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The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival. [ABSTRACT FROM AUTHOR]

Abstract Background Among patients with autism spectrum disorders (ASD) evaluated in our clinic, there appears to be a subset that can be clinically distinguished from other ASD children because of frequent infections (usually viral) accompanied by worsening behavioural symptoms and/or loss/decrease in acquired skills. This study assessed whether these clinical features of this ASD subset are associated with atopy, asthma, food allergy (FA), primary immunodeficiency (PID), or innate immune responses important in viral infections. Methods This study included the ASD children described above (ASD test, N = 26) and the following controls: ASD controls (N = 107), non-ASD controls with FA (N = 24), non-ASD controls with chronic rhinosinusitis/recurrent otitis media (CRS/ROM; N = 38), and normal controls (N = 43). We assessed prevalence of atopy, asthma, FA, CRS/ROM, and PID. Innate immune responses were assessed by measuring production of proinflammatory and counter-regulatory cytokines by peripheral blood mononuclear cells (PBMCs) in response to agonists of Toll-like receptors (TLRs), with or without pre-treatment of lipopolysaccharide (LPS), a TLR4 agonist. Results Non-IgE mediated FA was equally prevalent in both ASD test and ASD control groups, occurring at higher frequency than in the non-ASD controls. Allergic rhinitis, atopic/non-atopic asthma, and atopic dermatitis were equally prevalent among the study groups except for the CRS/ROM group in which non-atopic asthma was more prevalent (52.6%). CRS/ROM and specific polysaccharide antibody deficiency (SPAD) were more prevalent in the ASD test group than in the ASD control, FA, and normal control groups: 23.1% vs. < 5% for CRS/ROS and 19.2% vs. < 1% for SPAD. However, CRS/ROM patients had the highest prevalence of SPAD (34.2%). When compared to ASD and normal case controls, PBMCs from 19 non-SPAD, ASD test group children produced: 1) less IL-1β with a TLR7/8 agonist, less IL-10 with a TLR2/6 agonist, and more IL-23 with a TLR4 agonist without LPS pre-treatment, and 2) less IL-1β with TLR4/7/8 agonists with LPS pre-treatment. These are cytokines associated with the neuro-immune network. Conclusion Clinical features of the ASD test group were not associated with atopy, asthma, FA, or PID in our study but may be associated with altered TLR responses mediating neuro-immune interactions.

Croup refers to airway inflammation and edema leading to obstruction of the larynx, trachea, and bronchi. Croup is the most common cause of acute airway obstruction in young children. It is characterized by the onset of low-grade fever, barky cough, stridor, hoarseness, and respiratory distress. Croup is typically caused by a viral infection (viral croup) but can occur suddenly without a viral prodrome (spasmodic croup). Recurrent croup is defined as two or more episodes per year. Recurrent croup should be considered a symptom of an underlying structural or inflammatory airway abnormality and should prompt a work-up for the underlying cause., Competing Interests: Disclosure Nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Nuh, Haryana, is one of India's least developed districts. To improve TB case notifications, ZMQ carried out an active case-finding (ACF) intervention conducted by community health workers (MIRAs) using a digital TB storytelling platform to create TB awareness in the community. The combined storytelling and ACF intervention were conducted house-to-house or in community group settings. Steps included (A) the development of digital TB awareness-raising stories using a participatory approach called Story Labs; (B) the implementation of the intervention; and (C) process, outcome, and impact evaluation of these activities. Six digital stories were created and used during ACF in which 19,345 people were screened and 255 people were diagnosed with TB. Of 731 participants surveyed, the stories were well received and resulted in an increase in TB knowledge. ACF activities resulted in a 56% increase in bacteriologically confirmed TB and an 8% decrease in all forms of TB compared to baseline. All form notifications may have been impacted by COVID-19 lockdowns. Digital TB storytelling can improve TB awareness and knowledge, particularly for low-literacy populations. The use of these tools may benefit ACF campaigns and improve TB case finding.

