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A no-show appointment is clinically defined as a scheduled appointment in which a patient fails to attend without prior notification to the provider or staff. In primary care clinics, no-show rates have been shown to range from 15% to 30%. Smaller studies have shown that interventions including phone calls, emails or text message reminders can reduce no-show rates.1–9 Our retrospective review sought to evaluate a similar intervention performed at the Multispecialty Residency Clinic (MSC). A test of two proportions was performed to evaluate the effect of a 24-hour reminder phone call. The no-show rate before initiating a 24-hour phone call was 17.8%, and following the intervention this rate improved to 16%, an observed reduction of 1.9% with a 95% confidence interval (CI) from 0.1% to 3%, p = 0.003. New patient encounters, established patient visits and cancellations were analyzed as secondary endpoints to further evaluate the effects of a reminder phone call. Our retrospective analysis is the largest to date regarding the effectiveness of utilizing phone call reminders to reduce no-show rates in the setting of a residency clinic and has confirmed a significant 2% reduction in no-show appointments.

Sphenoid mucoceles, although rare, should be considered in patients with headache, visual disorders and eye paralysis. Due to close relationships with the orbit and neuromeningeal structures, early recognition is vital. We report the case of a patient who presented with bilateral abducens nerve palsies. At surgery, she was found to have a mucopyocele; this was drained and she required prolonged intravenous antibiotic therapy due to ongoing symptoms and persistent dural enhancement on imaging. A lesion of sufficient size in the clival area has the potential to cause bilateral abducens nerve palsies, though we believe this is the first time it has been described in relation to a sphenoid mucocele. Imaging plays a crucial role in diagnosis, and prompt surgical intervention is essential to avoid serious and permanent complications. The multi-disciplinary team approach is vital—these cases requiring input from ophthalmology, ear nose and throat, microbiology, radiology, neurology and neurosurgery.

Minority patients such as Blacks, Hispanics, and Native Americans are disproportionately impacted by critical limb ischemia and amputation due to multiple factors such as socioeconomic status, type or lack of insurance, lack of access to health care, capacity and expertise of local hospitals, prevalence of diabetes, and unconscious bias. The Society of Interventional Radiology Foundation recognizes that it is imperative to close the disparity gaps and funded a Research Consensus Panel to prioritize a research agenda. The following research priorities were ultimately prioritized: (a) randomized controlled trial with peripheral arterial disease screening of at-risk patients with oversampling of high-risk racial groups, (b) prospective trial with the introduction of an intervention to alter a social determinant of health, and (c) a prospective trial with the implementation of an algorithm that requires criteria be met prior to an amputation. This article presents the proceedings and recommendations from the panel.

Natural dyes are emerging globally as eco-friendly synthetic colorant. Natural dyeing is process of applying coloring matter directly on fiber, yarn or fabric without any additives. Butea monosperma (Lam.)Taub. is one of most important ornamental plants mainly grow in forest and rich in orange pigments. In the present study, the dyeing pigments present in naturally drop flowers of Butea monosperma (Lam.) Taub. Extraction by using four different Mordant with aqueous extraction method and one Ethno botanical local method on cotton-polyester mix fabric. The result revealed that, different color like light yellow, orange, brown, cream etc. were obtained from the dye when subjected to Mordant. The crud flower petals dye after further purification and refining has tremendous scope as medicine and also serve a coloring material in soft drink and other food product like jam, chow main, noodles, sausage etc. Natural dye from the flower of Butea monosperma (Lam.) Taub. In the field of textile, food item and pharmaceutical industry.

Of all the medications available to physicians worldwide, antibiotics play an essential role in inpatient and outpatient settings. Discovered in the early nineteenth century by Alexander Fleming, penicillin was the first antibiotic isolated from a mold. Dr. Gerhard Domagk developed synthetic sulfa drugs by altering the red dye used in chemical industries. Since then, multiple antibiotic classes have been discovered with varying antimicrobial effects enabling their use empirically or in specific clinical scenarios. Antibiotics with different mechanisms of action could be either bactericidal or bacteriostatic. However, no clinical significance has been observed between cidal and static antibiotics in multiple trials. Their presence has led to safer deep invasive surgeries, advanced chemotherapy in cancer, and organ transplantation. Indiscriminate usage of antibiotics has resulted in severe hospital-acquired infections, including nosocomial pneumonia, Clostridioides difficile infection, multidrug-resistant invasive bacterial infections, allergic reactions, and other significant side effects. Antibiotic stewardship is an essential process in the modern era to advocate judicial use of antibiotics for an appropriate duration. They play a vital role in medical and surgical intensive care units to address the various complications seen in these patients. Antibiotics are crucial in severe acute infections to improve overall mortality and morbidity.

