Correlation was used to assess the relationship between DNRS and anterior soft-tissue swelling., Results: Forty-three patients (24 females; average age, 47.9) were enrolled. Fifteen patients had one-level and 28 patients had two-level ACDF. The anterior soft-tissue shadow width increased significantly from preoperative values at all levels except C1 at 2 and 6 weeks and C2 at 6 weeks. At 2 weeks, 18 patients had no symptoms/mild dysphagia (Group 1) and 25 patients had moderate/severe dysphagia (Group 2). The average DNRS was 1.1 for Group 1 and 5.3 for Group 2 (p<.001). This difference decreased by 6 weeks but remained significant. There were no significant differences in the soft-tissue measurements between groups at any level. There was no significant correlation between the DNRS and anterior soft-tissue swelling at any time point., Conclusions: There is a significant increase in anterior cervical soft-tissue swelling after ACDF. The width of prevertebral soft-tissue does not correlate with postoperative dysphagia., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The negative compatibility effect (NCE) is the surprising result that low-visibility prime arrows facilitate responses to opposite-direction target arrows. Here we compare the priming obtained with simple arrows to the priming of emotions when categorizing human faces, which represents a more naturalistic set of stimuli and for which there are no preexisting response biases. When inverted faces with neutral expressions were presented alongside emotional prime and target faces, only strong positive priming occurred. However, when the neutral faces were made to resemble the target faces in geometry (upright orientation), time (flashing briefly), and space (appearing in the same location), positive priming gradually weakened and became negative priming. Implications for theories of the NCE are discussed.

Aquatic macroinvertebrates were collected from five sites in the Neversink Reservoir Watershed in Sullivan County, New York: Aden Brook, Biscuit Brook, Main Branch, Tison and Winnisook, and examined for gill abnormalities. The Neversink Reservoir is part of the New York City water supply system and is located in the Catskill Mountains. Total mercury and methylmercury concentrations were measured by the New York State Department of Environmental Conservation (NYSDEC) in composite samples of macroinvertebrates at the five sites and ranged from 13.6 to 20.9 ng/g total mercury and 2.4-9.8 ng/g methylmercury. Gill deformities in the organisms were evident from each sampling site. These were observed as puckering or dimpling of the gill lamellae and interior spotting. The greatest percentage of gill morphological abnormalities were from invertebrates at the Main Branch site where 28% of invertebrate gills exhibited abnormalities. This site had the highest mercury/methylmercury concentration in composite invertebrate samples. Macroinvertebrates from a reference location showed little evidence of gill abnormalities. Other factors may have contributed to the abnormalities such as dissolved oxygen, pH, temperature, other contaminants, and/or stream profiles.

Botox (Botulinum toxin A) has wide public recognition as a cosmetic agent. It has also established a firm foothold within the medical community for the treatment of a wide range of myospastic disorders. With imaging guidance, interventional radiologists can deliver this medication to a variety of otherwise difficult to reach targets with high accuracy and with minimal complications. We illustrate the use of Botox in interventional radiology by describing our fluoroscopic technique for the treatment of piriformis syndrome. The key to successful Botox therapy of myospastic disorders is accurate clinical diagnosis. Excellent communication and rapport with the referring clinicians is therefore essential to maximize the likelihood of a successful outcome. The range of services offered by interventional radiologists continues to evolve. With the recent growth of endovenous treatment for varicose veins, some have found it necessary to provide sclerotherapy for spider veins. As patients become accustomed to receiving these cosmetic treatments from interventionalists, they may come to us for advice about other esthetic therapy. The idea of some interventional radiologists adding cosmetic medicine to their practice should, therefore, not seem unreasonable. We illustrate the use of Botox for facial rejuvenation by describing our technique for the treatment of glabelar (frown) lines. Before entering into this type of practice, it is critical to obtain adequate and appropriate training for each cosmetic intervention. If possible, the interventionalist should seek to establish a mentor relationship with someone highly experienced in cosmetic medicine.

