The current UK perspective of breast surgeons on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

Abstract

Background

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of T cell lymphoma associated with breast implants. Five hundred and twenty-one cases have been reported worldwide to date. The clinical presentation has two distinct subtypes: late seroma and, rarely, a distinct mass lesion. We wanted to determine the implications of this emerging disease on the current practice of breast surgeons in the United Kingdom (UK) and Ireland and whether they have changed their practice following growing reports of associations with BIA-ALCL in the literature.

Methods

An 11-question survey was sent to four associations in the UK and Ireland: Association of Breast Surgery (ABS); British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS); British Association of Aesthetic Plastic Surgeons (BAAPS); and the Irish Association of Plastic Surgeons (IAPS). It was advertised in newsletters and also emailed to a list of consultant members of BAPRAS.

Results

Seventy-two responses were from consultant surgeons throughout both the UK and Ireland. Ninety-seven percent of consultants discussed the risks and associations of breast implants and BIA-ALCL with their patients. Seventeen percent had a patient who was diagnosed with ALCL in their practice. Seventeen percent of consultants have already changed their practice, including a transition to using smooth implants or using micro- or nano-textured implants. A further 11% will consider changing their practice in the future depending on more information and recommendations from higher departments.

Conclusions

BIA-ALCL is likely to be caused by a complex interplay of factors, allowing for the variation in clinical presentation and disease progression. Our survey has already shown a growing knowledge amongst breast surgeons in the UK and Ireland as well as a switch in practice in less than a third of consultants already.

Level of Evidence: not ratable

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NLRP1 promotes TGF-β1-induced myofibroblast differentiation in neonatal rat cardiac fibroblasts

Abstract

Nuclear localization leucine-rich-repeat protein 1 (NLRP1) is a member of Nod-like receptors (NLRs) family. Recent studies have reported that NLRP1 is involved in various diseases, especially in cardiovascular diseases. However, the effect of NLRP1 on cardiac fibrosis remains unclear. In this study, NLRP1 overexpression and NLRP1 silencing constructs were transfected into neonatal rat cardiac fibroblasts induced by TGF-β1 for 48 h to investigate the effect of NLRP1 in cardiac fibrosis and its molecular mechanisms. Cardiac fibroblasts were transfected with NLRP1 and then cultured in the presence and absence of TGF-β1and Smad3 inhibitor (SIS3). Our data indicated that NLRP1 not only promoted fibroblast activation and myofibroblast differentiation, but also upregulated the mRNA and protein levels of α-SMA in the TGF-β1-treated neonatal rat cardiac fibroblasts. Overexpressing NLRP1 in TGF-β1-induced cardiac fibroblasts upregulated the mRNA and protein levels of Collagen I, Collagen III, and connective tissue growth factor. Moreover, NLRP1 upregulated the protein levels of Smad2, Smad3, and Smad4 in nuclei of fibroblasts, and attenuated levels of phosphorylated Smad2 and Smad3 in the cytoplasm of fibroblasts induced by TGF-β1. In addition, the increase in fibrotic genes and Smad proteins was significantly reduced in the presence of SIS3. Our findings illustrated that NLRP1 promoted myofibroblast differentiation and excessive ECM production in TGF-β1-induced neonatal cardiac fibroblasts through directly targeting TGF-β1/Smad signaling pathways.

https://ift.tt/2MUNkrq

Diagnostic Performance of F-18 Fluorocholine PET/CT for Parathyroid Localization in Hyperparathyroidism: a Systematic Review and Meta-Analysis

Abstract

The purpose of the current study was to investigate the diagnostic performance of F-18 Fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) for localization of hyperfunctioning parathyroid gland in patients with hyperparathyroidism (HPT) through a systematic review and meta-analysis. The MEDLINE/PubMed and EMBASE database, from the earliest available date of indexing through April 30, 2018, were searched for studies evaluating the diagnostic performance of F-18 FCH PET/CT for localization of hyperfunctioning parathyroid gland in patients with HPT. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR−), and constructed summary receiver operating characteristic curves. Across eight studies (272 patients), the pooled sensitivity for F-18 FCH PET/CT was 0.90 (95% CI, 0.86–0.94) without heterogeneity (I² = 7.1) and a pooled specificity of 0.94 (95% CI, 0.90–0.96) with heterogeneity (I² = 79.8). Likelihood ratio (LR) syntheses gave an overall positive likelihood ratio (LR+) of 5.3 (95% CI, 1.2–24.3) and negative likelihood ratio (LR−) of 0.15 (95% CI, 0.08–0.29). The pooled diagnostic odds ratio (DOR) was 38 (95% CI, 8–174). Hierarchical summary receiver operating characteristic (ROC) curve indicates that the areas under the curve were 0.9492 (SE, 0.0215). In meta-regression analysis, no definite variable was the source of the study heterogeneity. The current meta-analysis showed the high sensitivity and specificity of F-18 FCH PET/CT for localization of hyperfunctioning parathyroid gland. At present, the literature regarding the use of F-18 FCH PET/CT for localization of hyperfunctioning parathyroid gland remains still limited; thus, further large multicenter studies would be necessary to substantiate the diagnostic accuracy of F-18 FCH PET/for localization of hyperfunctioning parathyroid gland in patients with HPT.

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Discussing sexuality in the field of plastic and reconstructive surgery: a national survey of current practice in the Netherlands

Abstract

Background

Patient-reported outcomes have become increasingly important to assess the value of surgical procedures. Sexual function is a proven important constituent of quality of life, but is often overlooked by health care professionals. We aim to investigate to what extent plastic surgeons address or discuss issues concerning sexuality with their patients, and if there is a need for improvement.

Methods

We developed a survey to assess whether topics pertaining to sexual function were discussed during plastic surgical consultations. In 2016, all 385 members of the Dutch Association for Plastic Surgery were invited via post mail to participate.

Results

We received 106 completed surveys (27.5%). The median age of the respondents was 45 (29–66) years. Most participants (78.3%) indicated that they rarely to never discuss sexuality with their patients. Surgeons in the subspecialization gender and genital surgery discussed sexual function most frequently. Two thirds of all respondents indicated that their current knowledge on this topic was insufficient, yet there was generally no interest expressed in receiving additional training (78.6%). However, there was a need for proper patient brochures (43.4%) and an organized referral network (36.5%) regarding sexuality.

Conclusions

In plastic surgery practice, sexuality appears to be a rarely discussed subject, with the gender and genital surgery subspecialties as the exception. Although professionals and patients emphasize the importance of sexuality, plastic surgeons express limited urge to be trained and prefer written patient information and referring patients to other healthcare professionals. The authors stimulate more education on sexuality during (continued) plastic surgery training.

Level of Evidence: Not ratable

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Postoperative pain management — 2018 consensus statement

brak

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Single‐Agent Regorafenib in Metastatic Colorectal Cancer Patients with Any RAS or BRAF Mutation Previously Treated with FOLFOXIRI plus Bevacizumab (PREVIUM Trial)

AbstractLessons Learned. RAS‐ or BRAF‐mutated metastatic colorectal cancers (mCRCs) progressing after first‐line treatment have a poor prognosis.European and U.S. guidelines include the multikinase inhibitor regorafenib as a standard option for second‐line therapy and beyond, based on the results of the randomized phase III CORRECT trial demonstrating improvement in survival.Although stopped prematurely for failing to accrue, the PREVIUM trial, the first prospective interventional study exploring regorafenib as second‐line treatment for patients with mCRC bearing RAS or BRAF mutations, failed to demonstrate clinical activity in the population analyzed.Background.Patients with RAS‐ or BRAF‐mutated (mut) metastatic colorectal cancer (mCRC) progressing on first‐line bevacizumab plus 5‐FU/irinotecan/oxaliplatin (FOLFOXIRI) have a poor prognosis. We aimed to assess the efficacy and safety of regorafenib in this population.Methods.Regorafenib was administered daily for 3 weeks of each 4‐week cycle until disease progression or other reason. The primary endpoint was 6‐month progression‐free survival (PFS).Results.KRAS, NRAS, or BRAF was mutated in mCRC samples in 60%, 20%, and 13% of patients, respectively. Median time from initial diagnosis of metastases to the start of regorafenib and treatment duration was 13.8 months and 7 weeks, respectively. Reasons for discontinuation included disease progression (80%), investigator decision (13%), and adverse events (AEs; 7%). Seven patients (47%) required dose reduction, mostly for asthenia (43%). The most common regorafenib‐related grade 3 AEs were asthenia (33%), dysphonia (13%), and hypertension (13%) (Table 1). There were no grade 4 toxicities. No patient was progression‐free at 6 months. Median PFS, time to progression (TTP), and overall survival (OS) were 2.2, 2.0, and 3.3 months, respectively.Conclusion.Although stopped prematurely for failing to accrue, in the population analyzed, regorafenib failed to demonstrate clinical activity in KRAS‐ or BRAF‐mutated mCRC with progression following first‐line with FOLFOXIRI plus bevacizumab, although tolerability was acceptable. Our trial suggests that exploring regorafenib efficacy in an earlier line of therapy should not be undertaken without better population refinement.