Natural dyes are emerging globally as eco-friendly synthetic colorant. Natural dyeing is process of applying coloring matter directly on fiber, yarn or fabric without any additives.Butea monosperma (Lam.)Taub.is one of most important ornamental plants mainly grow in forest and rich in orange pigments. In the present study, the dyeing pigments present in naturally drop flowers ofButea monosperma (Lam.) Taub.Extraction by using four different Mordant with aqueous extraction method and one Ethno botanical local method oncotton-polyester mix fabric.The result revealed that, different color like light yellow, orange, brown, cream etc. were obtained from the dye when subjected to Mordant. The crud flower petals dye after further purification and refining has tremendous scope as medicine and also serve a coloring material in soft drink and other food product like jam, chow main, noodles, sausage etc. Natural dye from the flower ofButea monosperma (Lam.) Taub.In the field of textile, food item and pharmaceutical industry. &nbsp

Background: Previous data suggest that tapentadol, an atypical opioid with a putative dual mechanism of action, has relatively low rates of abuse. A better understanding of the rates of abuse among different prescription opioids may help clinicians when considering their potential risks and benefits. The results of urine drug tests (UDTs) may provide a unique opportunity to help answer this question. Method: To investigate different rates of prescription-opioid abuse in this retrospective study, we examined urine drug test results from patients seeking treatment at four facilities of an opioid-use-disorder (OUD) treatment program in Ohio. Urine specimens were collected on admission, one from each patient, in the regular course of care. The opioids reviewed in the present study were tapentadol, hydrocodone, oxycodone, hydromorphone, oxymorphone, and tramadol. Drug dispensing data, including morphine-milligram equivalents (MME) dispensed, were examined to adjust for the relative prevalence of each opioid being examined. Results: Data from 4,162 patients were examined. Tapentadol was the least common finding in UDT results in this cohort and remained so after adjusting for drug availability. The percentage of specimens positive for a given opioid ranged from 0.12 percent (tapentadol) to 7.04 percent (oxycodone). The availability and MME adjustments resulted in a change of rank order, with tapentadol remaining the lowest but tramadol replacing oxycodone as the prescription opioid with the highest rate of abuse. Conclusions: In this sample of UDT results from patients seeking treatment at an OUD program in Ohio, tapentadol was the least frequent finding among the opioids examined, and this remained true when adjusting for dispensing data. Factors potentially contributing to this difference may include pharmacological properties unique to tapentadol. Several important limitations notwithstanding, these findings are consistent with previous real-world evidence and warrant an ongoing line of inquiry.

Tangential flow filtration is advantageous for bioreactor clarification as the permeate stream could be introduced directly to the subsequent product capture step. However, membrane fouling coupled with high product rejection has limited its use. Here, the performance of a reverse asymmetric hollow fiber membrane where the more open pore structure faces the feed stream and the barrier layer faces the permeate stream has been investigated. The open surface contains pores up to 40 μm in diameter while the tighter barrier layer has an average pore size of 0.4 μm. Filtration of Chinese hamster ovary cell feed streams has been investigated under conditions that could be expected in fed batch operations. The performance of the reverse asymmetric membrane is compared to that of symmetric hollow fiber membranes with nominal pore sizes of 0.2 and 0.65 μm. Laser scanning confocal microscopy was used to observe the locations of particle entrapment. The throughput of the reverse asymmetric membrane is significantly greater than the symmetric membranes. The membrane stabilizes an internal high permeability cake that acts like a depth filter. This stabilized cake can remove particulate matter that would foul the barrier layer if it faced the feed stream. An empirical model has been developed to describe the variation of flux and transmembrane pressure drop during filtration using reverse asymmetric membranes. Our results suggest that using a reverse asymmetric membrane could avoid severe flux decline associated with fouling of the barrier layer during bioreactor clarification.

Congenital cutis laxa is a rare inherited skin disorder and shows diverse phenotypic features among its different variants. Most forms are progressive and dysmorphic features worsen with age giving an appearance of early ageing. Autosomal recessive cutis laxa, type 2a, (ARCLIIa) is the only variant where phenotypic features undergo spontaneous regression and self-resolution with age. We are reporting a case of congenital ARCLIIa, in a child who had primarily presented with right-sided pneumonia. The child was investigated and worked up for cutis laxa based on skin appearance and characteristic facies (loose sagging skin, redundant skin folds, and hound-like facies). In view of history of a cousin having similar findings which had self-resolved overtime without any treatment, we further suspected it to be type 2A variant, which was proven by genetic analysis (ATP6V02 gene). Hence, we wish to report this case.

