Sensorineural Hearing Loss and the Diagnosis of Acoustic Neuroma

Sensorineural hearing loss and tinnitus are gradually receiving more attention in medicine due to advances in diagnosis and treatment. Acoustic neuromas can now be detected when they are small, and early microsurgical removal results in the lowest overall morbidity. We examine the historical development of acoustic neuroma management, discuss current diagnosis and treatment, and present illustrative cases from our recent experience. Complaints of tinnitus and hearing loss, especially when unilateral, require appropriate medical evaluation

Surgical Management of Spinal Epidural Disease: An Update

Management of spinal cord compression from metastatic malignant disease remains unsatisfactory. Results of surgical decompression are at best less than those of radiation therapy alone. However, new surgical approaches now focus on removing the anterior-situated tumor tissue which produces neural compression in about 85% of the cases. The results of these procedures that allow removal of the ventrally compressing tumor show significant improvement in the management of patients with spinal epidural disease. We review the surgical strategy of these new approaches and the attendant results

Pituitary Metastasis: Lung Cancer Presenting as Bitemporal Hemianopsia with Diabetes Insipidus and Anterior Pituitary Deficiency

Symptoms and signs of pituitary disease are rarely the first manifestations of malignancy originating in another organ. We present a case which exemplifies the key points that suggest a diagnosis of metastatic pituitary disease. Our patient\u27s diagnosis was adenocarcinoma of the lung with a metastasis to the intrasellar and suprasellar regions, which caused diabetes insipidus, anterior pituitary deficiency, and visual field defects. The metastasis had a dumbbell appearance and extended from the sella turcica into the suprasellar region. Diabetes insipidus was the initial clinical manifestation of lung cancer in this patient. A metastasis to the pituitary should be suspected if diabetes insipidus is the initial manifestation of an intrasellar mass

Functional reconstruction of the glenoid fossa utilizing a pedicled temporal osteomuscular flap

Current techniques in management of end stage pathology of the temporomandibular joint (TMJ) include the use of alloplastic joint reconstruction. A polyethylene glenoid fossa prosthesis is a necessity of this treatment as it provides a stable platform for function of the metal alloy condylar head. Additionally, the fossa prosthesis limits superior and posterior movement of the reconstructed joint which prevents complications such as migration of the condylar prosthesis into the middle cranial fossa and ear, ankylosis, and pain. When a pathologic process affects the glenoid fossa alone, alloplastic joint reconstruction becomes a less desirable treatment option. Lack of osseous structure along the temporal bone and zygomatic arch can impact the surgeon\u27s ability to fixate a glenoid fossa prosthesis. Additionally, resection of an uninvolved condylar head in situations where there is no advanced pathology would provide a functional solution, but may be overly aggressive and potentially unnecessary. The following is our experience with utilizing a pedicled temporal osteomuscular flap to reconstruct an acquired defect of the glenoid fossa in a 42-year-old male with a diffuse-type tenosynovial giant cell tumor. In this case the mandibular condyle was not affected by the pathology

Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

BACKGROUND: Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE: To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS: A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS: A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P \u3c .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION: A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns

The 'values journey' of nursing and midwifery students selected using multiple mini interviews: evaluations from a longitudinal study

Values-based practice is deemed essential for healthcare provision world-wide. In England, values-based recruitment methods, such as multiple mini interviews (MMIs), are employed to ensure that healthcare students’ personal values align with the values of the National Health Service (NHS), which focus on compassion and patient-centeredness. However, values cannot be seen as static constructs. They can be positively and negatively influenced by learning and socialisation. We have conceptualised students’ perceptions of their values over the duration of their education programme as a ‘values journey’. The aim of this hermeneutic longitudinal focus group study was to explore the ‘values journey’ of student nurses and midwives, recruited through MMIs, across the three years of their education programme. The study commenced in 2016, with 42 nursing and midwifery students, originally recruited onto their programmes through multiple mini interviews. At the third and final point of data collection, 25 participants remained. Findings indicate that students’ confidence, courage and sense of accountability increased over the three years. However, their values were also shaped by time constraints, emotional experiences and racial discrimination. We argue that adequate psychological support is necessary as healthcare students embark on and progress through their values journey, and propose a framework for this

Nasopharyngeal Bacterial Colonization and Gene Polymorphisms of Mannose-Binding Lectin and Toll-Like Receptors 2 and 4 in Infants

BACKGROUND: Human nasopharynx is often colonized by potentially pathogenic bacteria. Gene polymorphisms in mannose-binding lectin (MBL), toll-like receptor (TLR) 2 and TLR4 have been reported. The present study aimed to investigate possible association between nasopharyngeal bacterial colonization and gene polymorphisms of MBL, TLR2 and TLR4 in healthy infants. METHODOLOGY/PRINCIPAL FINDINGS: From August 2008 to June 2010, 489 nasopharyngeal swabs and 412 blood samples were taken from 3-month-old healthy Finnish infants. Semi-quantitative culture was performed and pyrosequencing was used for detection of polymorphisms in MBL structural gene at codons 52, 54, and 57, TLR2 Arg753Gln and TLR4 Asp299Gly. Fifty-nine percent of subjects were culture positive for at least one of the four species: 11% for Streptococcus pneumoniae, 23% for Moraxella catarrhalis, 1% for Haemophilus influenzae and 25% for Staphylococcus aureus. Thirty-two percent of subjects had variant types in MBL, 5% had polymorphism of TLR2, and 18% had polymorphism of TLR4. Colonization rates of S. pneumoniae and S. aureus were significantly higher in infants with variant types of MBL than those with wild type (p = .011 and p = .024). Colonization rates of S. aureus and M. catarrhalis were significantly higher in infants with polymorphisms of TLR2 and of TLR4 than those without (p = .027 and p = .002). CONCLUSIONS: Our study suggests that there is an association between nasopharyngeal bacterial colonization and genetic variation of MBL, TLR2 and TLR4 in young infants. This finding supports a role for these genetic variations in susceptibility of children to respiratory infections

Toll-Like Receptor 3 (TLR3) Plays a Major Role in the Formation of Rabies Virus Negri Bodies

Human neurons express the innate immune response receptor, Toll-like receptor 3 (TLR3). TLR3 levels are increased in pathological conditions such as brain virus infection. Here, we further investigated the production, cellular localisation, and function of neuronal TLR3 during neuronotropic rabies virus (RABV) infection in human neuronal cells. Following RABV infection, TLR3 is not only present in endosomes, as observed in the absence of infection, but also in detergent-resistant perinuclear inclusion bodies. As well as TLR3, these inclusion bodies contain the viral genome and viral proteins (N and P, but not G). The size and composition of inclusion bodies and the absence of a surrounding membrane, as shown by electron microscopy, suggest they correspond to the previously described Negri Bodies (NBs). NBs are not formed in the absence of TLR3, and TLR3−/− mice—in which brain tissue was less severely infected—had a better survival rate than WT mice. These observations demonstrate that TLR3 is a major molecule involved in the spatial arrangement of RABV–induced NBs and viral replication. This study shows how viruses can exploit cellular proteins and compartmentalisation for their own benefit