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Impact of Guideline‐Discordant Treatment on Cost and Health Care Utilization in Older Adults with Early‐Stage Breast Cancer

AbstractBackground.National Comprehensive Cancer Network (NCCN) guideline‐based treatment is a marker of high‐quality care. The impact of guideline discordance on cost and health care utilization is unclear.Materials and Methods.This retrospective cohort study of Medicare claims data from 2012 to 2015 included women age ≥65 with stage I–III breast cancer receiving care within the University of Alabama at Birmingham Cancer Community Network. Concordance with NCCN guidelines was assessed for treatment regimens. Costs to Medicare and health care utilization were identified from start of cancer treatment until death or available follow‐up. Adjusted monthly cost and utilization rates were estimated using linear mixed effect and generalized linear models.Results.Of 1,177 patients, 16% received guideline‐discordant treatment, which was associated with nonwhite race, estrogen receptor/progesterone receptor negative, human epidermal growth receptor 2 (HER2) positive, and later‐stage cancer. Discordant therapy was primarily related to reduced‐intensity treatments (single‐agent chemotherapy, HER2‐targeted therapy without chemotherapy, bevacizumab without chemotherapy, platinum combinations without anthracyclines). In adjusted models, average monthly costs for guideline‐discordant patients were $936 higher compared with concordant (95% confidence limits $611, $1,260). For guideline‐discordant patients, adjusted rates of emergency department visits and hospitalizations per thousand observations were 25% higher (49.9 vs. 39.9) and 19% higher (24.0 vs. 20.1) per month than concordant patients, respectively.Conclusion.One in six patients with early‐stage breast cancer received guideline‐discordant care, predominantly related to undertreatment, which was associated with higher costs and rates of health care utilization. Additional randomized trials are needed to test lower‐toxicity regimens and guide clinicians in treatment for older breast cancer patients.Implications for Practice.Previous studies lack details about types of deviations from chemotherapy guidelines that occur in older early‐stage breast cancer patients. Understanding the patterns of guideline discordance and its impact on patient outcomes will be particularly important for these patients. This study found 16% received guideline‐discordant care, predominantly related to reduced intensity treatment and associated with higher costs and rates of health care utilization. Increasing older adult participation in clinical trials should be a priority in order to fill the knowledge gap about how to treat older, less fit patients with breast cancer.

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Prognostic Factors in Patients with Metastatic Breast Cancer with Bone‐Only Metastases

AbstractBackground.Patients with metastatic breast cancer with bone‐only metastases (BOM) are a unique patient population without consensus regarding high‐risk characteristics, which we sought to establish.Methods.We identified 1,445 patients with BOM followed for at least 6 months at MD Anderson Cancer Center from January 1, 1997, to December 31, 2015.Results.Seventy‐one percent (n = 936) of the 1,325 patients with BOM with available pain characterization were symptomatic at time of BOM diagnosis. Pain was more common in patients with lytic compared with blastic or sclerotic metastases (odds ratio [OR], 1.79; 95% confidence interval [CI,] 1.26–2.53) and multiple versus single bone metastases (OR, 1.37; 95% CI, 1.03–1.83). Poorer overall survival (OS) was also noted in patients with multiple bone metastases (median OS, 4.80 years; 95% CI, 4.49–5.07) compared with single bone metastasis (median OS, 7.54 years; 95% CI, 6.28–10.10) and in patients with metastases in both the axial and appendicular skeleton (median OS, 4.58 years; 95% CI, 4.23–4.96) compared with appendicular‐only (median OS, 6.78 years; 95% CI, 5.26–7.96) or axial‐only metastases (median OS, 5.62 years; 95% CI, 4.81–6.69). Black/non‐Hispanic patients had poorer outcomes, and patients aged 40–49 years at time of breast cancer diagnosis had significantly better OS compared with both younger and older patient groups.Conclusion.Overall, several risk features for decreased OS were identified, including multiple bone metastases and both axial and appendicular skeleton involvement. Multiple bone metastases and lytic bone metastases were associated with increased pain.Implications for Practice.Patients with metastatic breast cancer and bone‐only metastases (BOM) represent a poorly characterized patient subset. The ability to identify unique patient characteristics at time of BOM diagnosis associated with increased morbidity or mortality would allow for recognition of patients who would benefit from more aggressive therapy. In this study, the largest sample of patients with BOM thus far reported is characterized, highlighting several higher‐risk BOM groups, including those with multiple bone metastases and bone metastases in both the axial and appendicular skeleton at time of BOM diagnosis. In addition to tailoring current practices for these high‐risk patients, ongoing studies of these patients are indicated.

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Adjuvant Anthracyclines in Breast Cancer: What Is Their Role?

AbstractAnthracyclines have been a mainstay of breast cancer therapy for decades, with strong evidence demonstrating their impact on breast cancer survival. However, concerns regarding rare but serious long‐term toxicities including cardiotoxicity and hematologic malignancies have driven interest in alternative adjuvant therapy options with more favorable toxicity profiles. This article provides an update of data that help inform clinicians of the role anthracyclines should play in adjuvant breast cancer therapy. Two recently reported large randomized trials—the Anthracycline in Early Breast Cancer and Western German Study Plan B studies—compared a taxane and cyclophosphamide regimen with an anthracycline, taxane, and cyclophosphamide regimen. Although the studies had conflicting results, together these studies suggest that the benefit of adjuvant anthracycline therapy over a nonanthracycline taxane‐containing regimen is modest at best and may be primarily seen in patients with especially high‐risk disease (i.e., triple‐negative breast cancer, involvement of multiple lymph nodes). A third study—the MINDACT study—compared an anthracycline‐based regimen to a nonanthracycline regimen, with similar outcomes in both groups. Despite the toxicities, no adjuvant breast cancer regimen has been shown to be superior to an anthracycline‐taxane regimen in high‐risk patients. These data can directly inform clinical decision‐making in determining which patients warrant use of adjuvant anthracycline therapy. Future research may focus on confirming subgroups for whom it is reasonable to forgo adjuvant anthracyclines and validating predictive biomarkers or scores for anthracycline benefit.Implications for Practice.In patients with early breast cancer, the choice of adjuvant chemotherapy should be based on its effectiveness in reducing breast cancer recurrences and its short‐ and long‐term toxicities. Although adjuvant anthracycline and taxane chemotherapy has the most data supporting its effectiveness, anthracyclines carry a small but important increased risk for cardiotoxicity and leukemia. Two recent clinical trials help describe the degree of benefit with adjuvant anthracycline therapy compared with taxane therapy alone. They suggest that in patients with hormone receptor‐positive breast cancer and limited lymph node involvement, nonanthracycline taxane‐based adjuvant therapy may be adequate.

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Permanent Chemotherapy‐Induced Alopecia in Patients with Breast Cancer: A 3‐Year Prospective Cohort Study

AbstractBackground.Although chemotherapy‐induced alopecia (CIA) is considered temporary, some patients report persistent alopecia several years after chemotherapy. There is, however, a paucity of long‐term prospective data on the incidence and impact of permanent CIA (PCIA). The objective of our study was to estimate the long‐term incidence of PCIA in a cohort of patients with breast cancer whose hair volume and density were measured prior to chemotherapy and who were followed for 3 years after chemotherapy.Materials and Methods.Prospective cohort study of consecutive patients ≥18 years of age with postoperative diagnosis of stage I–III breast cancer expected to receive adjuvant chemotherapy at the outpatient breast cancer clinic at the Samsung Medical Center in Seoul, Korea, from February 2012 to July 2013 (n = 61). Objective hair density and thickness were measured using a noninvasive bioengineering device.Results.The proportion of participants who had PCIA at 6 months and 3 years was 39.5% and 42.3%, respectively. PCIA was characterized in most patients by incomplete hair regrowth. Patients who received a taxane‐based regimen were more likely to experience PCIA compared with patients with other types of chemotherapy. At a 3‐year follow‐up, hair thinning was the most common problem reported by study participants (75.0%), followed by reduced hair volume (53.9%), hair loss (34.6%), and gray hair (34.6%).Conclusion.PCIA is a common adverse event of breast cancer adjuvant cytotoxic chemotherapy. Clinicians should be aware of this distressing adverse event and develop supportive care strategies to counsel patients and minimize its impact on quality of life.Implications for Practice.Knowledge of permanent chemotherapy‐induced alopecia, an under‐reported adverse event, should lead to optimized pretherapy counseling, anticipatory coping techniques, and potential therapeutic strategies for this sequela of treatment.

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In Reply

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Clinicopathological and Treatment‐Associated Prognostic Factors in Patients with Breast Cancer Leptomeningeal Metastases in Relation to Tumor Biology

AbstractBackground.Breast cancer (BC) is one of the solid tumors most commonly associated with leptomeningeal disease (LMD). LMD carries a devastating prognosis; however, disease presentation and prognostic factors are uncertain.Subjects, Materials, and Methods.In order to describe patient characteristics, treatment patterns, and factors associated with survival in a contemporary multicentric cohort, 153 consecutive BC patients diagnosed with LMD at two European institutions (2002–2017) were included. Time to LMD and overall survival (OS) after LMD diagnosis were evaluated using the Kaplan‐Meier method and Cox proportional hazards models.Results.Median age at LMD diagnosis was 58 years (25–84). Tumor phenotype distribution was as follows: hormone receptor (HR) positive (HR+)/human epidermal growth receptor 2 (HER2) negative 51.0%, triple‐negative 15.0%, HR+/HER2 positive (HER2+) 13.1% and HR negative/HER2+ 7.2%. Most patients received active anticancer treatments (radiation therapy [RT] n = 42, systemic therapy n = 110, intrathecal treatment n = 103).Median OS was 3.9 months (95% confidence interval [CI] 2.4–5.5). Eastern Cooperative Oncology Group performance status (ECOG PS) >2, high white blood cells count, low glucose, and high protein in cerebrospinal fluid (CSF) were poor prognostic factors. Having received RT or systemic treatment was associated with better prognosis. In multivariate analysis, ECOG PS (hazard ratio 2.22, 95% CI 1.25–3.94), CSF glucose levels (hazard ratio 1.74, 95% CI 1.05–2.88), and having received systemic treatment (hazard ratio 0.17, 95% CI 0.09–0.32) were confirmed as independent prognostic factors. In HER2+ BC patients, having received systemic HER2‐targeted therapy was the only factor maintaining independent prognostication (hazard ratio 0.12, 95% CI 0.02–0.67) in multivariate analysis.Conclusion.Despite being limited by their retrospective nature, these results highlight the need for clinical trials in BC LMD, stratified on tumor biology.Implications for Practice.Leptomeningeal disease (LMD) is a devastating complication of breast cancer (BC), and its optimal therapy is still not defined. Here, patient characteristics, treatment patterns, and prognostic factors from a contemporary cohort of 153 BC‐related LMD patients are reported. In multivariate analysis, Eastern Cooperative Oncology Group performance status, cerebrospinal fluid glucose levels, and having received systemic treatment were confirmed as independent prognostic factors in the overall population, whereas in human epidermal growth receptor 2 (HER2) positive BC patients, having received systemic HER2‐targeted therapy was the only factor maintaining independent prognostication in multivariate analysis. These results highlight the need to consider stratification on tumor biology in the treatment of BC LMD.

