Spontaneous coronary artery dissection: A review of medical management approaches.

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome (ACS) that usually presents in young female patients. Risk factors include female sex, physical and emotional stressors, and fibromuscular dysplasia, and diagnosis is usually made by coronary angiography aided by intravascular ultrasound (IVUS) or optical coherence tomography (OCT). While conservative treatment is usually preferred over percutaneous coronary intervention or surgery, medical management of SCAD has been under debate. This comprehensive review aims to summarize findings from recent studies exploring various medical treatment approaches for the management of SCAD. Antiplatelet therapy with aspirin is generally safe and beneficial for SCAD patients, with dual antiplatelet (DAPT) being recommended for patients undergoing PCI. In the absence of intervention, DAPT may be given for a short period followed by a longer single-antiplatelet (SAPT) therapy with aspirin. Beta-blockers appear to be safe and effective for SCAD patients. On the other hand, fibrinolytics, anticoagulants, and glycoprotein IIa/IIIb inhibitors are contraindicated. Cardiovascular medications such as renin-angiotensin-aldosterone system (RAAS) inhibitors, mineralocorticoid receptor antagonists, and statins are not recommended in the absence of left ventricular dysfunction. Hormonal therapy is contraindicated for patients who develop SCAD during pregnancy and future pregnancy is discouraged in that patient population.

Glans hypermobility scale (GHS): A simple grading scale and description of a modified glanspexy technique.

Glans hypermobility (GH) is a well-described clinical entity that can have significant implications for cosmesis and function, resulting in sexual dissatisfaction, penile pain, and early device erosion, with an estimated incidence of 0.04% to 10%. We developed a novel grading scale to assess GH severity intraoperatively during primary inflatable penile prosthesis (IPP) placement and describe a modified glanspexy technique to correct GH when encountered during IPP placement. 530 patients who underwent primary IPP placements from two high-volume prosthetic surgeons between February 2018 - November 2019 were retrospectively reviewed in order to identify the incidence of GH. Of these, 139 (26.2%) had hypermobility. Employing our new scaling system, grade 1, 2, and 3 GH was seen in 86 (16.2%), 29 (5.5%), and 24 (4.5%) cases, respectively. Increased implant size correlated with a decreased likelihood of GH incidence. Each increase in implant size by 1 cm decreased the incidence of detecting GH by 11.0% (OR = 0.89; p = 0.015). 11 patients underwent primary GH repair using our described technique. At one-year follow-up, one patient required repeat glanspexy for recurrent bothersome GH and a second patient developed a suture granuloma at the glanspexy incision requiring unilateral cylinder explant. Our modified glanspexy technique can be used to correct GH in any direction and is a useful tool for the prosthetic surgeon's armamentarium.

Phase comparison and equation of state for Ta2O5.

Tantalum pentoxide (Ta2O5) is among the most technologically useful heavy transition metal oxides. Unfortunately, its crystal structure is the subject of long-standing and unresolved disagreement. Among other consequences, this uncertainty has made it impossible to formulate a robust high pressure equation of state for Ta2O5. Here, we report the results of high pressure x-ray diffraction experiments indexed against a comprehensive list of proposed Ta2O5phases. Five of the proposed phases produce good matches to experimental observations, and the compressibility parameters for these phases are all consistent within uncertainty. This means that regardless of the particular phase chosen, the Ta2O5equation of state can be described with bulk modulusK0=138±3.68 GPa and pressure derivativeK0'=1.82±0.45. Combining these experimental results with new density-functional theory calculations allows us to identify theλphase as the best structural model of Ta2O5at ambient conditions.

A 16-Year Chronicle of Developing a Healthy Workplace Participatory Program for Total Worker Health® in the Connecticut Department of Correction: The Health Improvement through Employee Control (HITEC) Program.

