Neuro-Ophthalmology Subspecialty Highlight: With Dr. Sarah Thornton, Wills Eye Hospital

Neuro-Ophthalmology is a subspecialty within ophthalmology that combines the complexities of nervous system disease with the intricacies of the ocular manifestations of those diseases. Neuro-ophthalmologists work closely with neurologists, neurosurgeons, rheumatologists, and other ophthalmologists in different subspecialties, such as retina and glaucoma, to get to the source of their patients’ problems. Neuro-ophthalmology is typically a 1-year fellowship undertaken after residency training is completed, where physicians will learn the complex ways different diseases can manifest in the eye

Treatment of Intractable Neurogenic Cough with Cricopharyngeal Myotomy

Objectives: Neuropathic cough that is incompletely responsive to medical therapy may be due to cricopharyngeal hypertonicity. The objective was to describe the utility of cricopharyngeal myotomy in alleviating symptoms of intractable neuropathic cough. Study Design: Retrospective review. Methods: A retrospective chart review was performed for three patients who underwent cricopharyngeal myotomy for intractable cough. Trigger phenomena, previous evaluation and treatment, and outcomes after surgery, namely patient perception of improvement and medication use after surgery, were assessed and documented. Results: After cricopharyngeal myotomy, all three patients noted symptomatic improvement and were weaned off medication. Continued improvement was noted at follow up, with a mean length of 22 months (range: 7-36 months). Conclusions: Cricopharyngeal myotomy may be an alternative treatment for chronic cough in patients for whom workup is negative and medical management, dilation, and botulinum toxin have failed to provide long-term relief. Poster presented at CSOM: Combined Otolaryngology Spring Meeting in Orlando Florida, April 10-14, 2013

Novel Irradiated Axial Rotational Flap Model in the Rodent

Abstract Objectives: To design an easily reproducible rodent rotational skin flap and to evaluate the effects of radiation on flap viability. Methods: Ten rats received 40 Gy irradiation to the abdominal wall. Following a recovery period of one month, a 3 X 8 cm fasciocutaneous flap based axially on the inferior epigastric vessel, was raised and rotated 60 degrees into a contralateral deficit. Five non-irradiated rats underwent the identical procedure as a control. Animals were sacrificed seven days postoperatively, areas of flap necrosis were documented, and histological specimens were taken to compare flap viability and vessel density. Results: 60% of the rats in the irradiated group had necrosis of the distal flap ranging from 1 to 6 cm from the distal edge, whereas none of the animals (0%) in the control group exhibited necrosis (p\u3c0.001). Histology revealed collagen and vascular changes in the irradiated skin. Vascular density analysis revealed a significant difference between radiated and non-radiated flaps; p = 0.004, 0.029 and 0.014 in the distal, middle and proximal segments of the flap respectively. Conclusion: This novel rat axial rotational flap model demonstrates increases flap necrosis and a decrease in vascular density due to the effects of radiation. Using a linear electron accelerator a dose of 40 gy can be delivered to the skin without resulting in devastating gastrointestinal side effects

Effects of gender differences on the subjective perceived intensity of steering wheel rotational vibration based on a multivariate regression model

This is the post-print version of the Article. The official published version can be accessed from the link below - Copyright @ 2009 ElsevierThe aims of this study were to determine equal sensation curves for hand-arm steering wheel rotational vibration and to investigate the effect of gender on the subjective perceived intensity of steering wheel hand-arm vibration. Psychophysical response tests of 40 participants (20 mates and 20 females) were performed using a steering wheel rotational vibration simulator using the category-ratio Borg CR10 scale procedure for direct estimation of perceived intensity. The test stimuli were sinusoidal vibrations at 22 third octave band centre frequencies in the range from 3 to 400 Hz, with acceleration amplitudes in the range from 0.04 to 27 m/s(2) r.m.s. Multivariate regression procedures were applied to the experimentally acquired data in order to establish a regression model expressing the Borg CR10 perceived intensity values as a function of the two independent parameters of the frequency and amplitude of vibration. The equal sensation curves suggested a non-linear dependency of the subjective perceived intensity on both frequency and amplitude. Females were found to provide higher Borg CR10 perceived intensity values than males (p < 0.05), particularly at the higher intensity levels above approximately 1.0 m/s(2) r.m.s and at the higher frequencies above approximately 20 Hz.Relevance to industry: For the manufacturers of steering systems and of other automobile components this study provides vibration perception curves and identifies the possible importance of gender towards the perception of vibration which arrives at the steering wheel. (C) 2009 Elsevier B.V. All rights reserved

Association of CYP2C19*17 Allele and Choice of P2Y12 Inhibitor on Cardiovascular Outcomes Following Percutaneous Coronary Intervention