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FDA Approval Summary: Vemurafenib for the Treatment of Patients with Erdheim‐Chester Disease with the BRAFV600 Mutation

AbstractOn November 6, 2017, the U.S. Food and Drug Administration (FDA) granted regular approval to vemurafenib for the treatment of adult patients with Erdheim‐Chester disease (ECD) with BRAFV600 mutation. ECD is a type of histiocytosis, a rare disorder characterized by an abnormal accumulation and behavior of cells of the mononuclear phagocytic system, which includes antigen‐processing cells, dendritic cells, monocytes, or macrophages. Recently published data confirm a frequency of 54% of BRAFV600E mutations in patients with ECD.Approval was based on a cohort of 22 patients who received 960 mg of vemurafenib twice daily within the VE Basket Trial (MO28072), a single‐arm, multicenter, multiple cohort study. Patients in the ECD cohort had histologically confirmed ECD with BRAFV600 mutations that were refractory to standard therapy. The ECD cohort achieved an overall response rate of 54.5% (95% confidence interval: 32.2–75.6), with a complete response rate of 4.5%. With a median duration of follow‐up of 26.6 months, the median duration of response has not been reached. The most frequently reported adverse reactions (>50%) in the ECD cohort were arthralgia, rash maculo‐papular, alopecia, fatigue, electrocardiogram QT interval prolonged, and skin papilloma. The median treatment duration for ECD patients in this study was 14.2 months. This article describes the FDA review of the vemurafenib efficacy supplement for patients with ECD with BRAFV600 mutations.Implications for Practice.Vemurafenib, an oral monotherapy targeting a mutation in BRAF, is the first U.S. Food and Drug Administration approval for the treatment of Erdheim‐Chester disease (ECD). ECD is an extremely rare hematopoietic neoplasm that represents clonal proliferation of myeloid progenitor cells. ECD may involve bone and one or more organ systems, primarily affecting adults in their 5th and 7th decades of life, with a slight male predominance. This approval provides an effective and reasonably safe therapy for patients with a serious and life‐threatening condition for which no approved therapy exists.

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FDA Approval Summary: Pembrolizumab for Recurrent Locally Advanced or Metastatic Gastric or Gastroesophageal Junction Adenocarcinoma Expressing PD‐L1

AbstractOn September 22, 2017, the U.S. Food and Drug Administration (FDA) granted accelerated approval for pembrolizumab (Keytruda, Merck 1.4% had complete responses. Response durations ranged from 2.8+ to 19.4+ months; 11 patients (58%) had response durations of 6 months or longer, and 5 patients (26%) had response durations of 12 months or longer. The most common (≥20%) adverse reactions of pembrolizumab observed in KEYNOTE‐059/Cohort 1 were fatigue, decreased appetite, nausea, and constipation. The most frequent (≥2%) serious adverse drug reactions were pleural effusion, pneumonia, dyspnea, pulmonary embolism, and pneumonitis. Pembrolizumab was approved concurrently with the PD‐L1 immunohistochemistry 22C3 pharmDx test (Dako, Agilent, Santa Clara, CA) for selection of patients with gastric cancer for treatment with pembrolizumab based on PD‐L1 tumor expression.Implications for Practice.This report presents key information on the basis for Food and Drug Administration approval of pembrolizumab for the treatment of patients with locally advanced or metastatic gastric or GEJ adenocarcinoma whose tumors express PD‐L1. The report discusses the basis for limiting the indication to patients with PD‐L1‐expressing tumors and the basis for recommending that PD‐L1 status be assessed using a fresh tumor specimen if PD‐L1 expression is not detected in an archival gastric or GEJ cancer specimen.

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Prognostic Understanding at Diagnosis and Associated Factors in Patients with Advanced Lung Cancer and Their Caregivers

AbstractBackground.Prognostic understanding in advanced cancer patients and their caregivers may have an impact on the delivery of effective care. The aims of this study were to explore prognostic understanding at diagnosis in both patients with advanced lung cancer and their caregivers and to investigate correlates of their understanding.Subjects, Materials, and Methods.A total of 193 patients with newly diagnosed advanced lung cancer and their 167 caregivers were enrolled at 16 hospitals in Japan. We assessed their perceptions of prognosis and goals of therapy and examined their associations with their sociodemographic characteristics, clinical status, quality of life, mood symptoms, and the status of disclosure of information by their treating physicians.Results.One fifth of patients and caregivers (21.7% and 17.6%, respectively) mistakenly believed that the patients' cancer was "completely curable." Substantial proportions of them (16.9% and 10.3%, respectively) mistakenly believed that the primary goal of therapy was to remove all the cancer. Levels of anxiety and depression in both patients and caregivers were significantly higher among those who had accurate understanding of prognosis. In multivariate analyses, inaccurate perceptions of prognosis in patients were associated with sex, better emotional well‐being, and lower lung cancer‐specific symptom burden. Caregivers' inaccurate perceptions of patients' prognoses were associated with better performance status and better emotional well‐being of patients.Conclusion.Substantial proportions of advanced lung cancer patients and their caregivers misunderstood their prognosis. Interventions to improve their accurate prognostic understanding should be developed with careful attention paid to its associated factors.Implications for Practice.This study demonstrated that substantial proportions of patients with newly diagnosed advanced lung cancer and their caregivers had misunderstandings about their prognosis. Accurate perceptions of prognosis, which are indispensable in the delivery of effective care, were associated with elevated levels of anxiety and depression in both patients and caregivers, warranting psychosocial care and support for them immediately after diagnosis. Inaccurate perceptions of prognosis in patients were associated with better emotional well‐being and lower lung cancer‐specific symptom burden. Illness understanding in caregivers was associated with patients' physical and mental status. Those findings provide insight into how they obtain accurate illness understanding.

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Another Chapter of the Right Versus Left Story: Is Primary Tumor Location a Prognostic Feature in RAS Mutant Metastatic Colorectal Cancer?

AbstractBackground.The prognostic value of primary tumor location (PTL) in patients with metastatic colorectal cancer (mCRC) was reported by recent analyses in RAS wild‐type patients. Here, we investigated the prognostic value of PTL in RAS mutated mCRC patients.Materials and Methods.PTL was defined as left or right if distal or proximal to the splenic flexure. Primary endpoint was overall survival (OS) according to PTL. Subgroup analyses were conducted according to time to metastases and RAS mutation subtypes.Results.Five hundred sixty‐four patients were included. Left‐ and right‐sided cases were 65% and 35%, respectively. No difference in OS was detected according to PTL (hazard ratio [HR] = 0.99, p = .964). No difference in OS was observed in right versus left when looking at synchronous (HR 0.92, p = .557) or metachronous (HR 1.07, p = .807) patients.Conclusion.No OS difference was detected in RAS mutated mCRC. Molecular and clinical features able to improve prognosis and treatment strategies in this setting are needed.

https://ift.tt/2OKPLxh

Cardiorespiratory Fitness is Associated with Glycated Hemoglobin and Triglyceride Levels in Severely Obese Men: A Retrospective Clinical Data Analysis

Exp Clin Endocrinol Diabetes
DOI: 10.1055/a-0650-4020

Background Even subjects with severe obesity show a wide range of metabolic health states, with some showing marked alterations in glucose and lipid metabolism whereas others do not. In severely obese women, we could recently show that the degree of cardiorespiratory fitness is, independently of body mass and age, associated with several markers of glucose and lipid metabolism. Aims In our retrospective study on a clinical data set, we questioned whether such an association also exists in severely obese men. Methods Cardiorespiratory fitness, i. e. workload (Wpeak) and oxygen uptake (V̇O2,peak) at peak exercise, was assessed by a bicycle spiroergometry in 133 severely obese men (all BMI>35 kg m−2). The following metabolic blood markers were also measured: Fasting serum glucose, insulin, triglycerides (TG), total, low-, high-density cholesterol (Chol, LDL, HDL), uric acid, and whole blood glycated hemoglobin (HbA1c). The Chol/HDL ratio and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) were also calculated. Results Multiple stepwise linear regression models including age, body mass, and smoking status as independent variables revealed that Wpeak and V̇O2,peak, explained 4.5 to 10.7% of variance in HbA1c and TG (all beta<− 0.22; all p<0.02). Including fat free mass instead of body mass in respective models revealed that both Wpeak and V̇O2,peak were predictors of HbA1c and TG (all beta<− 0.265; all p<0.013), respectively, while Wpeak also accounted for variance in glucose and Chol (both beta<− 0.259; both p<0.023). Conclusions Similar to previous observations in women, our data indicate that cardiorespiratory fitness assessed by bicycle ergospirometry test is associated with glucose and lipid metabolism in severely obese men. The strength of the found associations suggest a mild to moderate influence of cardiorespiratory fitness on metabolic health in severe obesity.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Overall survival and mortality risk factors in Takayasu's arteritis: A multicenter study of 318 patients

Publication date: Available online 17 August 2018

Source: Journal of Autoimmunity

Author(s): Adrien Mirouse, Lucie Biard, Cloé Comarmond, Marc Lambert, Arsène Mekinian, Yasmina Ferfar, Jean-Emmanuel Kahn, Ygal Benhamou, Laurent Chiche, Fabien Koskas, Philippe Cluzel, Eric Hachulla, Emmanuel Messas, Patrice Cacoub, Tristan Mirault, Matthieu Resche-Rigon, David Saadoun, French Takayasu network

Abstract

Objective

To report the long term mortality in Takayasu arteritis (TA) and to identify prognosis factors.