Health Improvement Through Employee Control (HITEC) is a 16-year program directed toward the health of corrections personnel and developed through the application of the principles of Participatory Action Research (PAR) and participatory ergonomics. Its impetus has always been the adverse health status of the corrections workforce: early mortality, depression, obesity, and hypertension. The HITEC program trained small "Design Teams" (DTs) of front-line personnel in participatory methods for intervention design for health improvement and organizational change in line with the Total Worker Health® principles. Periodic surveys and physical testing were introduced for longitudinal assessments. Comparative interventions at comparable sites included DTs without a priori assignation, problem-focused kaizen effectiveness teams (KETs), and bargaining unit-centered DTs. DT resilience and the replacement of members who transferred facilities or retired was aided by novel cooperative administrative structures. DT-generated interventions included stress lounges, changes in critical event report writing, a joint program with trained inmates to improve air quality, and training in staff mental health and sleep behavior. A specialized peer-to-peer Health Mentoring Program (HMP) paired new officers with trained peers. Many interventions and program features were institutionalized, thus improving prospects for self-supporting program longevity. Participatory interventions designed and supported by the corrections workforce were found to be both feasible and exceptionally effective.

Does Tighter Glycemic Control Beyond Hemoglobin A1c of 8% Improve Outcome for Lumbar Spine Surgery? A MSSIC Study.

BACKGROUND AND OBJECTIVES: Diabetes mellitus is associated with increased risk of postoperative adverse outcomes. Previous studies have emphasized the role of glycemic control in postoperative complications. This study aims to ascertain whether controlling hemoglobin A1c (HbA1c) lower than 8% preoperatively results in meaningful risk reduction or improved outcomes. METHODS: We used patient-level data from the Michigan Spine Surgery Improvement Collaborative registry, focusing on patients who underwent elective lumbar spine surgery between 2018 and 2021. The primary outcomes were length of stay and the occurrence of postoperative adverse events. Secondary outcomes included patient satisfaction, achievement of a minimum clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System-Physical Function, the EuroQol-5D and NRS of leg and back pain, and return to work. RESULTS: A total of 11 348 patients were included in this analysis. Patients with HbA1c above the thresholds before surgery had significantly higher risks of urinary retention for all 3 possible threshold values (incidence rate ratio [IRR] = 1.30, P = .015; IRR = 1.35, P = .001; IRR = 1.25, P = .011 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively). They also had longer hospital stay (IRR = 1.04, P = .002; IRR = 1.03, P = .001; IRR = 1.03, P < .001 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and had higher risks of developing any complication with HbA1c cutoff of 7.5% (IRR = 1.09, P = .010) and 7% (IRR = 1.12, P = .001). Diabetics with preoperative HbA1c above all 3 thresholds were less likely to achieve Patient-Reported Outcomes Measurement Information System MCID at the 90-day follow-up (IRR = .81, P < .001; IRR = .86, P < .001; IRR = .90, P = .007 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and less likely to achieve EuroQol-5D MCID at the 2-year follow-up (IRR = .87, P = .027; IRR = .84, P = .005 for the HbA1c cutoffs of 7.5% and 7%, respectively). CONCLUSION: Our study suggests that reducing HbA1c below 8% may have diminishing returns regarding reducing complications after spine surgery.

Bone Grafting Options for Single-Level TLIF: So Many Options, What Is the Evidence?