Introduction: The CYP2C19*17 allele variant is a gain-of-function polymorphism which increases levels of the active metabolite of clopidogrel. Objective: *17 is associated with increased bleeding risk during clopidogrel therapy, but it is unclear whether alternative P2Y12 inhibitors, prasugrel and ticagrelor, produce better clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). Methods: A single-center observational study was conducted in 928 PCI patients who received CYP2C19 testing and dual anti-platelet therapy (DAPT). Risk of major adverse cardiovascular or cerebrovascular events (MACCE) and clinically significant bleeding over 12 months were compared across genotype and DAPT groups by proportional hazards regression. Results: 584 patients were treated with clopidogrel while 344 patients had alternative therapy. In the clopidogrel group, 173 patients were hetero- or homozygous for *17 and 91 patients were hetero- or homozygous for a loss of function allele (LOF; *2 or *3). Patients treated with clopidogrel were older, more commonly female, and more likely to have hypertension, diabetes, and an acute coronary syndrome (ACS) than patients on alternative therapy. There were no differences in MACCE or clinically significant bleeding events in *17 patients treated with clopidogrel compared to alternative therapy in either the total population (p=0.54) or in ACS patients (p=0.98). Patients with LOF alleles were 3.4 times more likely in the total population (p \u3c0.0001) and 6.7 times more likely among ACS patients (p \u3c0.0001) to have MACCE if prescribed clopidogrel compared with alternative therapy. Discussion: *17 patients had equivalent clinical outcomes when treated with clopidogrel or alternative P2Y12 inhibitors

Feasibility of diagnosis of postcardiotomy tamponade by miniaturized transesophageal echocardiography.

BACKGROUND: Pericardial tamponade after cardiac surgery is a critical diagnosis that can be difficult to diagnose using conventional cardiac monitoring. Transesophageal echocardiography can provide comprehensive information to make the diagnosis but is not always available, whereas transthoracic echocardiography has its utility limited because of the body habitus or other surgical effects. New monitoring devices, miniaturized hemodynamic transesophageal echocardiography (hTEE), which allows point of care assessment of cardiac filling and functions, may aid in diagnosis of postcardiotomy tamponade. METHODS: From May 2011 to July 2013, 21 patients underwent hTEE to rule out pericardial tamponade for clinical suspicion of tamponade after open heart surgery. The hTEE images were reviewed, and the patient outcomes were analyzed. RESULTS: Nine patients showed no evidence of pericardial collection and did not require reexploration. Two patients showed a presence of small hematoma without ventricular compression and also did not undergo exploration. Ten patients were positive for pericardial tamponade (effusion or hematoma with ventricular compression); eight of these cases underwent emergent surgical exploration. Of the two patients who did not undergo immediate reoperation, one was managed by chest tube manipulation and the other patient underwent subsequent surgical exploration after his extensive coagulopathy was corrected by medical treatment. CONCLUSIONS: The diagnosis of pericardial tamponade postcardiotomy is feasible using a disposable hTEE based on our limited experience. We avoided unnecessary explorations while concomitantly made prompt diagnosis in emergent situations. The hTEE device was a valuable tool in hemodynamic management in the intensive care unit, allowing rapid evaluations

Threshold for Synovial Cell Count and Neutrophil Differential in Diagnosis of Periprosthetic Knee Infection: A Multi-Institutional Study

Introduction: Synovial fl­uid analysis is an important tool in the work-up of suspected periprosthetic joint infection (PJI). Yet, there is confl­icting guidance for the analysis of synovial fl­uid aspiration, including a lack of uniform thresholds for white blood cell (WBC) count and neutrophil percentage (PMN%)1-3. Therefore, a multi-institutional study was undertaken to reassess these thresholds, compare preoperative versus intraoperative sample collection, and assess variation in results between institutions

Dynamics of the power-duration relationship during prolonged endurance exercise and influence of carbohydrate ingestion

This is the author accepted manuscript. The final version is available from the American Physiological Society via the DOI in this recordWe tested the hypotheses that the parameters of the power-duration relationship, estimated as the end-test power (EP) and work done above EP (WEP) during a 3-min all out exercise test (3MT), would be reduced progressively following 40 min, 80 min and 2 h of heavy-intensity cycling, and that carbohydrate (CHO) ingestion would attenuate the reduction in EP and WEP. Sixteen participants completed a 3MT without prior exercise (control), immediately after 40 min, 80 min and 2-h of heavy-intensity exercise while consuming a placebo beverage, and also after 2-h of heavy-intensity exercise while consuming a CHO supplement (60 g/h CHO). There was no difference in EP measured without prior exercise (260 ± 37 W) compared to EP following 40 min (268 ± 39 W) or 80 min (260 ± 40 W) of heavy-intensity exercise; however, after 2-h, EP was 9% lower compared to control (236 ± 47 W; P<0.05). There was no difference in WEP measured without prior exercise (17.9 ± 3.3 kJ) compared to after 40 min of heavy-intensity exercise (16.1 ± 3.3 kJ), but WEP was lower (P<0.05) than control after 80 min (14.7 ± 2.9 kJ) and 2-h (13.8 ± 2.7 kJ). Compared to placebo, CHO ingestion negated the reduction of EP following 2-h of heavy-intensity exercise (254 ± 49 W) but had no effect on WEP (13.5 ± 3.4 kJ). These results reveal a different time course for the deterioration of EP and WEP during prolonged endurance exercise and indicate that EP is sensitive to CHO availability