After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

We report a case of Gradenigo's syndrome successfully managed on an outpatient parenteral antibiotic service. This condition is classically described as a triad of otorrhoea, facial pain in the distribution of the trigeminal nerve and ipsilateral abducens nerve palsy, in the context of otitis media. Due to its rarity and variability in its presentation, it can be difficult to diagnose. A detailed history, examination and neuro-radiology imaging are essential in making the correct diagnosis and multidisciplinary management is imperative.

Background Queensland, Australia, has the highest rates of cutaneous squamous cell carcinoma (SCC). Perineural invasion (PNI) is associated with reduced local control and survival. Methods A retrospective review of a prospective database of patients with clinical PNI from cutaneous SCC of the head and neck (SCCHN) treated with surgery and postoperative radiotherapy (PORT) between 2000 and 2011 and a minimum of 24 months follow-up. Patients were excluded if immunosuppressed, had non-SCC histology, or were treated palliatively. Results Fifty patients (mean age, 60 years) with median follow-up of 50 months were included in this study. A total of 54.8% of known primary tumors had incidental PNI. Ten percent had nodal disease at presentation. MRI neurogram was positive in 95.8%. Recurrence-free survival (RFS) at 5-years was 62%. Five-year disease-specific survival (DSS) and overall survival (OS) were 75% and 64%, respectively. There were no perioperative deaths. Conclusion This report demonstrates that long-term survival is achievable in patients with clinical PNI from cutaneous SCCHN after surgery and PORT.

Purpose The purpose of this study was to implement a clinical pharmacist-led medication therapy management (MTM) service within a primary-care setting that is enhanced by 1) a clinical decision support system (CDSS) that includes a unique combination of medication risk mitigation factors, which aids the pharmacist in interpreting the medication profile, and 2) pharmacogenomics (PGx) testing. Methods This was a service implementation study, whereby Medicare beneficiaries were eligible if they were patients of Elmwood Family Physicians, a private family, primary care practice with 2 locations in New Jersey, and were on at least 7 medications. Patients had a medication reconciliation completed by a pharmacist and performed a PGx buccal swab. Patient information was run through a CDSS to aid the pharmacist with screening for multidrug interactions and assessing patient's medication-related risks. The output of the CDSS was used to create recommendations and provide a consult to the physicians. Recommendations were followed up by return of the consult. Results Enrolled patients used a mean (± standard deviation) of 12.1 (± 4.6) medications. The turnaround time for the MTM Plus consults was 11.7 (± 6.2) days. During the consults, the pharmacist identified 138 medication-related problems (MRPs). The most common MRPs were drug-drug interactions (29.0%) and drug-gene interactions (DGIs; 24.6%). Conclusion Implementing a clinical pharmacist-led MTM Plus service in the primary care setting is feasible. This study highlights that DGIs are common in older adults in family practice and indicates that PGx testing identifies additional MRPs that may otherwise go unnoticed in these patients. The experiences we shared can aid other clinicians in establishing successful MTM Plus services. Future studies should also measure the impact of such personalized medicine services on economic, clinical, and humanistic outcomes. This study has been registered with ClinicalTrials.gov (study No. NCT02748148).

Objectives This study sought to assess long-term outcomes in asymptomatic or minimally symptomatic patients with hypertrophic cardiomyopathy (HCM) who underwent exercise echocardiography, without invasive therapies for relief of left ventricular outflow tract (LVOT) obstruction. Background Many HCM patients present with LVOT obstruction, mitral regurgitation (MR), and diastolic dysfunction, often requiring invasive therapies for symptomatic relief. However, a significant proportion of truly asymptomatic patients can be closely monitored. In HCM patients, exercise echocardiography has been shown to be a useful assessment of functional capacity and risk stratification. Methods We included 426 HCM patients (44 ± 14 years; 78% men) undergoing exercise echocardiography, excluding hypertensive heart disease of elderly, ejection fraction Results Patients were asymptomatic or minimally symptomatic on history, but 82% of patients achieved 100% of age-sex predicted METs had 1% event rate versus 12% in those achieving Conclusions In asymptomatic or minimally symptomatic HCM patients, exercise stress testing provides excellent risk stratification, with a low event rate in patients achieving >100% of predicted METs.

