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ObjectivesRecurrence and regrowth of non-functioning pituitary macroadenomas (NFPMs) after surgery are common but remain unpredictable. Therefore, the optimal timing and frequency of follow-up imaging remain to be determined. We sought to determine the long-term surgical outcomes of NFPMs following surgery and develop an optimal follow-up strategy.MethodsPatients underwent surgery for NFPMs between 1987 and 2018, with a follow-up of 6 months or more, were identified. Demographics, presentation, management, histology, imaging, and surgical outcomes were retrospectively collected.ResultsIn total, 383 patients were included; 256 were men (256/383; 67%) with median follow-up of 8 years. Following primary surgery, 229 patients (229/383; 60%) achieved complete resection. Of those, 28 (28/229; 11%) developed recurrence, including six needed secondary surgery (6/229; 3%). The rate of complete resection improved over time; in the last quartile of cases, 77 achieved complete resection (77/95; 81%). Reoperation-free survival at 5, 10 and 15 years was 99%, 94% and 94%, respectively. NFPMs were incompletely resected in 154 patients (154/383; 40%); of those, 106 (106/154; 69%) had regrowth, and 84 (84/154; 55%) required reoperation. Surgical reintervention-free survival at 5, 10 and 15 years was 74%,49% and 35%, respectively. Young age and cavernous sinus invasion were risk factors for undergoing reoperation (P

The syndrome of inappropriate antidiuresis (SIAD), the commonest cause of hyponatraemia, is associated with significant morbidity and mortality. Tolvaptan, an oral vasopressin V2-receptor antagonist, leads through aquaresis to an increase in serum sodium concentration and is the only medication licenced in Europe for the treatment of euvolaemic hyponatraemia. Randomised controlled trials have shown that tolvaptan is highly efficacious in correcting SIAD-related hyponatraemia. Real-world data have confirmed the marked efficacy of tolvaptan, but they have also reported a high risk of overly rapid sodium increase in patients with a very low baseline serum sodium. The lower the baseline serum sodium, the higher the tolvaptan-induced correction rate occurs. Therefore, a lower starting tolvaptan dose of 7.5 mg has been evaluated in small cohort studies, demonstrating its efficacy, but it still remains unclear as to whether it can reduce the risk of overcorrection. Most international guidelines, except for the European ones, recommend tolvaptan as second-line treatment for SIAD after fluid restriction. However, the risk of unduly rapid sodium correction in combination with its high cost have limited its routine use. Prospective controlled studies are warranted to evaluate whether tolvaptan-related sodium increase can improve patient-related clinical outcomes, such as mortality and length of hospital stay in the acute setting or neurocognitive symptoms and quality of life in the chronic setting. In addition, the potential role of a low tolvaptan starting dose needs to be further explored. Until then, tolvaptan should mainly be used as second-line treatment for SIAD, especially when there is a clinical need for prompt restoration of normonatraemia. Tolvaptan should be used with specialist input according to a structured clinical pathway, including rigorous monitoring of electrolyte and fluid balance and, if needed, implementation of appropriate measures to prevent, or when necessary reverse, overly rapid hyponatraemia correction.

IntroductionCushing’s disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing’s disease.MethodsSearches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing’s disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging.Results166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37–0.69]; p