BACKGROUND: This review seeks to investigate the clinically relevant bone graft materials in single-level transforaminal lumbar interbody fusion (TLIF) procedures as defined by (1) primary outcomes (ie, fusion rates and complication rates) and (2) patient-reported outcomes (ie, visual analog scale [VAS] and Oswestry disability index [ODI]). Because of the advantages in stimulating bone growth, autologous bone grafts such as the iliac crest bone graft (ICBG) have been the gold standard. Numerous alternatives to ICBG have been introduced. Understanding the risks and benefits of bone graft options is vital to optimizing patient care. METHODS: A PubMed search was performed for all clinical studies published between January 2008 and March 2023 that referenced the single-level TLIF procedure as well as one of the following grafts: autograft, allograft, bone morphogenetic protein (BMP), demineralized bone matrix, or mesenchymal stem cells (MSCs). Case studies and reports were excluded. RESULTS: Twenty-eight studies met the inclusion criteria. Studies from the PubMed search demonstrated similarly high fusion rates across nearly all graft materials, the lone exception being MSCs, which showed lower fusion rates. ICBG grafts experienced higher rates of postoperative graft site pain. The BMP graft material had high rates of radiculitis, heterogeneous ossification, and vertebral osteolysis. Patients saw an overall improvement in VAS and ODI scores with all graft materials. CONCLUSION: Local autografts and ICBG have been the most studied. Fusion rates during single-level TLIF were similar across all graft materials except MSCs. Patient-reported pain levels improved after TLIF surgery regardless of the type of grafts used. While BMP implants have shown promising benefits, they have introduced a new array of complications not normally seen in ICBG implants. The study is limited by the lack of evidence of certain graft materials as well as nonuniformity in metrics evaluating the efficacy of graft materials.

Gluten Sensitivity Underlying Resistant "Laryngopharyngeal Reflux" Symptoms and Signs.

INTRODUCTION: Laryngopharyngeal reflux (LPR) is one of the most common conditions encountered in otolaryngology. Gluten sensitivity may mimic the signs and symptoms of LPR or act as an aggravating cofactor with LPR. Gluten sensitivity and food intolerance also have been implicated as conditions that may be associated specifically with LPR symptoms and signs resistant to traditional medical treatment. Medical management of LPR may be insufficient to control symptoms and laryngeal signs of reflux, constituting resistant LPR. Eliminating gluten from the diet could provide symptomatic relief to patients with gluten sensitivity and LPR that is not controlled adequately by current regimens. The purpose of our study was to investigate the relationship between gluten sensitivity and LPR. We aimed to evaluate reflux finding score (RFS) improvement following elimination of gluten from the diet in patients with resistant LPR who had positive blood tests associated with gluten sensitivity. Symptom improvement was also assessed following dietary gluten elimination. Lastly, we aimed to identify predictors for a positive response to a gluten-free diet. METHODS: Adult patients who underwent gluten sensitivity testing for treatment-resistant LPR symptoms and/or signs were included. Patients with ≥1 positive test were advised to begin a therapeutic trial of a gluten-free diet. Subjects who chose not to trial a gluten-free diet or tested negative for gluten sensitivity markers served as controls. RFS was the primary outcome measure. RESULTS: One hundred ninety-seven patients were included; 81 trialed a gluten-free diet. Subjects who trialed the gluten-free diet were significantly more likely to demonstrate objective improvement in RFS (77.14% vs 43.88%), and report subjective improvement (55.41% vs 25.77%) than those who did not. RFS had decreased significantly from baseline at 1-3, 3-6, 6-12, and >12-month interval follow-up examinations in subjects who trialed a gluten-free diet. Comparison between subjects who trialed the gluten-free diet, tested positive for a gluten sensitivity marker but did not trial the gluten-free diet, and subjects who were negative for all gluten sensitivity markers revealed that a gluten-free diet was associated with a significantly greater percent improvement in RFS compared to controls at 1-3, 6-12, and >12-months. CONCLUSION: Gluten sensitivity can mimic or aggravate LPR. A gluten-free diet should be considered for patients with resistant LPR, especially if blood test abnormalities that suggest gluten sensitivity are identified. The diet should be maintained for a minimum of three months to demonstrate objective improvement using RFS.

Does the Severity of Vocal Fold Paresis on Laryngeal Electromyography Correlate With Radiographic Findings on Cross Sectional Imaging?