Methods

We analyzed the causes of death and the factors associated with mortality in a cohort of 318 patients [median age at diagnosis was 36 [25–47] years and 276 (86%) patients were women] fulfilling American College of Rheumatology and/or Ishikawa criteria of TA. A prognostic score for death and vascular complications was elaborated based on a multivariate model.

Results

Among 318 TA patients, 16 (5%) died after a median [IQR] follow-up of 6.1 [2.8–13.0] years. The median age at death was 38 [25–47] years with 88% of women. Main causes of death included mesenteric ischemia (n = 4, 25%) and aortic aneurysm rupture (n = 4, 25%). The mortality rate at 5 and 10 years was of 1.9% and 3.9%, respectively. Caucasians (p = 0.049) and smokers (p = 0.002) TA patients were more likely to die. There was an increased mortality in TA (SMR with 95% confidence interval, 2.73 [1.69–4.22]) as compared to age and sex matched healthy controls. We defined high risk patients for death and vascular complications according to the presence of two of the following factors (i.e a progressive clinical course, thoracic aorta involvement and/or retinopathy). In the high risk TA group, the 5-year incidence of death and vascular complication was 48.5% compared to 21.6% (p = 0.001) in those with low risk.

Conclusion

The overall mortality in our Takayasu cohort was 5% after a median follow-up of 6.1 years. We identified specific characteristics that distinguish TA patients at highest risk for death and vascular complications.

https://ift.tt/2OLgQAG

Fingolimod modulates T cell phenotype and regulatory T cell plasticity in vivo

Publication date: Available online 16 August 2018

Source: Journal of Autoimmunity

Author(s): Margarita Dominguez-Villar, Khadir Raddassi, Ann Caroline Danielsen, Joseph Guarnaccia, David A. Hafler

Abstract

Fingolimod is an approved therapeutic option for patients with relapsing-remitting multiple sclerosis that primarily functions by sequestering T cells in lymph nodes inhibiting their egress to the central nervous system. However, recent data suggests that Fingolimod may also directly affect the immune cell function. Here we examined the in vivo effects of Fingolimod in modulating the phenotype and function of T cell and Foxp3 regulatory T cell populations in patients with multiple sclerosis under Fingolimod treatment. Besides decreasing the cell numbers in peripheral blood and sera levels of pro-inflammatory cytokines, Fingolimod inhibited the expression of Th1 and Th17 cytokines on CD4⁺ T cells and increased the expression of exhaustion markers. Furthermore, treatment increased the frequency of regulatory T cells in blood and inhibited the Th1-like phenotype that is characteristic of patients with multiple sclerosis, augmenting the expression of markers associated with increased suppressive function. Overall, our data suggest that Fingolimod performs other important immunomodulatory functions besides altering T cell migratory capacities, with consequences for other autoimmune pathologies characterized by excessive Th1/Th17 responses and Th1-like regulatory T cell effector phenotypes.

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Magnetic ion exchange resin for effective removal of perfluorooctanoate from water: study of a response surface methodology and adsorption performances

Abstract

This research exhibited the use of magnetic ion exchange (MIEX) resin as an effective adsorbent for the removal of perfluorooctanoate (PFOA) in aqueous solution. The adsorption performance of PFOA was investigated by a batch experiment. All kinds of factors affecting the adsorption of PFOA, including adsorbent dosage, initial concentration, adsorption time, temperature, stirring intensity, coexistent anions, initial solution pH, natural organic matter, ion strength, and bed volume were studied. Moreover, the response surface methodology was put into use to know the key parameters affecting PFOA removal efficiency. The sorption equilibrium and kinetic data could conform well to the Langmuir and pseudo-second-order model, respectively. Thermodynamic parameters were obtained, and it was observed that the adsorption of PFOA onto MIEX resin was an endothermic and spontaneous process at the temperatures under investigation. It was summarized that both chemical absorption and physical adsorption were involved in the PFOA sorption onto the MIEX resin. Moreover, the MIEX resin could be effectively regenerated using a saturated sodium chloride solution. A series of batch experiments and characterizations demonstrated that the MIEX resin possessed a strong adsorption ability with the removal efficiency exceeding 90%, allowing a possible practical application in future water treatment.

https://ift.tt/2vRfUDH

Effects of organic-inorganic amendments on the cadmium fraction in soil and its accumulation in rice ( Oryza sativa L.)

Abstract

Cadmium (Cd) stress is a serious concern in agricultural soils worldwide, and increasing accumulation and subsequent transfer to humans via the food chain can have potentially harmful effects. In this study, field experiments were conducted to examine the uptake and translocation of Cd in rice, changes in the soil Cd speciation, and the subsequent effect on Cd accumulation in rice under combined organic (farmyard manure and crop straw) and inorganic (sepiolite, lime, and calcium-magnesium phosphate) soil amendments. The results showed that farmyard manure combined with sepiolite or lime and straw combined with lime or calcium-magnesium phosphate reduced the Cd translocation from the rice roots to the straw and the grains, significantly decreasing the Cd accumulation in brown rice. In addition, straw combined with sepiolite, lime, or calcium-magnesium phosphate reduced the Cd accumulation in brown rice but increased the Cd translocation from the roots to the straw by 37.8–279.3% compared with the control. Organic-inorganic amendments also decreased the soil exchangeable Cd and increased the organic-bound Cd by more than 40%. Fe-Mn oxide-bound Cd also increased but varied with growth. Cd accumulation in brown rice showed a significant positive relationship with soil exchangeable Cd at 90 days after transplantation, while at 30 days, the increase in Fe-Mn oxide- and organic-bound Cd was found to be the key factor in reducing the Cd accumulation in rice. These findings suggest that straw (under rice-rape rotation) and farmyard manure (under rice-wheat rotation) combined with sepiolite or lime are widely applicable as agronomic control techniques aimed at lowering Cd pollution.

https://ift.tt/2L2MIOP

The 44th Annual Meeting of the North American Neuro-Ophthalmology Society in Waikola Village on the Big Island, Hawaii 2018

No abstract available

https://ift.tt/2MZQElm

Ocular Motor Dysfunction Due to Brainstem Disorders

Background: The brainstem contains numerous structures including afferent and efferent fibers that are involved in generation and control of eye movements. Evidence Acquisition: These structures give rise to distinct patterns of abnormal eye movements when damaged. Defining these ocular motor abnormalities allows a topographic diagnosis of a lesion within the brainstem. Results: Although diverse patterns of impaired eye movements may be observed in lesions of the brainstem, medullary lesions primarily cause various patterns of nystagmus and impaired vestibular eye movements without obvious ophthalmoplegia. By contrast, pontine ophthalmoplegia is characterized by abnormal eye movements in the horizontal plane, while midbrain lesions typically show vertical ophthalmoplegia in addition to pupillary and eyelid abnormalities. Conclusions: Recognition of the patterns and characteristics of abnormal eye movements observed in brainstem lesions is important in understanding the roles of each neural structure and circuit in ocular motor control as well as in localizing the offending lesion.

https://ift.tt/2Pi3qNq

Optic Disc Edema in Glial Fibrillary Acidic Protein Autoantibody–Positive Meningoencephalitis

Background: Glial fibrillary acidic protein (GFAP) autoantibody–positive meningoencephalitis is a newly described entity characterized by a corticosteroid-responsive meningoencephalomyelitis. Some patients with GFAP autoantibody–positive meningoencephalitis have been found to have optic disc edema, which has previously not been well characterized. Methods: We performed a retrospective, observational case series of Mayo Clinic patients found to have GFAP-IgG and optic disc edema from January 1, 2000, to December 31, 2016. We identified 40 patients with GFAP-IgG seropositivity by tissue-based immunofluorescence and cell-based assay. Patients were screened for the following inclusion criteria: 1) serum, cerebrospinal fluid, or both that yielded a characteristic astrocytic pattern of mouse tissue immunostaining with confirmation of IgG reactive with specific GFAPα isoform by cell-based assay; 2) meningoencephalitis or encephalitis; and 3) optic disc edema. We excluded those with coexisting aquaporin-4-IgG or insufficient clinical information. Results: Ten patients had optic disc edema and met inclusion criteria. The median age was 39.5 years and 60% were men. Visual acuity was unaffected and disc edema was bilateral in all cases. Mild vitreous cell was noted in 3 patients. The optic disc edema resolved with corticosteroid treatment but resulted in mild optic atrophy in 2 patients. The median lumbar puncture opening pressure was 144 mm H2O (range, 84–298 mm H2O). Brain MRI revealed radial perivascular enhancement in all except 1 patient. Fluorescein angiography was available for 1 patient with optic disc edema, which showed leakage from the venules. Conclusions: Patients with GFAP autoantibody–positive meningoencephalitis can have optic disc edema that can mimic papilledema. The cause of the optic disc edema remains uncertain, but most patients did not have raised intracranial pressure.