In independent studies, abnormal global longitudinal strain (GLS) and myocardial inflammation or scar detected by 18F-fludeoxyglucose positron emission tomography (FDG-PET) are associated with poor prognosis among patients with high likelihood for cardiac sarcoidosis. However, commonly used imaging modalities have not been evaluated in the same population. Our goals were to examine the relation between GLS and FDG-PET, and to evaluate the incremental prognostic value of these imaging techniques for predicting major adverse cardiac events (MACE) in patients suspected to have cardiac sarcoidosis. We identified patients with systemic sarcoidosis who underwent an echocardiogram and FDG-PET within 60 days. Regional strain (average of base, mid, and apical segmental strains from each of 6 wall regions) was calculated and compared with regional FDG-PET findings. The associations among GLS, FDG-PET findings, and MACE (defined as death, ventricular tachycardia, heart failure hospitalization, or transplantation) were evaluated using a Cox model. Of 84 patients, 51 had abnormal FDG-PET. GLS was impaired in patients with abnormal versus normal FDG-PET (-14.2 ± 4.7% vs -17.9 ± 3.5%, p0.01). After adjusting for clinical risk factors, both GLS and the number of segments with abnormal perfusion and metabolism on FDG-PET were associated with adverse cardiac events (p0.01 for both). In conclusion, GLS and regional LS are impaired in patients with abnormal perfusion and metabolism detected using FDG-PET. Additionally, both GLS and abnormal FDG-PET have incremental prognostic value for predicting MACE in patients with systemic sarcoidosis.

Mitral regurgitation (MR) has a high prevalence in older patient populations of industrialized nations. Common etiologies are structural, degenerative MR and functional MR secondary to myocardial remodeling. Because of co-morbidities and associated high surgical risk, open surgical mitral repair/replacement is deferred in a significant percentage of patients. For these patients transcatheter repair/replacement are emerging as treatment options. Because of the lack of direct visualization, pre- and intra-procedural imaging is critical for these procedures. In this review, we summarize mitral valve anatomy, trans-catheter mitral valve replacement (TMVR) options, and imaging in the context of TMVR.

Background— Obesity is a risk factor for development of left ventricular systolic dysfunction (LVSD) and can complicate LVSD management, especially for individuals in whom cardiac transplantation is indicated. Bariatric surgery is increasingly recognized as a safe and effective intervention to achieve marked weight loss, but experience is limited in the LVSD population. Methods and Results— We retrospectively reviewed patients with obesity and left ventricular ejection fraction (LVEF) P =0.0005) for surgical subjects, but not for controls (+3.4%±10.5, P =0.056). Among surgical subjects, 11 patients had an LVEF improvement of >10%, whereas only 6 improved by >10% among nonsurgical controls. Conclusions— At experienced centers, bariatric surgery may be a safe and effective intervention for obese patients with LVSD. Bariatric surgery was associated with an improvement in LVEF, although the magnitude of change was on the cusp of clinical significance.

Introduction Various laser systems have been used for volume reduction of hyperplastic nasal turbinates. For endonasal application, fiber controlled diode lasers are preferred over conventional laser systems for reasons of cost and practicability. This study compares coagulative tissue effects using λ = 1,470 nm and λ = 940 nm lasers in treatment of hyperplastic inferior nasal turbinates in an intraindividual manner. Methods Twenty patients underwent laser coagulation for hyperplastic inferior nasal turbinates in this prospective, randomized, double-blind, clinical feasibility trial. In each case, one nasal cavity was treated using 1,470 nm laser (4–5 W power), the other one with 940 nm laser (12 W power), endoscopically controlled in noncontact mode. Clinical presentation and patients symptoms were documented preoperatively and on day 1, 3, 7, 14, and 21 postoperatively using rhinomanometry, standardized questionnaires including SNOT 20 GAV (German adapted version), and separate endoscopic examination, respectively. Results No infections, hemorrhages, or other complications occurred intra- or postoperatively. The mean operation time was significantly shorter using the 1,470 nm diode laser as compared to the 940 nm laser. There was a significant reduction of nasal obstruction on day 21 postoperatively compared to the preoperative condition on both sides regardless of the laser system used. Evaluation of the SNOT-Scores as assessed before and 3 weeks after surgery showed significant subjective improvements. Conclusions 1,470 nm diode laser system offers an efficient method for tissue reduction in hyperplasia of inferior nasal turbinate. Compared with our standard practice (940 nm diode laser), 1,470 nm diode laser application provides an equivalent tissue reduction in shorter operation time using less total energy and a comparable relief of nasal obstruction postoperatively. Lasers Surg. Med. 43:881-886, 2011. © 2011 Wiley Periodicals, Inc.