OBJECTIVES: Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity of injury and direct treatment plans. Despite extensive research involving findings suggestive of UVFP with radiographic imaging, no study has attempted to determine which findings suggestive of UVFP on imaging are clinically significant and suggest a need for intervention. The purpose of this study was to evaluate whether the severity of vocal fold paresis/paralysis affects the likelihood of encountering radiographic findings suggestive of UVFP. We also aimed to determine which findings suggestive of UVFP on imaging were clinically significant and were associated with surgical intervention. MATERIALS AND METHODS: A retrospective chart review was conducted of patients who had been diagnosed with unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or magnetic resonance imaging and laryngeal electromyography (EMG) between the dates of January 1, 2017 and January 9, 2018. Fisher's exact testing with Monte Carlo Simulation was utilized to determine statistical significance of identified relationships. Univariate analysis was conducted to assess for individual relationships between imaging results and the potential predictor variables. Chi square analysis was conducted with the various categorical variables to assess for any potential relationships to imaging results. Statistical significance was determined utilizing chi square analysis. RESULTS: After data collection, 130 patients were included in the study population. Of the 112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively. The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%, respectively. Seventy four percent of patients who exhibited abnormal MRI were found to have isolated SLN weakness, and 21% of patients were found to have a combined SLN and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness. MRI imaging again failed to display any significant degree of paresis. However, abnormal CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for each increase in the degree of severity of CN X paresis. When looking at the ability of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients with an abnormal MRI underwent surgery compared to just 14.61% of those with normal scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging. CONCLUSIONS: There is a relationship between severity of vocal fold paresis found on laryngeal EMG and likelihood of detection on imaging. While CT was more likely to find characteristics of UVFP than MRI, patients who had an abnormal finding on either modality were more likely to undergo surgical intervention. These findings highlight the importance of early referral of patients with abnormal laryngeal imaging to an otolaryngologist for evaluation and possible intervention.

Surgical Outcome of Potassium-Titanyl-Phosphate (KTP) Laser Photocoagulation for Vocal Fold Vascular Lesions.

INTRODUCTION: Laser technology is used in microscopic direct laryngeal surgery for a variety of indications. Lasers are categorized broadly as photoangiolytic or cutting/ablating lasers, based on the chromophores that absorb their energy. Photoangiolytic lasers such as the 532 nm Potassium-Titanyl-Phosphate (KTP) laser are absorbed selectively by the chromophore hemoglobin, facilitating controlled intravascular coagulation, with preservation of the overlying epithelium and adjacent tissue. Efficacy of the KTP laser has been demonstrated for incision, coagulation, and ablation in vocal fold (VF) surgery. OBJECTIVE: The purpose of the present study was to examine surgical outcomes following KTP laser photocoagulation for the management of VF vascular lesions. METHODS: Adult patients with sufficient data who had undergone KTP laser photocoagulation in the operating room for the treatment of VF vascular lesions were included in this retrospective study. Strobovideolaryngoscopy (SVL) video footage from all preoperative visits and all available postoperative visits was compiled and de-identified. Patients were followed up at days 1-7, 8-14, 30-60, and greater than 60 days after surgery. Three blinded physician evaluators reviewed and evaluated the SVL footage independently for postoperative outcome parameters. Postoperative SVL video footage was evaluated on a 5-point scale for surgical success (surgical objective score; 1 = failure and 5 = complete success). The average surgical objective score was 4.36, 4.04, 4.25, and 4.46 (out of 5) at postoperative visits 1-4, respectively. RESULTS: There were 60 cases (19 male and 41 female) included in the retrospective cohort. The average age was 42.42 ± 15.51 (range = 18-74). Fifty-one-point six seven percent of subjects were professional voice users (singers, teachers, public speakers, and others). All subjects were diagnosed preoperatively with VF vascular malformations and had undergone pulsed KTP laser photocoagulation. There were 40 bilateral cases and 20 unilateral cases, for a total of 100 VFs included in the study. Vascular malformation recurrence was identified in 3.00% and 10.00% of subjects at the third and fourth postoperative visits, retrospectively. The formation of new vascular malformations was identified in 0.00%, 1.00%, 6.00%, and 7.00% of subjects at postoperative visits 1-4, respectively. CONCLUSION: KTP laser photocoagulation is highly effective for the management of vocal fold vascular lesions. Presence of hemorrhage or edema does not affect the long-term surgical outcome. In relatively few cases, vascular lesion recurrence or formation of new vascular lesions may occur.