https://ift.tt/2OIqILe

Acute Management of Optic Neuritis: An Evolving Paradigm

Abstract: The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.

https://ift.tt/2PgBBoN

Glial Fibrillary Acidic Protein Antibody: Another Antibody in the Multiple Sclerosis Diagnostic Mix

No abstract available

https://ift.tt/2OObTXR

Why Therapeutic Compliance in Optic Neuritis Deserves to be More Than Just a Footnote

No abstract available

https://ift.tt/2Pi3kW4

Visual Structure and Function in Collision Sport Athletes

Background: Vision-based measures have been shown to be useful markers in multiple sclerosis (MS), Alzheimer and Parkinson disease. Therefore, these testing paradigms may have applications to populations explaining repetitive head trauma that has been associated with long-term neurodegenerative sequelae. We investigated retinal structure and visual function in professional collision sport athletes compared to age- and race-matched control participants. Methods: In this cross-sectional study, participants underwent spectral-domain optical coherence tomography (OCT) measurements of peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC = ganglion cell + inner plexiform layers) thickness. High-contrast visual acuity (100% level), low-contrast letter acuity (LCLA) (1.25% and 2.5% levels), and King–Devick Test of rapid number naming performance were administered. Vision-specific quality of life (QOL) measures were assessed. Results: Among 46 collision sport athletes (boxing, n = 14; football, n = 29; ice hockey, n = 3) and 104 control participants, average RNFL thickness was a significant predictor of athlete vs control status with athletes demonstrating 4.8-μm of thinning compared to controls (P = 0.01, generalized estimating equation [GEE] models accounting for age and within-subject, intereye correlations). Athlete vs control status was not a predictor of RNFL thickness for the subgroup of football players in this cohort (P = 0.60). Binocular (P = 0.001) and monocular (P = 0.02) LCLA at 2.5% contrast and vision-specific QOL (P = 0.04) were significant predictors of athlete vs control status (GEE models accounting for age and within-subject, intereye correlations). Rapid number naming performance times were not significantly different between the control and athlete groups. Conclusions: This study showed that retinal axonal and neuronal loss is present among collision sport athletes, with most notable differences seen in boxers. These findings are accompanied by reductions in visual function and QOL, similar to patterns observed in multiple sclerosis, Alzheimer and Parkinson diseases. Vision-based changes associated with head trauma exposure that have the potential to be detected in vivo represent a unique opportunity for further study to determine if these changes in collision sport athletes are predictive of future neurodegeneration.

https://ift.tt/2MVSAuQ

Vision: It Is About the Brain

No abstract available

https://ift.tt/2nLXYWx

Images in Neuro-Ophthalmology

No abstract available

https://ift.tt/2MVcJkG

Sudden Bilateral Ptosis in a 61-Year-Old Woman

No abstract available

https://ift.tt/2nJ7HNc

Altered Macular Microvasculature in Mild Cognitive Impairment and Alzheimer Disease

Background: The goal of the present study was to analyze the macular microvacular network in mild cognitive impirment (MCI) and Alzheimer disease (AD). Methods: Twelve patients with AD and 19 patients with MCI were recruited together with 21 cognitively normal controls with a similar range of ages. Optical coherence tomography angiography was used to image the retinal microvascular network at the macular region, including retinal vascular network (RVN), superficial vascular plexus (SVP), and deep vascular plexus (DVP). Fractal analysis (box counting, Dbox) representing the microvascular density was performed in different annular zones and quadrantal sectors. The macular ganglion cell–inner plexiform layer (GC-IPL) thickness was measured using Zeiss OCT. The relationship between the retinal microvasculature and clinical manifestations was analyzed. Results: Patients with AD had lower densities of RVN, SVP, and DVP in the annulus, from 0.6 to 2.5 mm in diameter (P 0.05). There was a trend of vascular density loss from control to MCI then AD (P

https://ift.tt/2MXOaE2

Vanishing Act: Gorham-Stout Disease Leading to Dynamic Cerebrospinal Fluid Abnormalities

No abstract available

https://ift.tt/2Pkw4Ob

The Optic Disc Drusen Studies Consortium Recommendations for Diagnosis of Optic Disc Drusen Using Optical Coherence Tomography

Background: Making an accurate diagnosis of optic disc drusen (ODD) is important as part of the work-up for possible life-threatening optic disc edema. It also is important to follow the slowly progressive visual field defects many patients with ODD experience. The introduction of enhanced depth imaging optical coherence tomography (EDI-OCT) has improved the visualization of more deeply buried ODD. There is, however, no consensus regarding the diagnosis of ODD using OCT. The purpose of this study was to develop a consensus recommendation for diagnosing ODD using OCT. Methods: The members of the Optic Disc Drusen Studies (ODDS) Consortium are either fellowship trained neuro-ophthalmologists with an interest in ODD, or researchers with an interest in ODD. Four standardization steps were performed by the consortium members with a focus on both image acquisition and diagnosis of ODD. Results: Based on prior knowledge and experiences from the standardization steps, the ODDS Consortium reached a consensus regarding OCT acquisition and diagnosis of ODD. The recommendations from the ODDS Consortium include scanning protocol, data selection, data analysis, and nomenclature. Conclusions: The ODDS Consortium recommendations are important in the process of establishing a reliable and consistent diagnosis of ODD using OCT for both clinicians and researchers.

https://ift.tt/2OJF2TS

Conservative Treatment for Penetrating Injuries Involving the Cavernous Sinus

No abstract available

https://ift.tt/2nNLIF4

Neuro-Ophthalmology at a Tertiary Eye Care Centre in India

Background: Neuro-ophthalmology as a specialty is underdeveloped in India. The aim of our study was to determine the spectrum and profile of patients presenting to a tertiary eye care center with neuro-ophthalmic disorders. Methods: A retrospective hospital-based study was conducted, and records of all patients seen at the neuro-ophthalmology clinic of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India, over a 1-year period were retrieved and evaluated. Results: Of a total of 30,111 patients referred to various specialty clinics in a span of 1 year, 1597 (5%) were referred for neuro-ophthalmology evaluation. The mean patient age was 30.8 ± 19.5 years, with a male dominance (M:F = 2.02:1). Among these patients, optic nerve disorders were noted in 63.8% (n = 1,020), cranial nerve palsy in 7% (n = 114), cortical visual impairment in 6.5% (n = 105), and others (eye/optic nerve hypophasia, blepharospasm, and optic disc drusen) in 6% (n = 95). Among the patients with optic nerve disorders, optic neuropathy without disc edema/(traumatic optic neuropathy, hereditary, tumor-related, retrobulbar neuritis, toxic, and idiopathic) was noted in 42.8% (n = 685) and optic neuropathy with disc edema (ischemic optic neuropathy, papilledema, post-papilledema optic atrophy, papillitis, neuroretinitis, and inflammatory optic neuropathy) in 20.9% (n = 335). Sixteen percent of patients (n = 263) were incorrect referrals. Conclusion: The neuro-ophthalmic clinic constitutes a significant referral unit in a tertiary eye care center in India. Traumatic and ischemic optic neuropathies are the most common diagnoses. Neuro-ophthalmology requires further development as a subspecialty in India to better serve the nation's population.

https://ift.tt/2N0MUQc

Kline's Neuro-Ophthalmology Review Manual, 8th Edition

No abstract available

https://ift.tt/2PjwLqC

Optical Coherence Tomography in Optic Nerve Hypoplasia: Correlation With Optic Disc Diameter, Nerve Fiber Layer Thickness, and Visual Function

Background: The correlation between optic disc diameters (DDs) with average retinal nerve fiber layer thickness (RNFLT) and visual function in children with optic nerve hypoplasia (ONH) having nystagmus is unknown. Methods: Data were obtained from a retrospective review of 28 children (mean age: 9.4 years; ±5.1). Optic DD was defined as the maximal horizontal opening of Bruch membrane with spectral optical coherence tomography combined with a confocal laser ophthalmoscope. Average RNFLT was obtained from circumpapillary b-scans. RNFLT was also remeasured at eccentricities that were proportionate with DD to rule out potential sampling artifacts. Visual function was assessed by visual acuity at last follow-up and by visual evoked potentials (VEP) in 11 patients. The eye with the larger DD, which had better visual acuity, was analyzed to exclude potential effects of amblyopia. Results: DD was correlated with average RNFLT (r2 = 0.61), visual acuity (r2 = 0.32), and VEPs (r2 = 0.66). The relationship between RNFLT and DD was as follows: average RNFLT (μm) = 0.074 * DD (μm) − 18.8. RNFLT also correlated with the ratio of horizontal optic DD to macula-disc-margin distance (DD:DM; r2 = 0.59). RNFLT measured at eccentricities proportionate with DD showed progressive decrease in thickness only for DDs

https://ift.tt/2OKotr0

Visual Evoked Potentials as a Biomarker in Multiple Sclerosis and Associated Optic Neuritis