Crohn disease (CD) not uncommonly involves the upper gastrointestinal tract, usually gastric antrum and proximal duodenum. The most consistent histopathologic manifestations of CD in duodenal biopsies are mucosal erosion, focal active inflammation, and granulomas. Since CD is a transmural inflammation and since duodenal biopsy may include submucosal Brunner glands, we aimed to find if CD has any specific histopathologic manifestations in Brunner gland lobules and their ducts compared to other duodenal inflammatory lesions. We carried out a retrospective review study over 6 years retrieving duodenal biopsy specimens in CD patients. We compared duodenal specimens involved by CD with other inflammatory lesions, for example, ulcerative colitis (UC), Helicobacter pylori -associated gastritis, non-Helicobacter gastritis, Celiac sprue, infections, and drugs. We found focal active duodenitis and erosion in CD cases and non-CD cases. Granulomas were found in CD cases. Five cases of CD showed inflammatory and degenerative changes of Brunner glands. Focal patchy active inflammation of only portion of submucosal Brunner gland lobule, mucosal Brunner glands, and their ducts was solely found in CD cases. This focally enhanced inflammation of Brunner glands was not found in other lesions. Whether this phenomenon of focal active "lobulitis" and "ductitis" is a specific sign of duodenal CD compared to UC and other inflammatory lesions warrants verification. We encourage endoscopists to include submucosal Brunner lobules in their duodenal biopsy samples and pathologists to look for these patterns of involvement particularly in patients suspected of CD.

Background and Aims: The Middle East (ME) has a high prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), driven by obesity and type-2 diabetes mellitus (T2DM). Studies in Saudi Arabia (KSA) and United Arab Emirates (UAE) predict an escalating impact of NAFLD/NASH, particularly advanced fibrosis due to NASH (AF-NASH), increasing cases of cirrhosis, liver cancer and death. The scale of this burden in other ME countries is unknown with no reports of NAFLD/NASH healthcare resource utilization (HCRU) or costs. We estimated the clinical and economic burden of NAFLD/NASH in KSA, UAE and Kuwait., Methods: Markov models populated with country-specific obesity and T2DM prevalence data estimated numbers and progression of NAFLD/NASH patients from 2018 to 2030. Model inputs, assumptions and outputs were collected from literature, national statistics, and expert consensus., Results: Over 13 years, the KSA model estimated cases increasing as follows: patients with fibrosis F0-3 doubled to 2.5 m, compensated and decompensated cirrhosis and hepatocellular carcinoma trebled to 212,000; liver failure or transplant patients increased four-fold to 4,086 and liver-related death escalated from < 10,000 to > 200,000. Similar trends occurred in UAE and Kuwait. Discounted lifetime costs of NASH standard-care increased totaling USD40.41 bn, 1.59 bn and 6.36 bn in KSA, UAE (Emiratis only) and Kuwait, respectively. NASH-related costs in 2019 comprised, respectively, 5.83%, 5.80% and 7.66% of national healthcare spending., Conclusions: NASH, especially AF-NASH, should be considered a higher priority in ME Public Health policy. Our analyses should inform health policy makers to mitigate the enormity of this escalating regional burden., (© 2021. The Author(s).)

Background/aim: Due to epidemic levels of obesity and type 2 diabetes mellitus (DM), nonalcoholic fatty liver disease (NAFLD) and resulting nonalcoholic steatohepatitis (NASH) will be driving factors in liver disease burden in the coming years in Saudi Arabia and United Arab Emirates (UAE)., Materials and Methods: Models were used to estimate NAFLD and NASH disease progression, primarily based on changes in adult prevalence rates of adult obesity and DM. The published estimates and expert interviews were used to build and validate the model projections., Results: In both countries, the prevalence of NAFLD increased through 2030 parallel to projected increases in the prevalence of obesity and DM. By 2030, there were an estimated 12,534,000 NAFLD cases in Saudi Arabia and 372,000 cases in UAE. Increases in NASH cases were relatively greater than the NAFLD cases due to aging of the population and disease progression. Likewise, prevalent cases of compensated cirrhosis and advanced liver disease are projected to at least double by 2030, while annual incident liver deaths increase in both countries to 4800 deaths in Saudi Arabia and 140 deaths in UAE., Conclusions: Continued high rates of adult obesity and DM, in combination with aging populations, suggest that advanced liver disease and mortality attributable to NAFLD/NASH will increase across both countries. Reducing the growth of the NAFLD population, along with potential therapeutic options, will be needed to reduce liver disease burden., Competing Interests: There are no conflicts of interest