Atrial fibrillation (AF) is a common arrhythmia and is associated with significant morbidity and mortality. The pathogenesis of AF remains incompletely understood and management remains a difficult task. Over the past decade there has been accumulating evidence implicating inflammation in the pathogenesis of AF. Inflammation appears to play a significant role in the initiation and perpetuation of AF as well as the prothrombotic state associated with AF. Inflammatory biomarkers (C-reactive protein and interleukin-6) have been shown to be associated with the future development, recurrence and burden of AF, and the likelihood of successful cardioversion. Therapies directed at attenuating the inflammatory burden appear promising. Animal and clinical studies have evaluated statins, angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, and corticosteroids for the treatment or prevention of AF. The purpose of this review is to provide current evidence on the relationship between inflammation and AF and potential therapies available to modulate the inflammatory state in AF.

The ATP binding cassette transporter A1 (ABCA1) mediates cellular cholesterol and phospholipid efflux, and is implicated in phosphatidylserine translocation and apoptosis. Loss of functional ABCA1 in null mice results in severe placental malformation. This study aimed to establish the placental localisation of ABCA1 and to investigate whether ABCA1 expression is altered in placentas from pregnancies complicated by pre-eclampsia and antiphospholipid syndrome. ABCA1 mRNA and protein localisation studies were carried out using in situ hybridization and immunohistochemistry. Comparisons of gene expression were performed using real-time PCR and immunoblotting. ABCA1 mRNA and protein was localised to the apical syncytium of placental villi and endothelia of fetal blood vessels within the villi. ABCA1 mRNA expression was reduced in placentas from women with APS when compared to controls (p

Background— In patients with hypertrophic cardiomyopathy and left ventricular outflow tract (LVOT) obstruction, but without basal septal hypertrophy, we sought to identify mitral valve (MV) and papillary muscle (PM) abnormalities that predisposed to LVOT obstruction, using echo and cardiac magnetic resonance. Methods and Results— We studied 121 patients with hypertrophic cardiomyopathy hypertrophic cardiomyopathy (age, 49±17 years; 60% men; 57% on β-blockers) with a basal septal thickness of ≤1.8 cm who underwent echocardiography (rest+stress) and cine cardiac magnetic resonance. Echo measurements included maximal LVOT gradient (rest/provocable), MV leaflet length (parasternal long, 4 and 3-chamber views), and abnormal chordal attachment to mid/base of anterior MV. Cine cardiac magnetic resonance measurements included basal septal thickness, number/area of PM heads, and bifid PM mobility (in systole and diastole). Mean basal septal thickness, LVOT gradient, and LV ejection fraction were 1.5±0.3 cm, 72±54 mm Hg, and 61±6%, respectively. The number of anterolateral and posteromedial PM heads was 2.7±0.7 and 2.6±0.7, respectively. Anterolateral and posteromedial PM areas were 19.9±7 cm 2 and 17.1±6 cm 2 , respectively. PM mobility was 11±6°. On multivariable analysis, predictors of maximal LVOT gradient were basal septal thickness, bifid PM mobility, anterior mitral leaflet length, and abnormal chordal attachment to base of anterior mitral leaflet. Forty-five patients underwent surgery to relieve LVOT obstruction, of which 52% needed an additional nonmyectomy (MV repair/replacement or PM reorientation) approach. Conclusions— In hypertrophic cardiomyopathy patients without significant LV hypertrophy, in addition to basal septal thickness, anterior MV length, abnormal chordal attachment, and bifid PM mobility are associated with LVOT obstruction. In such patients, additional procedures on MV and PM (±myectomy) could be considered.

Objective:To assess nasal morbidity resulting from nasoseptal flap use in the repair of skull base defects in endoscopic anterior skull base surgery.Methods:Thirty-six patients awaiting endoscopic anterior skull base surgery were prospectively recruited. A nasoseptal flap was used for reconstruction in all cases. Patients were assessed pre-operatively and 90 days post-operatively via the Sino-Nasal Outcome Test 20 questionnaire and visual analogue scales for nasal obstruction, pain, secretions and smell; endoscopic examination findings and mucociliary clearance times were also recorded.Results:Sino-Nasal Outcome Test 20 questionnaire data and visual analogue scale scores for pain, smell and secretions showed no significant differences between pre- and post-operative outcomes, with visual analogue scale scores for nasal obstruction actually showing a significant improvement (p = 0.0007). A significant deterioration for both flap and non-flap sides was demonstrated post-operatively on endoscopic examination (p = 0.002 and p = 0.02 respectively).Conclusion:Whilst elevation of a nasoseptal flap in endoscopic surgery of the anterior skull base engendered significant clinical deterioration on examination post-operatively, quality of life outcomes showed that no such deterioration was subjectively experienced by the patient. In fact, there was significant nasal airway improvement following nasoseptal flap reconstruction.