From the Section Editor: The next two installments in the JNO "Disease of the Year: Multiple Sclerosis" series focus on lessons that can be learned form the afferent visual pathway, as a putative model of MS. In their article entitled, "Visual evoked potentials as a biomarker in multiple sclerosis and associated optic neuritis" Leocani and colleagues highlight the role of visual evoked potential (VEP) testing as a means of capturing the effects of demyelination, remyelination, and associated neuroaxonal injury in the central nervous system (CNS). Conjointly, Horton and Bennett discuss the acute management of optic neuritis, which is aptly described as an "evolving paradigm." In their state-of-the art overview of the topic, these authors explore the spectrum of inflammatory optic neuropathies, with emphasis on clinical features, neuroimaging findings, and serological markers that help refine diagnosis, and target appropriate treatment strategies. When considered holistically, these reviews prompt us to consider how VEP and other surrogate endpoints can be used to differentiate subtypes of optic neuritis that may ultimately herald a wide variety of CNS inflammatory disorders. Abstract: Multiple sclerosis (MS) is an inflammatory, degenerative disease of the central nervous system (CNS) characterized by progressive neurological decline over time. The need for better "biomarkers" to more precisely capture and track the effects of demyelination, remyelination, and associated neuroaxonal injury is a well-recognized challenge in the field of MS. To this end, visual evoked potentials (VEPs) have a role in assessing the extent of demyelination along the optic nerve, as a functionally eloquent CNS region. Moreover, VEPs testing can be used to predict the extent of recovery after optic neuritis (ON) and capture disabling effects of clinical and subclinical demyelination events in the afferent visual pathway. In this review, the evolving role of VEPs in the diagnosis of patients with ON and MS and the utility of VEPs testing in determining therapeutic benefits of emerging MS treatments is discussed.

https://ift.tt/2nKTort

The Most Common Causes of Eye Pain at 2 Tertiary Ophthalmology and Neurology Clinics

Background: Eye pain is a common complaint, but no previous studies have determined the most common causes of this presenting symptom. Our objective was to determine the most common causes of eye pain in 2 ophthalmology and neurology departments at academic medical centers. Methods: This was a retrospective cross-sectional analysis and chart review at the departments of ophthalmology and neurology at the University Hospital Zurich (USZ), University of Zürich, Switzerland, and the University of Utah (UU), USA. Data were analyzed from January 2012 to December 2013. We included patients aged 18 years or older presenting with eye pain as a major complaint. Results: Two thousand six hundred three patient charts met inclusion criteria; 742 were included from USZ and 1,861 were included from UU. Of these, 2,407 had been seen in an ophthalmology clinic and 196 had been seen in a neurology clinic. Inflammatory eye disease (conjunctivitis, blepharitis, keratitis, uveitis, dry eye, chalazion, and scleritis) was the underlying cause of eye pain in 1,801 (69.1%) of all patients analyzed. Although only 71 (3%) of 2,407 patients had migraine diagnosed in an ophthalmology clinic as the cause of eye pain, migraine was the predominant cause of eye pain in the neurology clinics (100/196; 51%). Other causes of eye pain in the neurology clinics included optic neuritis (44 patients), trigeminal neuralgia, and other cranial nerve disorders (8 patients). Conclusions: Eye pain may be associated with a number of different causes, some benign and others sight- or life-threatening. Because patients with eye pain may present to either a neurology or an ophthalmology clinic and because the causes of eye pain may be primarily ophthalmic or neurologic, the diagnosis and management of these patients often requires collaboration and consultation between the 2 specialties.

https://ift.tt/2MUI3QO

Does Dolichoectasia of the Carotid Artery Cause Optic Neuropathy?

No abstract available

https://ift.tt/2nK0zQT

Preclinical experience using a new robotic system created for microsurgery

Background: Completing microsurgical anastomosis requires great technical skills. Robotic assistance in microsurgery can exceed the maximum human level of precision and manual dexterity to improve clinical outcomes. Since no robotic device has been designed primarily for microsurgery the authors developed a dedicated microsurgical robotic system (MSR). This preclinical study investigates whether microsurgical anastomosis can be successfully completed on silicone vessels using a prototype of this newly developed robotic system, and compares outcomes of robotic-assisted versus conventional anastomotic microsurgery. Methods: Three participants at different levels of microsurgical training completed ten anastomoses by hand and ten anastomoses with robotic assistance. Four blinded experienced microsurgeons evaluated the quality of the microsurgical skills using a modified version of the Structured Assessment of Microsurgical Skills (SAMS). Time to perform the anastomosis and adverse events were recorded. Results: The total time to perform the anastomoses with and without robotic assistance decreased to 35.1 minutes and 12.5 minutes respectively during the study. The overall performance and indicative skill of the SAMS improved during the conventional method (from respectively 2.8 to 3.6 and 2.6 to 3.7) and the robotic-assisted method (from respectively 2.3 to 3.0 and 2.3 to 3.1). Conclusions: It is feasible to complete anastomotic microsurgery on silicone vessels using the MSR. In comparison to the conventional method, time to perform the anastomosis was longer and quality of the microsurgical skills were lower in the robotic-assisted group. However, the robotic-assisted performance showed steeper learning curves (faster improvement) compared to the conventional performance for both surgical time and domains of microsurgical skills. The encouraging results indicate further development of the MSR and additional preclinical trials as step up towards clinical validation. FINANCIAL DISCLOSURE STATEMENT: Tom van Mulken has a financial disclosure, as he is Chief Medical Officer of the spin off company MicroSure: costs of travel and share in company. Rene van der Hulst has a financial disclosure as shareholder of MicroSure. Raimondo Cau has a financial disclosure, as he is Chief Technical Officer and shareholder of MicroSure. Ferry Schoenmakers is a software developer for MicroSure. The other authors have no financial disclosures. ACKNOWLEDGEMENTS: The four microsurgeons, forming the assessment panel, are gratefully acknowledged for their efforts. CORRESPONDING AUTHOR: Tom J.M. van Mulken, MD, Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands, Tel: (+31) 043-3875474; Fax: (+31) 043-3875473, Email: tom.van.mulken@mumc.nl ©2018American Society of Plastic Surgeons

https://ift.tt/2BlaGFf

Donor Site Morbidity and Functional Status Following Medial Femoral Condyle Flap Harvest

Background: The medial femoral condyle (MFC) free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor site morbidity and functional outcomes after flap harvest have not been fully appreciated. Herein, we report the postoperative outcomes and analyze the impact of increasing the size of the flap on the knee donor site morbidity. Methods: A retrospective chart review of patients who underwent MFC flap between 2001 and 2012 at our institution was done. The size of the flap was stratified, based on the largest dimension, into 3 groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure: the Lower Extremity Functional Scale (LEFS) questionnaire. A univariate logistic regression analysis was done, and results were analyzed. Results: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years (range: 14-72). Average follow-up time was 13 months postoperatively. Overall Complication rate was 18.6%. Donor site paresthesia in the saphenous nerve distribution was the most common complication. Increasing size of the flap did result in a significant elevation in complication risk (p<.05 a total of patients completed the lefs questionnaire. average score was scored points indicating normal level function on average. conclusions: mfc flap has overall acceptable donor site morbidity with good post-operatively. larger flaps are associated greater number complications. meetings at which paper partially presented: none financial disclosures: authors interest in any products devices or drugs mentioned this manuscript. corresponding author: brian t. carlsen md division plastic surgery department mayo clinic first street sw rochester minnesota usa. phone: fax: email: carlsen.brian society surgeons>

https://ift.tt/2vTF70i

Introducing Knowledge Translation to Plastic Surgery: Turning Evidence into Practice

Best evidence has no bearing on quality of life if it is not implemented in clinical practice. We introduce knowledge translation as a theoretical framework for closing the gap between evidence and practice in plastic surgery. The current state of published evidence in plastic surgery is reviewed and evaluated, with the recommendation to utilize the EQUATOR network's guidelines for reporting clinical research findings. Tools and strategies are offered for the reader to understand and integrate evidence at the bedside. Systemic solutions are also proposed for the dissemination of best evidence to facilitate its translation into practice. Financial Disclosure: The authors have no financial conflicts of interest or sources of funding to declare. Correspondence: Dr. Achilleas Thoma, 101-206 James Street South Hamilton, ON, L8P 3A9,, Phone (905) 523-0019, Fax (905) 523-0229, Email: drathoma@cogeco.net ©2018American Society of Plastic Surgeons

https://ift.tt/2Blaeqx

“Increasing Diversity in Plastic Surgery”

No abstract available

https://ift.tt/2MlKxeH

Reply to “Lymphedema Quality of Life Score (LeQOLiS): A Simple Method for Evaluation of Subjective Symptoms in Extremity Lymphedema Patients”

No abstract available

https://ift.tt/2KXd1pD

An Intraoperative 3D Imaging System for Better Image Sharing and Protection of Reconstructive Surgeons’ Neck

No abstract available

https://ift.tt/2nIXAIu

Reply: Reconstruction of the Heel, Middle Foot Sole, and Plantar Forefoot with the Medial Plantar Artery Perforator Flap Clinical Experience with 28 Cases.

No abstract available

https://ift.tt/2L4IrdI

Commentary to “Targeting Reflux-free Vein Using Indocyanine Green Dye Angiography”

No abstract available

https://ift.tt/2MoCUnE

Reply: An Intraoperative 3D Imaging System for Better Image Sharing and Protection of Reconstructive Surgeons' Neck

No abstract available

https://ift.tt/2L4HAd0

Reply to the letter of Klinger et al. on our manuscript “Autologous Fat Injection vs. Lundborg´s Resection Arthroplasty for the Treatment of Trapeziometacarpal Joint Osteoarthritis”

No abstract available

https://ift.tt/2MptzfG

Aesthetic Functional Surgery with ulnar artery perforator, an easier alternative to super-thin SCIP.