Surprisingly, singing and music sometimes are connected with poor or even lethal outcomes. One example is personified in the legend of Orpheus, who through the power of his songs, succeeded in leading the wild Thracians into the Greek religion. This did not save him, however, from being murdered by Thracian women probably because of his paedophilic tendency. The scene has been illustrated since 490 BC on Attic red-figure vases. The Sirens, with the body of a bird and the head of a female and dwelling in the Sicilian Sea, were creatures who attracted sailors by their song and devoured the unhappy wretches who had been unable to resist their seductive singing. This topic has also been depicted on ancient Greek vases as part of the Odyssey. The idea that beautiful singing with an instrument can also be a symbol of sin and a sign of the devil is deeply rooted in Christian thinking. This aspect of music as the power of evil is extensively depicted in Dutch and Flemish genre paintings where singing and playing string instruments were also common symbols of lust and vices, seduction and, therefore, moral decay. Some examples of the power of evil in singing in representative art are presented in this article., ((c) 2005 S. Karger AG, Basel)

Purpose: To compare computed tomography (CT) in the sagittal plane and plain film radiography in the diagnosis of scaphoid fracture and displacement., Methods: Three groups of scaphoids (no fracture, undisplaced fractures, fractures with displacement > 1 mm) from 11 cadaver wrists were prepared. Each wrist then was imaged by using sagittal plane CT scans in the long axis of the scaphoid and plain film imaging using 6 standard scaphoid views. Eight readers from 3 specialties read each group of images. The sensitivity and specificity for the presence of fracture and fracture displacement were calculated in addition to interobserver and intraobserver reliabilities for each., Results: Both x-ray and CT scans showed a high sensitivity and specificity in detecting the presence of a fracture with no interspecialty differences. The sensitivity for displacement greater than 1 mm was lower for both modalities with no inter-specialty differences. The specificities for x-ray and CT for detecting displacement greater than 1 mm were 84% and 89%, respectively. The poor sensitivity for detecting displacement was explained by the low sensitivity of CT in the diagnosis of radial/ulnar displacement compared with x-ray and the low sensitivity of x-ray in the diagnosis of volar/dorsal displacement compared with CT scans. When fellowship-trained hand surgeons reviewed CT scans and plain films together the sensitivity and specificity for fracture displacement increased significantly. Intraobserver and interobserver reliability for both x-ray and CT scans was excellent except for the reading of CT scans among emergency physicians and for the reading of plain x-rays among senior house staff, representing moderate agreement., Conclusions: Based on these results both CT scans in the sagittal plane and plain films accurately detect fractures with a high degree of interobserver and intraobserver reliability, but they fall short in detecting displacement greater than 1 mm.

The objectives of this study were to identify the presence/absence and location of any embolic material and to describe the morphologic appearance of the leiomyoma and adjacent tissues of cases undergoing surgical intervention following uterine artery embolization (UAE) for leiomyomas. A total of 555 women underwent UAE using polyvinyl alcohol particles (PVA) in a multicenter clinical trial. The histopathologic slides from 17 of 18 women who subsequently underwent myomectomy or hysterectomy in the follow-up period (median 8.2 months) were reviewed without knowledge of the indication for surgery or time elapsed since UAE. The presence/absence and distribution of PVA emboli, associated inflammatory response, and necrosis were noted. Necrosis of leiomyoma(s) was classified as hyaline-type, coagulative tumor cell necrosis, and/or acute suppurative necrosis. In all cases PVA emboli were identified within smooth muscle tumors of the uterine body, its periphery, cervix, uterine body, myometrium, and/or the adnexa. A florid foreign body giant cell type of chronic inflammatory reaction was seen within 1 week of UAE and persisted with visible PVA for up to 14 months post-UAE. Typically, post-UAE leiomyomas showed hyaline-type, but rarely coagulative tumor cell necrosis and acute suppurative necrosis could be seen as well. Five of eight cases coming to surgery for complications showed necrotizing endomyometritis with tissue infarction. PVA particles are recognizable in post-UAE specimens. Leiomyoma necrosis is typically of the hyaline type; coagulative tumor cell necrosis was rarely seen. In some cases with complications, uterine and/or cervical necrosis occurred. The applicability of these findings for UAE patients who have been successfully treated and not resected is uncertain.

Objective: The hemodynamic effects of local anesthetic administration with and without a vasoconstrictor were compared by using laser Doppler flowmetry., Study Design: Seventeen people participated in a single study session in which they were given 2 intraoral injections. The injections, which were administered in random order, consisted of 1.8 mL lidocaine (2%) with epinephrine (1:100,000) and mepivacaine (3%). Hemodynamic parameters consisting of blood pressure, heart rate, and laser Doppler flowmetry were reordered at regular intervals., Results: The laser Doppler flowmeter detected changes in the peripheral perfusion of the finger that were not detected by changes in blood pressure and heart rate. The greatest change was associated with anxiety and occurred just before the injection. The inclusion of epinephrine in the local anesthetic resulted in a persistence of these changes., Conclusion: This investigation has confirmed the sensitivity of laser Doppler flowmetry as an investigational tool for assessing hemodynamic changes associated with anxiety and the administration of local anesthesia.