Squamous cell carcinoma (SCC) of the temporal bone is an aggressive malignancy. It presents as a primary tumour of the temporal bone arising in the middle ear or external auditory canal (EAC). Secondary invasion of the temporal bone occurs because of direct spread from a primary lesion of the pinna and its surrounds, or from cutaneous SCC (cSCC) metastasis to the first echelon lymph node bed. In Australia, SCC of the temporal bone typically presents from direct invasion from a cutaneous primary, or from metastatic spread from a cutaneous primary to the parotid lymph nodes abutting the temporal bone [1].

Epidemiological studies have shown lower levels of chromium among men with diabetes and cardiovascular disease (CVD) compared with healthy control subjects. The mechanism by which chromium may decrease the incidence of CVD and insulin resistance is not known. Using erythrocytes as a model, this study demonstrates that chromium inhibits the glycosylation of proteins and oxidative stress, both risk factors in the development of CVD. Erythrocytes were treated with high levels of glucose (mimicking diabetes) in the presence or absence of chromium chloride in the medium at 37 degrees C for 24 hours. Chromium supplementation prevented the increases in protein glycosylation and oxidative stress caused by the high levels of glucose in erythrocytes. This study demonstrates for the first time that chromium supplementation inhibits protein glycosylation in erythrocytes exposed to high glucose medium, which appears to be mediated by its antioxidative effect. This provides evidence for a novel mechanism by which chromium supplementation may decrease incidence of CVD in diabetic patients.

Calcitonin gene-related peptide is a potent vasodilator neuropeptide that is localized in perivascular sensory nerves. To determine whether alpha-calcitonin gene-related peptide possesses protective activity against hypertension-induced end organ damage, hypertension was induced in alpha-calcitonin gene-related/calcitonin peptide knockout and wild-type mice by uninephrectomy, deoxycorticosteroid administration, and 0.9% saline drinking water. These mice were instrumented previously for long-term telemetric blood pressure recording. Control groups were sham-operated and given tap water. Mean arterial pressures were determined, and 3 weeks after initiation of each protocol, tissues were taken for histopathologic studies. The deoxycorticosteroid-salt protocol produced a significant 35% mean arterial pressure increase in both mouse strains. No pathological changes were observed in sections of aortas and femoral arteries from any of the groups studied. Likewise, heart and kidney sections from the hypertensive wild-type mice showed no pathological changes compared with their normotensive counterparts. In contrast, marked vasculitis was seen in the heart sections from the deoxycorticosteroid-salt-treated alpha-calcitonin gene-related peptide knockout mice with thickening and inflammation of the vessel walls. In addition, myocarditis and focal epicarditis with areas of myocardial necrosis were present. Kidneys of these mice exhibited prominent glomerular changes including congestion of the capillary loops, focal mesangial and crescent proliferation, and focal histocytic infiltration. Urinary microalbumin was significantly higher in the hypertensive alpha-calcitonin gene-related peptide knockout compared with hypertensive wild-type mice. These data suggest that deletion of the alpha-calcitonin gene-related peptide gene makes the heart and kidneys more vulnerable to hypertension-induced end organ damage.

This study evaluates transcoronary changes in neutrophil and platelet activation and conjugate formation in patients with angina pectoris secondary to coronary artery disease. We examined parameters of neutrophil and platelet activation as well as the neutrophil-platelet conjugate formation in patients who underwent diagnostic coronary angiography. Thirty-nine patients with chest pain referred for cardiac catheterization were studied (23 patients with unstable angina pectoris [UAP] and 16 with stable angina pectoris [SAP]). Before coronary angiography, blood samples were obtained simultaneously from the aortic root and coronary sinus to assess leukocyte (CD11b) and platelet (CD62P) activation and leukocyte-platelet conjugates. There was a 94% increase in CD62-expressing platelets from the aorta to the coronary sinus in patients with UAP compared with a 49% increase in patients with SAP. The percentage of neutrophil-platelet conjugates increased by 22% in patients with UAP compared with a 16% decrease in those with SAP (p

Using real time RT-PCR, we have detected expression of seven genes that influence bile acid transport,MDR3, FIC1, BSEP, OATP-A, OATP-C, OATP-D and OATP-E, in normal human placenta. With the exception of OATP-C and OATP-E these genes were found to be differentially expressed in 1st trimester and 3rd trimester placentae. MDR3 gene expression was found to be up regulated four fold in 3rd trimester placentae compared to 1st trimester, OATP-A gene expression was down regulated eight fold, OATP-D was down regulated 17 fold, while FIC1 expression was reduced by 33 fold in the 3rd trimester. OATP-C and BSEP gene expression was not detected in the 3rd trimester placenta, while low levels of transcripts were detected in the 1st trimester placentae. Transcripts of the hepatic sinusoidal bile acid transporter, NTCP, were not detected in placenta.