Utilization of point-of-care 3-dimensional printing (3DP) has decreased length of surgery in facial trauma. Little is known regarding 3DP's impact on length of surgery in orbital fracture. The purpose of this study was to compare length of surgery between 3DP/preadapted (3DPPA) orbital plates and intraoperative adapted plates (IOAP) for orbital fracture reconstruction. This was a prospective, non-blinded, randomized clinical study of consecutive subjects with orbital fractures presented to Grady Memorial Hospital in Atlanta, Georgia, between January 2018 and June 2021. Subjects ≥ 18 years, unilateral fracture, no previous orbital surgery, and/or congenital craniofacial anomaly were included. We excluded subjects <18 years and bilateral fractures. Primary predictor variable was the treatment approach. Randomization software was used, and subjects were randomized to 3DPPA or IOAP groups. Primary outcome variable was length of surgery in minutes. Secondary outcomes were the time required for plate insertion and fixation in minutes, operating room (OR) charges, and orbital volume (OV) calculation. Age, sex, race, etiology, laterality, location, dimension, indication for surgery, postoperative enophthalmos, and diplopia. Univariate and bivariate analyses were calculated. Statistical significance was P <.05. Twenty-five subjects met the inclusion criteria. Mean ages in 3DPPA and conventional IOAP groups were 41.5 (±9) and 38.2 (±10, P =.31), respectively. The mean length of surgery was 32.6 (±13.7) in 3DPPA and 53.3 (±12.8, P <.001) in conventional IOAP. The mean time required for plate insertion and fixation was 15.8n (±14.4) in 3DPPA and 41.4 (±9.4, P <.001) in conventional IOAP. The mean OR charges were $1,072.5 (±524.6) in 3DPPA and $1,757.3 (±422.6, P ≤ 0.001) in conventional IOAP. The mean calculated OV of uninjured and reconstructed orbit for the 3DPPA was 23.5 (±3.2)cm3 and 23 (±3.5, P =.37)cm3, respectively. The mean calculated OV of uninjured and reconstructed orbit for conventional IOAP was 28.6 (±3.6)cm3 and 22.8 (±2.6, P <.001)cm3, respectively. Using 3DP to produce a model that enables preoperative plate bending/adaptation reduces the length of surgery, decreases OR charges, and results in predictable OV. [ABSTRACT FROM AUTHOR]

The understanding of the causes of temporomandibular joint pain and dysfunction has evolved over 50 years. Historically, the term internal derangement has been used to describe the abnormal relationship between the articular disc, condyle, and glenoid fossa, which was thought to correlate with patient symptoms. It is now known that the pathophysiology of intra-articular pain and dysfunction (IPD) involves synovitis, capsular impingement, symptomatic disc displacement, or a combination of these. Symptomatic disc displacement should only be considered to be a potential source of IPD after synovitis and capsular impingement have been treated. This philosophy provides the opportunity for most patients with IPD to be initially treated nonsurgically or with minimally invasive procedures such as arthrocentesis or arthroscopy. [ABSTRACT FROM AUTHOR]

Poorly controlled postoperative pain results in prolonged length of stay (LOS). The use of liposome bupivacaine injectable suspension (LB) for postoperative pain control is a relatively recent practice. The purpose of this study was to investigate the following. In patients undergoing open reduction and internal fixation of mandibular fracture(s), does the use of LB reduce LOS compared with regular bupivacaine? We implemented a retrospective cohort study of consecutive patients with mandibular fracture(s) presented to Grady Memorial Hospital in Atlanta, GA, from January 2021 to January 2022. Adult patients diagnosed with 1 or more isolated mandibular fracture(s) and treated by open reduction and internal fixation were included. We excluded patients with non-isolated mandibular fracture(s), isolated condyle, infected, previously treated fractures, and documented allergy to amide local anesthetics and/or its preservatives. Primary predictor variable was local anesthetic (regular bupivacaine alone or LB/regular bupivacaine). Primary outcome variable was LOS, defined as the number of days from surgical procedure until discharge. Secondary outcome variables were number of opioid prescription refill(s) and postoperative pain at discharge, determined with visual analogue scale. The covariates were Demographics, American Society of Anesthesiologists classification, smoking, alcohol exposure, illicit drug use, etiology, location, laterality, number of fracture(s), surgical approach, and method of maxillomandibular fixation. Univariate and bivariate analyses were calculated. Statistical significance was P <.05. Sixty-two subjects met the inclusion criteria (31 subjects in each group). The mean ages in LB/regular bupivacaine and regular bupivacaine alone groups were 33.3 (±12) and 35.1 (±15.6), respectively (P =.94), the mean LOS in days was 0.23 (±0.44) in LB/regular bupivacaine and 1.48 (±1.77) in regular bupivacaine alone (P = <.001), and the mean VAS pain scores for LB/regular bupivacaine and regular bupivacaine alone groups were 0.53 (±1.07) and 1.87 (±2.66), respectively (P =.02). Mean number of opioid prescription refill(s) was 0 in LB/regular bupivacaine and 1 in regular bupivacaine alone group, respectively (P =.01). The use of LB/regular bupivacaine for mandibular fracture(s) results in decrease in LOS and number of opioid refills compared to regular bupivacaine alone. [ABSTRACT FROM AUTHOR]