Background: Dexmedetomidine, a specific α(2) agonist, has an analgesic-sparing effect and reduces emergence agitation. We compared an intraoperative dexmedetomidine infusion with bolus fentanyl to reduce perioperative opioid use and decrease emergence agitation in children with obstructive sleep apnea syndrome undergoing adenotonsillectomy (T&A)., Methods: One hundred twenty-two patients with obstructive sleep apnea syndrome undergoing T&A, ages 2 to 10 years, completed this prospective, randomized, U.S. Food and Drug Administration-approved study. After mask induction with sevoflurane, group D received IV dexmedetomidine 2 μg · kg(-1) over 10 minutes, followed by 0.7 μg · kg(-1) · h(-1), and group F received IV fentanyl bolus 1 μg · kg(-1). Anesthesia was maintained with sevoflurane, oxygen, and nitrous oxide. Fentanyl 0.5 to 1 μg · kg(-1) was given to subjects in both groups for an increase in heart rate or systolic blood pressure 30% above preincision values that continued for 5 minutes. Observers in the postanesthesia care unit (PACU) were blinded to treatment groups. Pain was evaluated using the objective pain score in the PACU on arrival, at 5 minutes, at 15 minutes, then every 15 minutes for 120 minutes. Emergence agitation was evaluated at the same intervals by 2 scales: the Pediatric Anesthesia Emergence Delirium scale and a 5-point scale described by Cole. Morphine (0.05 to 0.1 mg · kg(-1)) was given for pain (score >4) or severe agitation (score 4 or 5) lasting more than 5 minutes., Results: In group D, 9.8% patients needed intraoperative rescue fentanyl in comparison with 36% in group F (P = 0.001). Mean systolic blood pressure and heart rate were significantly lower in group D (P < 0.05). Minimum alveolar concentration values were significantly different between the 2 groups (P = 0.015). The median objective pain score was 3 for group D and 5 for group F (P = 0.001). In group D, 10 (16.3%) patients required rescue morphine, in comparison with 29 (47.5%) in group F (P = 0.002). The frequency of severe emergence agitation on arrival in the PACU was 18% in group D and 45.9% in group F (P = 0.004); at 5 minutes and at 15 minutes, it was lower in group D (P = 0.028). The duration of agitation on the Cole scale was statistically lower in group D (P = 0.004). In group D, 18% of patients and 40.9% in group F had an episode of Spo(2) below 95% (P = 0.01)., Conclusions: An intraoperative infusion of dexmedetomidine combined with inhalation anesthetics provided satisfactory intraoperative conditions for T&A without adverse hemodynamic effects. Postoperative opioid requirements were significantly reduced, and the incidence and duration of severe emergence agitation was lower with fewer patients having desaturation episodes.

Background: Among patients with autism spectrum disorders (ASD) evaluated in our clinic, there appears to be a subset that can be clinically distinguished from other ASD children because of frequent infections (usually viral) accompanied by worsening behavioural symptoms and/or loss/decrease in acquired skills. This study assessed whether these clinical features of this ASD subset are associated with atopy, asthma, food allergy (FA), primary immunodeficiency (PID), or innate immune responses important in viral infections., Methods: This study included the ASD children described above (ASD test, N = 26) and the following controls: ASD controls (N = 107), non-ASD controls with FA (N = 24), non-ASD controls with chronic rhinosinusitis/recurrent otitis media (CRS/ROM; N = 38), and normal controls (N = 43). We assessed prevalence of atopy, asthma, FA, CRS/ROM, and PID. Innate immune responses were assessed by measuring production of proinflammatory and counter-regulatory cytokines by peripheral blood mononuclear cells (PBMCs) in response to agonists of Toll-like receptors (TLRs), with or without pre-treatment of lipopolysaccharide (LPS), a TLR4 agonist., Results: Non-IgE mediated FA was equally prevalent in both ASD test and ASD control groups, occurring at higher frequency than in the non-ASD controls. Allergic rhinitis, atopic/non-atopic asthma, and atopic dermatitis were equally prevalent among the study groups except for the CRS/ROM group in which non-atopic asthma was more prevalent (52.6%). CRS/ROM and specific polysaccharide antibody deficiency (SPAD) were more prevalent in the ASD test group than in the ASD control, FA, and normal control groups: 23.1% vs. < 5% for CRS/ROS and 19.2% vs. < 1% for SPAD. However, CRS/ROM patients had the highest prevalence of SPAD (34.2%). When compared to ASD and normal case controls, PBMCs from 19 non-SPAD, ASD test group children produced: 1) less IL-1beta with a TLR7/8 agonist, less IL-10 with a TLR2/6 agonist, and more IL-23 with a TLR4 agonist without LPS pre-treatment, and 2) less IL-1beta with TLR4/7/8 agonists with LPS pre-treatment. These are cytokines associated with the neuro-immune network., Conclusion: Clinical features of the ASD test group were not associated with atopy, asthma, FA, or PID in our study but may be associated with altered TLR responses mediating neuro-immune interactions.