Queensland, Australia, has the highest rates of cutaneous squamous cell carcinoma (SCC). Perineural invasion (PNI) is associated with reduced local control and survival.A retrospective review of a prospective database of patients with clinical PNI from cutaneous SCC of the head and neck (SCCHN) treated with surgery and postoperative radiotherapy (PORT) between 2000 and 2011 and a minimum of 24 months follow-up. Patients were excluded if immunosuppressed, had non-SCC histology, or were treated palliatively.Fifty patients (mean age, 60 years) with median follow-up of 50 months were included in this study. A total of 54.8% of known primary tumors had incidental PNI. Ten percent had nodal disease at presentation. MRI neurogram was positive in 95.8%. Recurrence-free survival (RFS) at 5-years was 62%. Five-year disease-specific survival (DSS) and overall survival (OS) were 75% and 64%, respectively. There were no perioperative deaths.This report demonstrates that long-term survival is achievable in patients with clinical PNI from cutaneous SCCHN after surgery and PORT. © 2015 Wiley Periodicals, Inc. Head Neck 38: 824-831, 2016.

This study sought to assess long-term outcomes in asymptomatic or minimally symptomatic patients with hypertrophic cardiomyopathy (HCM) who underwent exercise echocardiography, without invasive therapies for relief of left ventricular outflow tract (LVOT) obstruction.Many HCM patients present with LVOT obstruction, mitral regurgitation (MR), and diastolic dysfunction, often requiring invasive therapies for symptomatic relief. However, a significant proportion of truly asymptomatic patients can be closely monitored. In HCM patients, exercise echocardiography has been shown to be a useful assessment of functional capacity and risk stratification.We included 426 HCM patients (44 ± 14 years; 78% men) undergoing exercise echocardiography, excluding hypertensive heart disease of elderly, ejection fraction50% and invasive therapy (myectomy or alcohol ablation) during follow-up. Clinical, echocardiographic (LV thickness, LVOT gradient, and MR) and exercise variables (percent of age-sex predicted metabolic equivalents [METs] and heart rate recovery [HRR] at 1 min post-exercise) were recorded. A composite endpoint of death, appropriate internal defibrillator discharge, and admission for congestive heart failure was recorded.Patients were asymptomatic or minimally symptomatic on history, but 82% of patients achieved100% of age-sex predicted METs, and 43% had ≥II+ post-stress MR. The mean LV septal thickness, post-exercise LVOT gradient, and HRR were 2.0 ± 0.5 cm, 62 ± 47 mm Hg, and 31 ± 14 beats/min, respectively. During a mean follow-up of 8.7 ± 3 years, there were 52 events (12%). Patients achieving100% of age-sex predicted METs had 1% event rate versus 12% in those achieving85%. On stepwise multivariate survival analysis, percent of age-sex predicted METs (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.64 to 0.90), abnormal HRR (HR: 0.89; 95% CI: 0.82 to 0.97), and atrial fibrillation (HR: 2.73; 95% CI: 1.30 to 5.74) (overall, p0.001) independently predicted outcomes.In asymptomatic or minimally symptomatic HCM patients, exercise stress testing provides excellent risk stratification, with a low event rate in patients achieving100% of predicted METs.

Despite being different disease processes, pericardial constriction and restrictive cardiomyopathy are often discussed together due to their similar clinical and hemodynamic features. Physiologically, both processes lead to impaired diastolic filling via different mechanisms; a rigid, adherent pericardium is noted in constriction while abnormal myocardium is the culprit in restriction. Pericardial constriction (or constrictive pericarditis) usually is a chronic process, and variant forms do exist (effusive-constrictive, subacute, transient, occult) which share many of the clinical findings, but have subtle clinical nuances that distinguish each type. Restrictive cardiomyopathy is associated with a normal pericardium, but is often associated with infiltrative diseases such as amyloidosis, hemochromatosis, and sarcoidosis. Given the spectrum of disease and the various clinical manifestations of pericardial constriction and cardiac restriction, initial history and physical findings along with hemodynamic considerations and newer non-invasive imaging criteria now lead the way in making the diagnosis. However, using all available data in distinguishing between the two processes becomes important, as the treatment for each is very different.