Objective. The insulin tolerance test (ITT) is the gold standard endocrine test used to assess the integrity of the growth hormone (GH) and cortisol axes. The ITT has potential risks, and severe hypoglycaemia may necessitate intravenous glucose rescue. There is no clear consensus as to the optimal insulin dose for the ITT. Therefore, we sought to compare the standard dose (0.15 U/kg) and a low-dose ITT (0.1 U/kg). Design. Single-centre audit of ITT data (2012–2021). Patients and Measurements. Patients who underwent an ITT to assess possible GH deficiency/adrenal insufficiency were included. Glucose, GH, and cortisol were measured at baseline and 30, 45, 60, 90, and 120 minutes following I.V. insulin bolus (0.15 U/kg or 0.10 U/kg). Results. Of the ITTs performed, only 3/177 (1.7%) did not achieve adequate hypoglycaemia (≤2.2 mmol/L) with a single insulin dose. In total, 174 patients (43.5 ± 12.1 yrs, mean ± standard deviation) were included for analysis (0.15 U/kg: n = 113, 0.10 U/kg: n = 61). All 174 subjects had adequate hypoglycaemia regardless of baseline fasting blood glucose level or insulin dose. Neither nadir glucose nor glucose delta (i.e., baseline minus nadir) differed between insulin doses. Trends in both cortisol and GH responses over time were similar between groups, and a greater proportion of patients receiving the standard dose had an adequate cortisol response (77/106 (72.6%) vs. 32/60 (53.3%), p=0.01). The rates of glucose rescue did not differ in a subset of 79 patients, with on-demand glucose rescue in 4/35 (11%) for the standard dose and 2/44 (5%) for the low dose (p=0.25). Conclusions. Our results suggest that the low-dose ITT produces comparable glucose, cortisol, and GH responses to the higher dose. Given the risks associated with hypoglycaemia, the low dose appears to be preferable to the standard dose ITT in most circumstances.

In August 1441, an embassy of eight monks (four from the Coptic communauty of Cairo, four ethiopans monks from Jerusalem) arrive at the Council of Florence. Two humanists, Poggio Bracciolini and Biondo Flavio, are among the witnesses of the event that they report in their writings. In the fourth book of the De varietate fortunae, Poggio describes a prosperous and exotic Ethiopia, whereas Biondo, by transcribing the questioning of the monks by a commission of cardinals in his Historiarum ab inclinatione Romanorum imperii decades, shows the conflicts between the various representations of Ethiopia and their implications. These texts give evidence of the fascination of some humanists for the far-off lands and of the diverse modes of insertion of Ethiopia in the imago mundi.