No abstract available

https://ift.tt/2Blj47P

Response to: Autologus Fat Injection versus Lundborg Resection Arthroplasty for the treatment of Trapeziometacarpal Joint Osteoarthritis

No abstract available

https://ift.tt/2MlJPy3

Reply: Aesthetic Functional Surgery with proximal ulnar artery perforator, an easier alternative to super-thin SCIP.

No abstract available

https://ift.tt/2L4HO3Q

“Vascular Anomalies: From a Clinicohistologic to a Genetic Framework”

No abstract available

https://ift.tt/2Mxg6Bn

Reply: Increasing Diversity in Plastic Surgery

No abstract available

https://ift.tt/2BtqLJo

Lymphedema Quality of Life Score (LeQOLiS): A Simple Method for Evaluation of Subjective Symptoms in Extremity Lymphedema Patients

No abstract available

https://ift.tt/2nNhZw0

Three-dimensional reconstruction: the waveform design of free perforator flap for the heel defect repair

No abstract available

https://ift.tt/2BwIHTt

Endoscopic Nipple-sparing Mastectomy with Immediate Multi-Stage Fat Grafting for Total Breast Reconstruction: A New Combination for Minimal Scar Breast Cancer Surgery

No abstract available

https://ift.tt/2MoK0bS

A new simple maneuver to manipulate sutures during microvascular anastomosis using micro-suction

No abstract available

https://ift.tt/2L1ZSM3

Coned Radial Forearm Free Flap for Improved Retention of Orbital Prosthesis Following Orbital Exenteration

No abstract available

https://ift.tt/2vTp1Uh

Adsorption characteristics of methylene blue by biochar prepared using sheep, rabbit and pig manure

Abstract

Sheep manure biochar (SMB₅₀₀), rabbit faeces biochar (RFB₅₀₀) and pig manure biochar (PMB₅₀₀) prepared by controlled thermal decomposition at 500 °C were used to adsorb methylene blue (MB) in water. Elemental analysis, BET and SEM results showed that the specific surface area, total pore volume and average pore diameter of SMB₅₀₀ were 7.59, 4.20 and 1.16 times greater than those of RFB₅₀₀, which were also 12.02, 6.88 and 1.37 times greater than those of PMB_500, respectively. SMB₅₀₀ had stronger stability and aromaticity. When the initial concentration of MB was 50 mg L⁻¹ and pH was 11, adsorption achieved equilibrium at approximately 210 min. The adsorption followed pseudo-second-order kinetics (R² > 0.96), indicating that liquid film diffusion, surface adsorption and intraparticle diffusion all contributed to the adsorption rate. The results of isothermal adsorption showed that the adsorption performance of SMB₅₀₀ was more consistent with a Freundlich model, whereas the performance of RFB₅₀₀ and PMB₅₀₀ was more consistent with a Langmuir model with a maximum adsorption capacity of 53.68 to 238.31 mg g⁻¹. Thermodynamic and FTIR studies showed that the adsorption of MB on SMB₅₀₀, RFB₅₀₀ and PMB₅₀₀ was spontaneous and endothermic, and hydrogen bonds and π-π bonds were closely related to the adsorption process. The results of regeneration show that the optimal number of cycles for SMB₅₀₀, RFB₅₀₀ and PMB₅₀₀ are 8, 5 and 3, respectively.

https://ift.tt/2Mp0XTP

Scholar : Baltic Journal of Economics, Volume 18, Issue 1, May 2018 is now available online on Taylor & Francis Online

The online platform for Taylor & Francis Online content Baltic Journal of Economics, Volume 18, Issue 1, May 2018 is now available online on Taylor & Francis Online. This new issue contains the following articles: Research Articles The Baltic banking system in the enlarged European Union: the effect of the financial crisis on efficiency | José Luis Gallizo, Jordi Moreno & Manuel Salvador Pages: 1-24 | DOI: 10.1080/1406099X.2017.1376430 The public–private sector wage gap in Latvia | Karlis Vilerts Pages: 25-50 | DOI: 10.1080/1406099X.2018.1457356 Minimum wages and employment retention: A microeconometric study for Estonia | Simona Ferraro, Birgit Hänilane & Karsten Staehr Pages: 51-67 | DOI: 10.1080/1406099X.2018.1485422 To update which email alerts you receive, manage your alerts within the My Account area. Unsubscribe from new content alerts for this journal (both new issue and latest article notifications) with one click. If you need any further help, please contact us at support@tandfonline.com Please do not reply to this email. To ensure that you receive your alerts and information from Taylor & Francis Online, please add "alerts@tandfonline.com" and "info@tandfonline.com" to your safe senders list. Taylor & Francis, an Informa business. Taylor & Francis is a trading name of Informa UK Limited, registered in England under no. 1072954. Registered office: 5 Howick Place, London, SW1P 1WG.

Dose Escalation of RMC-4630 Monotherapy in Relapsed/Refractory Solid Tumors

Condition:   Solid Tumors
Intervention:   Drug: RMC-4630
Sponsors:   Revolution Medicines, Inc.;   Sanofi
Not yet recruiting

https://ift.tt/2MCFeXO

Evaluation of 18F-FDOPA PET-CT in the Preoperative Initial Assessment of Medullary Thyroid Carcinoma

Condition:   Medullary Thyroid Carcinoma
Intervention:   Other: PET at 18F-FDOPA
Sponsor:   Assistance Publique Hopitaux De Marseille
Not yet recruiting

https://ift.tt/2L3fcYD

Effect of IONM on Efficacy and Safety Using Sugammadex in Thyroid Surgery

Conditions:   Vocal Cord Paralysis;   Recurrent Laryngeal Nerve
Intervention:   Drug: Group B. Sugammadex sodium-IONM
Sponsor:   Lütfiye Nuri Burat Government Hospital
Recruiting

https://ift.tt/2MswBPr

Radiotherapy With Durvalumab Prior to Surgical Resection for HPV Negative Squamous Cell Carcinoma

Condition:   Squamous Cell Carcinoma of the Head and Neck
Interventions:   Drug: Durvalumab;   Radiation: Stereotactic Body Radiation Therapy (SBRT);   Procedure: Standard of Care Therapy
Sponsors:   University of Colorado, Denver;   AstraZeneca
Not yet recruiting

https://ift.tt/2BloCiO

The Application of 3T MRI in Esophageal Cancer

Conditions:   Esophageal Cancer TNM Staging;   Magnetic Resonance Imaging;   Prognosis
Intervention:   Other: No intervention
Sponsor:   Henan Cancer Hospital
Not yet recruiting

https://ift.tt/2vTHKz2

Are Your Patients Satisfied? A Systematic Review of Treatment Satisfaction Measures in Psoriasis

Treatment satisfaction is paramount to the field of dermatology. Treatment dissatisfaction directly impacts patient outcomes and health care delivery. A critical need exists for standardized, validated treatment satisfaction measures in dermatology. Comprehensive evaluation of the performance of treatment satisfaction instruments used in psoriasis is lacking. We sought to critically appraise the literature on measurement properties of treatment satisfaction instruments used in psoriasis. We performed a systematic review to identify treatment satisfaction instruments used in psoriasis and corresponding studies on their measurement properties. We followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology to inform a best evidence synthesis. Eleven instruments were identified. Six achieved positive content validity ratings, 2 achieved positive reliability and structural validity ratings, and 1 achieved a positive internal consistency rating. The REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) and the Spanish Satisfaction With Treatment of Psoriasis Questionnaire (SSWTPQ) had the highest overall performance. Measurement property data for treatment satisfaction instruments were found to be insufficient in identifying a single best treatment satisfaction instrument for psoriasis. Additional studies are required to better characterize the measurement properties of treatment satisfaction measures and allow for standardized assessments across psoriasis clinical trials and clinical practice.
Dermatology

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Age-corrected hearing loss after chemoradiation in cervical cancer patients

Abstract

Objective

This study aimed to evaluate subjective and objective hearing loss in cervical cancer patients after chemoradiation with cisplatin (mono).

Patients and methods

A total of 51 cervical cancer patients with indication for chemoradiation were included. Pure tone and impedance audiometry were performed before and after chemoradiation. Hearing loss was scaled according to ASHA criteria. Subjective hearing was assessed with the Oldenburger Sentence Test. To consider age-dependent changes, hearing loss was corrected for age and the time interval between measurements.

Results

Median age at diagnosis was 46 years, 46% were active/former smokers (n = 24), 28 (54%) patients were never-smokers. Median total weekly cisplatin dose was 70 ± 14.2 mg. Cumulative doses of cisplatin during chemoradiation ranged between 115.2 and 400 mg cisplatin (mean 336.1 mg, median 342 ± 52.7 mg). The median interval between last chemotherapy and second audiometry was 320 ± 538 days (35–2262 days). Changes in hearing threshold ≥20 dB were experienced by 32/52 patients (62%) following chemoradiation, 55% of them for frequencies ≥6000 Hz. No statistically significant hearing loss remained after chemoradiation upon correction for age and time interval. Patients >40 years had a higher risk of hearing loss than younger patients. Objective data on hearing function did not correlate with subjective hearing loss and did not impair daily activity in any patient.

Conclusion

Chemoradiation with cumulative cisplatin doses up to 400 mg did not lead to significant impairment of objective or subjective hearing. For cervical cancer patients undergoing chemoradiation, standard audiometry is not indicated.