Early identification of coronary artery disease (CAD) among symptomatic women is critical given their worse outcomes as compared to men. We evaluated the value of the Morise score, a simple clinical risk score, for the assessment for CAD as determined by computed tomography coronary angiography (CTCA) and compared it to the Diamond-Forrester risk assessment.One hundred forty women (mean age, 64±11 years) with chest pain syndromes and no known CAD referred for CTCA were analyzed. Patients were risk stratified for likelihood of CAD by Morise and Diamond-Forrester scores. The presence and degree of CAD were determined by CTCA and classified as normal, nonobstructive (50% stenosis), or obstructive (50% stenosis). Total coronary calcium was calculated based on Agatston scores.When risk was assessed by Morise vs. Diamond-Forrester, 5% vs. 7% of women were stratified as low, 41% vs. 82% as intermediate, and 54% vs. 11% as high risk for CAD, respectively. CAD was present in 95 (68%) patients; 22 (16%) had obstructive CAD, and 73 (52%) had nonobstructive CAD. Morise scores significantly correlated with calcium scores (p0.001) as well as the presence and degree of CAD (p0.0001). Morise scores also demonstrated significantly higher accuracy (66% vs. 48%, p0.005) and higher sensitivity (56% vs. 16%, p0.001) but lower specificity (82% vs. 97%, p0.05) when compared to Diamond-Forrester risk assessment.The Morise score performed better than Diamond-Forrester for CAD risk assessment, which highlights the importance and power of a simple history and physical examination in determining women at risk for CAD.

Background: ACC/AHA guidelines strongly recommend the use of aspirin, beta blockers, clopidogrel, statin, and angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in post myocardial infarction (MI) patients. Reductions in mortality have been demonstrated with consistent administration of recommended therapies. Patients who discontinue taking evidence-based medications are at increased mortality risk. The purpose of this study was to identify gender and age based differences in drug therapies at discharge in post MI patients at a tertiary care teaching hospital. Methods: We retrospectively analyzed data of 610 consecutive patients admitted with MI from 2006 to 2007. The use of appropriate discharge medications was compared using chi-square test. Results: There were 371 males (60.8%) with mean age 65.4 ±13 years and 239 females (39.2%) with mean age 73 ±12 years. Medications Male (%) Female (%) OR (CI) p value Aspirin 97.9 93.2 3.4 (1.3-8.5) 0.006 Clopidogrel 77.6 63.6 1.98(1.4-2.87) Beta blocker 94.6 84.4 3.2 (1.75-5.9) Statin 88 79 1.9 (1.2-3.1) 0.006 ACEI/ARB 70 58.5 1.66(1.15-2.3) 0.006 Clopidogrel use was 59% and 84.4% in patients greater than 70 years and less than 70 years respectively (OR= 0.26, CI 0.18-0.39, p = Conclusions: In an era of evidence-based guidelines and quality improvement initiatives, there is still under utilization of recommended medications in women even though they receive same treatment benefit. Elderly patients in spite of being at high risk for recurrent events were less likely to be discharged with dual antiplatelet therapy.

Various laser systems have been used for volume reduction of hyperplastic nasal turbinates. For endonasal application, fiber controlled diode lasers are preferred over conventional laser systems for reasons of cost and practicability. This study compares coagulative tissue effects using λ = 1,470 nm and λ = 940 nm lasers in treatment of hyperplastic inferior nasal turbinates in an intraindividual manner.Twenty patients underwent laser coagulation for hyperplastic inferior nasal turbinates in this prospective, randomized, double-blind, clinical feasibility trial. In each case, one nasal cavity was treated using 1,470 nm laser (4-5 W power), the other one with 940 nm laser (12 W power), endoscopically controlled in noncontact mode. Clinical presentation and patients symptoms were documented preoperatively and on day 1, 3, 7, 14, and 21 postoperatively using rhinomanometry, standardized questionnaires including SNOT 20 GAV (German adapted version), and separate endoscopic examination, respectively.No infections, hemorrhages, or other complications occurred intra- or postoperatively. The mean operation time was significantly shorter using the 1,470 nm diode laser as compared to the 940 nm laser. There was a significant reduction of nasal obstruction on day 21 postoperatively compared to the preoperative condition on both sides regardless of the laser system used. Evaluation of the SNOT-Scores as assessed before and 3 weeks after surgery showed significant subjective improvements.1,470 nm diode laser system offers an efficient method for tissue reduction in hyperplasia of inferior nasal turbinate. Compared with our standard practice (940 nm diode laser), 1,470 nm diode laser application provides an equivalent tissue reduction in shorter operation time using less total energy and a comparable relief of nasal obstruction postoperatively.