Objective: Sinusitis is a rare cause of intracranial infection in children. While intracranial complications of sinusitis are rare, the morbidity and mortality remain high. Subdural empyema is recognized as the most common sinogenic intracranial complication. We undertook a review of our cases of subdural empyema and other intracranial complications of sinusitis over the past 8 years at a busy inner city hospital. Our intent was to identify factors that may predispose children to these serious complications., Methods: A retrospective chart review was conducted using ICD-9 codes to identify pediatric patients treated for complications of sinusitis at University Hospital (UH) from 1996 to 2004. Only patients age 18 or younger at the time of admission were included in this study. The following data were collected from hospital medical records: age, gender, past medical and social history, presenting symptoms, history of present illness, microbiology, surgical and medical intervention, and outcome., Results: Twelve patients were identified that fit the criteria for this study. The mean age of these patients was 14.1 years, and 10 of our 12 patients were male (83.3%). The most common presenting complaints were fever, headache, altered mental status, orbital cellulitis, nasal symptoms, nausea and vomiting, and photophobia. In the week prior to admission for intracranial complications, nine patients were seen by a physician: five patients were seen in the ER and four by a primary care physician. Subdural empyema was the most commonly observed intracranial complication in this series. Microaerophilic and anaerobic organisms were most commonly identified in this series. Most sinus procedures consisted of endoscopic ethmoid and maxillary sinus drainage. There was a long-term morbidity rate of 16% and a mortality rate of 8%., Conclusions: Three conclusions may be drawn from this study. First, the morbidity and mortality of intracranial complications of sinusitis remain high in the pediatric inner-city population despite adequate access to medical care. Second, subdural empyema appears to arise in the setting of subacute rather than acute frontal sinusitis. Lastly, there may be an under-diagnosis and delay in treatment of patients with frontal sinusitis, resulting in subsequent intracranial complications.

Background: There are many models used to explore ischemic-related phenomena. The rat epigastric fasciocutaneous flap model is the one most commonly used. Critical ischemic time is the maximum ischemic insult that tissue can undergo and still remain viable. Experimentally, ischemia is induced either by clamping the vascular pedicle or by dividing the pedicle then performing microvascular arterial and venous anastomosis. We sought to determine what effect the different methods of inducing ischemia have on the critical primary ischemic time and, thus, flap survival., Methods: A right 3 cm x 6 cm groin flap based on the inferior epigastric vessels was raised in each rat. Ischemic times of 4, 6, 8, or 10 hours were induced either by placing temporary occlusion clamps on each vessel of the vascular pedicle (island pedicle group) or by ligation and division of the pedicle with subsequent microvascular anastomosis (free flap group). Survival was assessed at 7 days., Results: The primary ischemic time at which one half of free flaps are predicted to die was calculated to be 7.60 hours, compared with 6.09 hours for the island pedicle flaps (p<.05)., Conclusions: Fasciocutaneous flaps undergoing ligation and anastomosis are more resistant to ischemia than are those undergoing clamping of the pedicle. Possible etiologic factors responsible for this experimental finding are discussed.