Mutations in the ATM gene, which maps to 11q22-23, cause the multisystem recessive syndrome ataxia-telangiectasia (AT). Breast cancer has been reported in AT patients and carriers. Sporadic breast cancer is associated with loss of heterozygosity at or in the region of ATM and chromosomal abnormalities involving 11q23. We have investigated the chromosomes, nuclei and released chromatin fibers from nine primary breast carcinoma and eight cell lines by fluorescence in situ hybridization with four fluorochrome-labeled cosmids spanning the ATM gene. The ATM gene was disrupted in one primary breast carcinoma and in the cell lines MDA-MB-231 and MCF-7. The role of these aberrations in breast carcinomas, which may lead to gene dosage or dominant negative effects on gene function, requires further investigation.

Computed tomography was used to image the distal radioulnar joint (DRUJ) for instability. Four methods were used to quantify subluxation of the DRUJ: the Mino criteria, the epicenter method, the congruency method, and a new method called the radioulnar ratio (RUR). Validity of the various methods was evaluated in clinical and laboratory situations. Rheumatoid patients with symptomatic DRUJ pathology had significantly more abnormal RUR values (100% vs 73% [epicenter method] and 88% [Mino criteria]). The RUR detected instability sooner in a progressive laboratory-induced instability model. The intraobserver and interobserver reliability of the RUR was high, with intraclass correlation coefficients of 0.89 and 0.87, respectively. The RUR demonstrated superior performance in the diagnosis of DRUJ subluxation.

This preliminary report on the Chelex-based extraction method of HPV DNA from verruca plantaris is the first step in a series of studies on verruca plantaris undertaken, jointly, by the Departments of Podiatric Medicine and Microbiology at Des Moines University-Osteopathic Medical Center, Des Moines, Iowa. Current projects include the development of new primers for PCR studies of HPV, exploration of different viral DNA extraction methods, and surveys concerning treatment, success of therapies, and the epidemiology of verruca plantaris.

Purpose: To evaluate transdiverticular percutaneous nephrolithotomy (TDPN) with creation of a neoinfundibulum in the treatment of caliceal diverticular stones., Patients and Methods: Between 1990 and 1998, 18 patients with symptomatic calculi in caliceal diverticula underwent TDPN. Transdiverticular puncture into the renal collecting system with creation of a neoinfundibulum was used, eliminating the need for prolonged probing with a wire for the neck of the diverticulum. Eight diverticula were upper polar, six were interpolar, and four were in the lower pole. Stones were endoscopically treated with use of Lithoclast (Electromedical Systems, Lausanne, Switzerland), graspers, ultrasound, or a combination of these methods., Results: Sixteen kidneys (89%) were rendered stone-free at discharge. Two kidneys (11%) were left with stone fragments of 5 mm or smaller. Hospital stay ranged from 3 to 15 days (average, 7 days). Procedure time ranged from 45 to 169 minutes (average, 87 minutes). One patient developed a left renal-pleural fistula, which closed 1 week after chest tube drainage. No other complications were encountered for an overall complication rate of 6%., Conclusion: TDPN is a safe and effective method for treating caliceal diverticular stones, with a complication rate comparable to other methods.

Purpose: To validate a dynamic single-section computed tomographic (CT) method to measure cerebral blood volume (CBV) and cerebral blood flow (CBF) by using a noncarotid artery as the input and to demonstrate the feasibility of this method in a pilot series of patients., Materials and Methods: Twelve dynamic contrast material-enhanced CT studies were performed in beagles. CBV, CBF, and mean transit time (MTT) values were calculated by using an internal carotid artery (ICA) and a noncarotid artery as the input artery to the brain. Patient studies with use of the radial artery as the input were performed (a) repetitively in two patients after subarachnoid hemorrhage, (b) in a patient with a symptomatic ICA occlusion before and after the intravenous injection of 1 g of acetazolamide, and (c) in a patient with a malignant brain tumor., Results: Linear regression analyses revealed highly significant correlations (P < .001) between CBV (r, 0.98; slope, 0.96), CBF (r, 0.89; slope, 0.87), and MTT (r, 0.80; slope, 0.76) values calculated with the ICA and the noncarotid inputs. The CT-derived patient data correlated well with ancillary clinical and neuroradiologic findings., Conclusion: Dynamic single-section CT scanning to measure CBV and CBF on the basis of a noncarotid input is a highly accessible and cost-effective blood flow measurement technique.

The features and mechanism of Acute Acoustic Trauma (AAT) together with available treatments are discussed and the current guidelines in use by the Bundeswehr are also presented.