The article discusses the importance of distinguishing between arthrogenous and myogenous sources of pain and dysfunction in temporomandibular disorders (TMD). It highlights the complexity of the temporomandibular joint (TMJ) and the need to consider various factors when dealing with any joint disorder. The article emphasizes the potential causes of intra-articular pain and dysfunction (IPD) and the availability of non-surgical treatment options, such as anti-inflammatory medications and minimally invasive procedures. It also stresses the importance of making the correct diagnosis and adopting evidence-based treatments. The article concludes by emphasizing the need for education, understanding psychosocial factors, and supporting continued research in the field. [Extracted from the article]

No abstract

Surgical ciliated cyst (SCiC) represents a late-occurring complication related to prior midface surgery or trauma, often presenting years even decades after the initial event. In the absence of correlative clinical history and imaging, distinguishing SCiC from similar appearing entities such as nasopalatine duct cyst (NPDC) or sinonasal mucocele (MC) may present a diagnostic challenge. A retrospective search for patients diagnosed with SCiC, frontoethmoidal MC and NPDC at one institution between 2005 and 2022 was conducted. Clinical and imaging data were retrospectively reviewed and histopathologic features were analyzed and compared. Maxillary sinus mucoceles were excluded. Twenty-nine cases of SCiC, 11 frontoethmoidal MC and 8 NPDC with available slides were reviewed. While age at presentation was similar across these entities, SCiC showed a predilection for females in contrast to MC and NPDC. Microscopically, the cystic lesions showed histologic overlap if lined by atrophic squamoid epithelium with subepithelial fibrosis or hyalinization; a feature most common to SCiC (86%) and MC (82%), but also over half of NPDC cases. Respiratory (ciliated) epithelium was present within the specimens across all 3 entities. Seromucinous glands were identified in all 3 cohorts, but most frequently seen in MC (91%) compared to NPDC (3%) and SCiC (1 case). Cartilage was never identified in SCiC specimens, and skeletal muscle was never identified in MC. Well developed stratified squamous epithelium helped to distinguish NPDC (present) from SCiC and MC (absent). While SCiC, NDPC, and frontoethmoidal MC demonstrate areas of histologic overlap, several histological contextual clues including assessment for cartilage, seromucinous tissue, skeletal muscle, and well-developed/mature stratified squamous epithelium may be diagnostically helpful, even in the absence of correlative clinical history and imaging. Additional study to include maxillary sinus mucoceles and antral pseudocysts will be essential to improve the practical utility of these findings. [ABSTRACT FROM AUTHOR]

We study a continuous deterministic host-macroparasite system which involves populations of hosts, parasites, and larvae. This system leads to a countable number of partial differential equations that under certain hypotheses, is reduced to finitely many equations. Also we assume hypotheses to close the system and to define the global dynamics for the hosts. Then, we analyze the spatially homogeneous model without demography (aquaculture hypothesis), and show some preliminary results for the spatially structured model.

Purpose: Successful orbital reconstruction relies on an accurate restoration of orbital volume (OV). The purpose of this study was to determine if the OV of African American (AA) subjects differs from that of Caucasian subjects.Methods: The authors implemented a retrospective observational study of successive subjects who received a maxillofacial computed tomography (CT) scan at a level I trauma center between 2017 and 2020. The primary predictor variable was race (AA/Caucasian). The primary outcome variable was orbital volume. Two independent examiners calculated OV with an open access OsiriX MD software version 10.0.5 (Pixmeo, Switzerland). Inter-rater reliability was calculated. Differences between races, genders, and sides were tested using independent samples t test with a significance of P < .05.Results: Sixty subjects (120 orbits) were included in the study. The mean age was 36.7 (SD ± 13.2) years with a range of 22 to 78 years. Gender distribution was equal with 30 male (50%) and 30 female (50%) subjects. Inter-examiner reliability was 0.973. The mean OV of AA and Caucasians was 22.38 and 23.23 cm3, respectively (P = .07). The mean OV of AA and Caucasian males was 23.92, and 24.17cm3, respectively (P = .71). The mean OV in AA and Caucasian females was 20.84 and 22.28cm3, respectively (P = .013).Conclusions: African-American female subjects appear to have a smaller OV when compared with Caucasians which may influence orbital reconstruction. Laterality does not appear to be associated with any differences in OV. [ABSTRACT FROM AUTHOR]