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Megestrol Acetate-Induced Symptomatic Hypogonadism in a Male Patient.

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Megestrol Acetate-Induced Symptomatic Hypogonadism in a Male Patient.

Case Rep Endocrinol. 2018;2018:7048610

Authors: Munshi LB, Tsushima Y, Cheng K, Brito M

Abstract
The hypothalamic-pituitary-adrenal (HPA) axis and the hypothalamic-pituitary-gonadal (HPG) axis are very sensitive and can be affected by external factors like stress, starvation, and medication. Medication-induced suppression of these axes can cause adrenal insufficiency (AI) and hypogonadism. Exogenous glucocorticoid use is the most common cause of iatrogenic AI. Our aim is to bring attention to another broadly prescribed medication, megestrol acetate (MA), as the cause of suppression of both these axes. We report a case of symptomatic hypogonadism and asymptomatic AI in a male patient secondary to MA. The patient presented with decrease in testicular size and erectile dysfunction. His total testosterone and morning cortisol levels were low, but FH, LH, and TSH were normal. His pituitary MRI was unremarkable. Upon discontinuation of MA, the patient's testosterone and cortisol levels normalized and his symptoms resolved. Hypogonadism and AI are known adverse effects of MA, but symptomatic hypogonadism as the primary manifestation has only been reported once in previous literature. Prolonged hypogonadism can lead to sarcopenia, depression, and osteoporosis, while asymptomatic AI carries the risk of becoming overt AI. Thus, heightened awareness of the impact of MA on both these axes is necessary.

PMID: 30112227 [PubMed]

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A Case of Diabetic Ketoacidosis Presenting with Hypernatremia, Hyperosmolarity, and Altered Sensorium.

Related Articles

A Case of Diabetic Ketoacidosis Presenting with Hypernatremia, Hyperosmolarity, and Altered Sensorium.

Case Rep Endocrinol. 2018;2018:4806598

Authors: Kumar V, Nanavati SM, Melki G, Upadhyaya M, Dhillon R, Gibiezaite S, Michael P, Singhal M

Abstract
Diabetic Ketoacidosis commonly presents with hyponatremia, but hypernatremia is a rare entity. We report a unique case of a 50-year-old woman admitted with altered sensorium with blood glucose 979 milligrams/deciliter, serum osmolarity 363 mOsm/kilograms, and serum sodium 144 milliequivalents/liter. Patient was given initial bolus of isotonic saline and continued on half isotonic saline for correction of hypernatremia along with insulin infusion therapy. Patient was successfully treated with intravenous fluids, insulin infusion, and the altered sensorium was resolved without any sequelae. This case illustrates a teaching point in the use of intravenous fluids for the treatment of Diabetic Ketoacidosis with hypernatremia.

PMID: 30112226 [PubMed]

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Extreme and Cyclical Blood Pressure Elevation in a Pheochromocytoma Hypertensive Crisis.

Related Articles

Extreme and Cyclical Blood Pressure Elevation in a Pheochromocytoma Hypertensive Crisis.

Case Rep Endocrinol. 2018;2018:4073536

Authors: Larouche V, Garfield N, Mitmaker E

Abstract
Pheochromocytomas are rare adrenal neoplasms characterized by excess secretion of catecholamines. We describe the case of a 65-year-old man, known for hypertension, with no family history of hereditary pheochromocytoma syndromes. He reported a two-year history of flushing, systolic blood pressure surges to 200 mmHg, headaches, tremors, and syncope. His initial workup revealed elevated 24h urine catecholamines and metanephrines. An adrenal MRI in March 2017 showed a large 7.6 cm heterogeneous right adrenal lesion. Given orthostatic hypotension, his final preoperative dose was limited to a low dose of terazosin and metoprolol. In the operating room, shortly after intubation and Foley insertion, his blood pressure rose to 350 mmHg. Surgery was cancelled and he was admitted to the intensive care unit, where intravenous phentolamine, nitroprusside, and nicardipine were started. His systolic blood pressure would oscillate between 60 mmHg and 350 mmHg at 2-3 minutes' intervals. After 3 days, he was weaned off intravenous medications. His oral medications were uptitrated to high doses of phenoxybenzamine, metoprolol, and nifedipine. Three weeks later, he underwent successful open right adrenalectomy. This case outlines the importance of preoperative preparation of pheochromocytomas and raises the question if phenoxybenzamine is the alpha-blocker of choice for larger tumours with significant hormonal secretion.

PMID: 30112225 [PubMed]

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A Large PROP1 Gene Deletion in a Turkish Pedigree.

Related Articles

A Large PROP1 Gene Deletion in a Turkish Pedigree.

Case Rep Endocrinol. 2018;2018:2403430

Authors: Gorar S, Turkkahraman D, Yararbas K

Abstract
Pituitary-specific paired-like homeodomain transcription factor, PROP1, is associated with multiple pituitary hormone deficiency. Alteration of the gene encoding the PROP1 may affect somatotropes, thyrotropes, and lactotropes, as well as gonadotropes and corticotropes. We performed genetic analysis of PROP1 gene in a Turkish pedigree with three siblings who presented with short stature. Parents were first degree cousins. Index case, a boy, had somatotrope, gonadotrope, thyrotrope, and corticotrope deficiency. However, two elder sisters had somatotroph, gonadotroph, and thyrotroph deficiency and no corticotroph deficiency. On pituitary magnetic resonance, partial empty sella was detected with normal bright spot in all siblings. In genetic analysis, we found a gross deletion involving PROP1 coding region. In conclusion, we report three Turkish siblings with a gross deletion in PROP1 gene. Interestingly, although little boy with combined pituitary hormone deficiency has adrenocorticotropic hormone (ACTH) deficiency, his elder sisters with the same gross PROP1 deletion have no ACTH deficiency. This finding is in line with the fact that patients with PROP1 mutations may have different phenotype/genotype correlation.

PMID: 30112224 [PubMed]

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MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment

Hypophysitis is a rare condition characterised by inflammation of the pituitary gland, usually resulting in hypopituitarism and pituitary enlargement. Pituitary inflammation can occur as a primary hypophysitis (most commonly lymphocytic, granulomatous or xanthomatous disease) or as secondary hypophysitis (as a result of systemic diseases, immunotherapy or alternative sella-based pathologies). Hypophysitis can be classified using anatomical, histopathological and aetiological criteria. Non-invasive diagnosis of hypophysitis remains elusive, and the use of currently available serum anti-pituitary antibodies are limited by low sensitivity and specificity. Newer serum markers such as anti-rabphilin 3A are yet to show consistent diagnostic value and are not yet commercially available. Traditionally considered a very rare condition, the recent recognition of IgG4-related disease and hypophysitis as a consequence of use of immune modulatory therapy has resulted in increased understanding of the pathophysiology of hypophysitis. Modern imaging techniques, histological classification and immune profiling are improving the accuracy of the diagnosis of the patient with hypophysitis. The objective of this review is to bring readers up-to-date with current understanding of conditions presenting as hypophysitis, focussing on recent advances and areas for future development. We describe the presenting features, investigation and diagnostic approach of the patient with likely hypophysitis, including existing conventional techniques and those in the research/development arena. Hypophysitis usually results in acute and persistent pituitary hormone deficiency requiring long-term replacement. Management of hypophysitis includes control of the inflammatory pituitary mass using a variety of treatment strategies including surgery and medical therapy. Glucocorticoids remain the mainstay of medical treatment but other immunosuppressive agents (e.g. azathioprine, rituximab) show benefit in some cases, but there is a need for controlled studies to inform practice.

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Scholar : These new articles for Classroom Discourse are available online

The online platform for Taylor & Francis Online content New for Classroom Discourse and online now on Taylor & Francis Online: Articles Knowledge disagreement formulations in problem-based learning tutorials: balancing pedagogical demands with 'saving face' Robert McQuade, Sally Wiggins, Esther Ventura-Medina & Tony Anderson Pages: 1-17 | DOI: 10.1080/19463014.2018.1495089 To update which email alerts you receive, manage your alerts within the My Account area. Unsubscribe from new content alerts for this journal (both new issue and latest article notifications) with one click. If you need any further help, please contact us at support@tandfonline.com Please do not reply to this email. To ensure that you receive your alerts and information from Taylor & Francis Online, please add "alerts@tandfonline.com" and "info@tandfonline.com" to your safe senders list. Taylor & Francis, an Informa business. Taylor & Francis is a trading name of Informa UK Limited, registered in England under no. 1072954. Registered office: 5 Howick Place, London, SW1P 1WG.

Scholar : These new articles for Contemporary Music Review are available online

The online platform for Taylor & Francis Online content New for Contemporary Music Review and online now on Taylor & Francis Online: Articles Saying Hello to the Lunatic Men: A Critical Reading of 'Love is Lost' Eoin Devereux, Aileen Dillane & Martin J. Power Pages: 1-15 | DOI: 10.1080/07494467.2018.1507356 To update which email alerts you receive, manage your alerts within the My Account area. Unsubscribe from new content alerts for this journal (both new issue and latest article notifications) with one click. If you need any further help, please contact us at support@tandfonline.com Please do not reply to this email. To ensure that you receive your alerts and information from Taylor & Francis Online, please add "alerts@tandfonline.com" and "info@tandfonline.com" to your safe senders list. Taylor & Francis, an Informa business. Taylor & Francis is a trading name of Informa UK Limited, registered in England under no. 1072954. Registered office: 5 Howick Place, London, SW1P 1WG.