Objective: To determine the incidence of internal jugular vein thrombosis after functional or selective neck dissection., Design: Patients underwent serial Doppler ultrasonographic examinations of their internal jugular veins, on postoperative days 1 and 7, following functional neck dissection. Long-term follow-up was conducted at a minimum of 3 months., Setting: Department of Otolaryngology, West Virginia University, Morgantown., Patients: Sixty-five patients (51 men and 14 women) underwent 100 functional neck dissections between 1993 and 1995. Thirty-five patients had N0, 10 had N1, and 20 had N2 node involvement, respectively. Thirty-five patients underwent bilateral neck dissection, 17 underwent left neck dissection, and 13 underwent right neck dissection., Main Outcome Measures: Thrombosis of the internal jugular veins was determined using duplex Doppler scanning. Correlation with the length of the procedure, intraoperative blood loss, preoperative radiation therapy, stage of neck disease, presence of extracapsular spread, wound infection, and pedicled musculocutaneous flap closure was determined., Results: Of the 100 internal jugular veins studied, 20 (24.7%) of 81 and 19 (26.4%) of 72 were found to have evidence of thrombosis on postoperative days 1 and 7, respectively. On long-term follow-up, the incidence of internal jugular vein thrombosis was significantly lower (5.8%; P < .001). None of the variables examined correlated significantly with the presence of thrombosis. Of the 20 veins that were thrombosed initially, on follow-up 13 had normal flow and 2 had persistent thrombosis. Five patients were unavailable for follow-up. No thrombosis developed as a late finding., Conclusions: Our results indicate that even though the incidence of internal jugular vein thrombosis is relatively high immediately following neck dissection, a significant number of these veins will undergo recanalization and have excellent long-term patency.

Fungal sinusitis has been seen increasingly in immunocompetent individuals. The literature has stressed the importance of diagnosing these cases. Surgical debridement is the treatment of choice. Six immunocompetent individuals with allergic fungal sinusitis were seen at West Virginia University between January 1992 and December 1993. After adequate evaluation, endoscopic surgical debridement was performed. After surgery they were treated with systemic or topical steroids and oral antibiotics for several weeks. Two patients required a second procedure within a year. Four of our six patients had positive fungal cultures for Aspergillus or Curvularia. None of our patients had evidence of invasive disease on histopathology, and systemic antifungal therapy was not required. Patient course and response will be discussed in detail along with a brief review of allergic fungal sinusitis.

Allergic fungal sinusitis (AFS) is a distinct clinical pathologic entity that has been recognized for over a decade. The hallmark of this process is eosinophilic allergic mucin with fungal hyphae on histopathology. We have identified a subset of patients who present with a clinical picture similar to that of AFS patients in which fungus could not be demonstrated pathologically or on culture. We present four cases of allergic mucin sinusitis without fungus. A comparison of the clinical presentation of this group of patients with those with AFS will be discussed. Both groups had nasal polyposis and a history of multiple sinonasal procedures. By contrast, the patients with allergic mucin sinusitis were older than the AFS group. All of the patients with allergic mucin sinusitis also had asthma. Treatment was the same for both groups of patients.

Tissue-specific differences were apparent in the constitutive level of hsp90 in various body tissues of the unstressed rabbit. Western blotting with monoclonal antibody 29A revealed very low levels in muscle and highest levels in neural regions (cerebellum, cerebral hemispheres, and retina) and in testes and thymus. Intermediate levels were apparent in other tissues such as liver, kidney, heart, and small intestine. Following hyperthermia, induction of hsp90 was not detected with 1-D Western blotting in tissues which demonstrated high constitutive levels; however, elevations were noted in tissues which showed lower constitutive amounts of the protein, such as kidney, heart, and muscle. Immunocytochemical studies revealed that hsp90 is preferentially localized to neuronal cell populations in the rabbit brain and that this pattern does not alter following hyperthermic conditions which result in glial induction of hsp70. In kidney, where constitutive levels of hsp90 are lower than in brain, an induction of hsp90 was noted in renal tubules following hyperthermia.

To study the effect of hydroxychloroquine on cytokine production by monocytes and T cells, cells were pretreated with varying concentrations of hydroxychloroquine and stimulated with lipopolysaccharide (monocytes), phytohemagglutinin or anti-CD-3 monoclonal antibodies (T cells). Interleukin 1 alpha (IL-1-alpha), IL-6 and tumor necrosis factor alpha (TNF-alpha) production were measured from the stimulated monocytes and IL-2, IL-4 and gamma interferon (IFN-gamma) were measured from the stimulated T cells. Hydroxychloroquine inhibited production of IL-1-alpha (monocytes) and IL-6 (T cells and monocytes). In contrast IL-2, IL-4, TNF-alpha and IFN-gamma production were not affected. Preferential inhibition of IL-1-alpha production by monocytes and IL-6 production by T cells and monocytes may contribute to its antiinflammatory effect in autoimmune diseases.