Bronchogenic cysts are rare congenital benign lesions that are usually detected in the paediatric patient with symptoms of infection or compression on vital structures. They are rarely diagnosed in the adult population. We present a case of bronchogenic cyst presenting as a lump in the neck in an adult patient. Radiological imaging helped to diagnose this lesion accurately before any form of intervention. Complete surgical excision is the treatment of choice.

Background: Although many treatment modalities have been described for xanthelasma palpebrarum, no single technique has emerged as dominant., Objectives: Our purpose was to review the various therapeutic modalities for xanthelasma and to assess the efficacy of topical bichloracetic acid., Methods: Thirteen patients with 25 xanthelasma were treated with topical 100% bichloracetic acid. Efficacy was assessed over a follow-up period of 7 months to 10.5 years (average, 64 months)., Results: Eighty-five percent of patients experienced initial complete clearing, and 72% of their lesions have not required retreatment over an average period of 68 months. Recurrences responded well to repeat treatment. Eighty-three percent of recurrent or poorly responsive lesions were associated with high cholesterol. The most resistant patient had four-lid involvement. Excellent cosmetic results and high patient satisfaction were seen., Conclusions: Topical bichloracetic acid is a viable alternative to other modalities in the management of xanthelasma. Advantages include simplicity, cost-effectiveness, speed, safety, and efficacy.

The serious nature of laryngeal trauma sustained during sporting activity can be easily overlooked. Concomitant injury should not distract from the diagnosis of potential airway problems. The effects of head and neck trauma on the airway may be delayed. The assessment and management of a patient with suspected laryngeal injury should be carried out by experienced medical practitioners.

Objective: To determine any differences in the complications following radiologic placement of 2 devices--Hickman catheters and central venous ports--to permit long-term central venous access in patients with AIDS., Patients and Methods: Thirty-eight patients with AIDS received 52 long-term central venous access catheters. Seventeen received 23 Hickman catheters and 27 received 29 central venous ports (hence, 6 patients received both). Complications rates were determined retrospectively from clinical records and radiologic studies., Results: The only acute complications were pneumothoraces--3 in the patients receiving Hickman catheters and 2 in the patients receiving central venous ports. Infections developed in 12 of the patients receiving Hickman catheters a median of 53 and a mean of 96 days after placement. Infection developed in 8 of the patients receiving central venous ports a median of 125 days and a mean of 184 days after placement. This difference was statistically significant (p < 0.001). The most common organism in these infections was Staphylococcus aureus. The only other nonacute complication was 1 nonocclusive thrombosis of the superior vena cava, which occurred in a patient with a Hickman catheter 240 days after placement and resolved once the catheter was removed., Conclusion: Central venous ports are preferred over Hickman catheters for long-term central venous access in patients with AIDS.

The intra- and interobserver variability of 3 techniques for measuring the humpback deformity of 37 scaphoids using longitudinal computed tomography was assessed. The 3 measuring techniques were the lateral intrascaphoid angle, the dorsal cortical angle, and the height-to-length ratio. The intraobserver reliability of the intrascaphoid angle was poor; the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was excellent. The interobserver reliability of the intrascaphoid angle was poor to moderate, the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was moderate to excellent. For all 3 observers, the intra- and interobserver reliability was the best for the height-to-length ratio and worst for the intrascaphoid angle. The height-to-length ratio is the most reproducible method of assessing the humpback deformity. Clinical correlation is required to establish whether the height-to-length ratio will be of value in predicting the outcome of fractures of the scaphoid.

The infectious bronchitis virus (IBV) spike glycoprotein S1 subunit is required to initiate infection and contains virus-neutralizing and serotype-specific epitope(s). Reported are the S1 gene nucleotide and predicted amino acid sequences for the Florida 18288 strain and isolates GA-92, CV-56b, CV-9437, CV-1686, and 1013. These sequences were compared with previously published gene sequences of IBV strains, and phylogenetic relationships are reported. The S1 amino acid sequence of Florida 18288 was 94.9% similar to the Connecticut strain, and GA-92 was 92.8% similar to the Arkansas 99 strain. S1 amino acid sequences of the California variants, CV-56b, CV-9437, and CV-1686, were 97.6-99.3% similar to one another and only 76.6%-76.8% similar to the Arkansas-type strains. Isolate 1013, also from California, was 84.0% similar to Ark DPI and 77.9% similar to CV-56b. When comparing 19 viruses isolated from the United States, sequence variations were observed between amino acids 55-96, 115-149, 255-309, and 378-395. Similar regions are reported to be involved in virus-neutralizing and/or serotype-specific epitopes. These data demonstrate that variant IBV strains continue to emerge, and unique variants may circulate among poultry in geographically isolated areas.