De novo mapping of α-helix recognition sites on protein surfaces using unbiased libraries.

The α-helix is one of the most common protein surface recognition motifs found in nature, and its unique amide-cloaking properties also enable α-helical polypeptide motifs to exist in membranes. Together, these properties have inspired the development of α-helically constrained (Helicon) therapeutics that can enter cells and bind targets that have been considered "undruggable", such as protein-protein interactions. To date, no general method for discovering α-helical binders to proteins has been reported, limiting Helicon drug discovery to only those proteins with previously characterized α-helix recognition sites, and restricting the starting chemical matter to those known α-helical binders. Here, we report a general and rapid screening method to empirically map the α-helix binding sites on a broad range of target proteins in parallel using large, unbiased Helicon phage display libraries and next-generation sequencing. We apply this method to screen six structurally diverse protein domains, only one of which had been previously reported to bind isolated α-helical peptides, discovering 20 families that collectively comprise several hundred individual Helicons. Analysis of 14 X-ray cocrystal structures reveals at least nine distinct α-helix recognition sites across these six proteins, and biochemical and biophysical studies show that these Helicons can block protein-protein interactions, inhibit enzymatic activity, induce conformational rearrangements, and cause protein dimerization. We anticipate that this method will prove broadly useful for the study of protein recognition and for the development of both biochemical tools and therapeutics for traditionally challenging protein targets.

Detection and molecular characterization of Salmonella species on U.S. goat operations.

Salmonella species are an important cause of gastrointestinal disease in animals, including goats. Additionally, Salmonella species are among the top five U.S. foodborne pathogens causing illness to humans. The goat industry is rapidly expanding in the U.S. yet estimates of Salmonella prevalence within these populations is lacking. The aim of this study was to investigate the fecal prevalence, antimicrobial resistance (AMR), biofilm potential, and virulence profile of Salmonella species isolated from goat feces as part of the United States Department of Agriculture (USDA) National Animal Health Monitoring System (NAHMS) Goat 2019 study, enteric microbe component. A total of 4917 fecal samples were collected from 332 operations, from September 2019-March 2020. Salmonella were isolated using standard enrichment and culture methods; antimicrobial susceptibility was determined by broth microdilution. Biofilm production was assessed using a crystal violet assay and normalized to a positive control strain, and PCR was used to detect virulence genes. Overall, we detected a low prevalence (0.7%, n = 35/4917) of Salmonella in goat feces and identified a broad range of serotypes including S. Bareilly (35%) and a single rare S. Sharon. All isolates were pansusceptible to 14 antimicrobials except one, which was resistant to only tetracycline (MIC ≥ 32 µg/mL). All strains were found to possess the majority of virulence determinants screened, and 40% (14 of 35) formed weak, moderate, or strong biofilm. We found a low prevalence of Salmonella, and characteristics of Salmonella in the U.S. goat population informs ongoing public health efforts to manage risk of animal food products and animal interactions.

Surgical Outcome of Low-Power-Density Blue Laser for Vascular Lesions of the Vocal Fold.

Photoangiolytic lasers such as the 532-nm potassium-titanyl-phosphate (KTP) and the novel 445-nm blue laser (introduced into the United States in 2020) are absorbed selectively by hemoglobin, permitting targeted ablation of vascular structures such as vascular malformations of the vocal fold (VF). Previously, we reported the high rate of success of KTP laser photocoagulation for VF vascular lesions. Compared with other photoangiolytic lasers, blue laser has the highest absorption in hemoglobin, and therefore it can be operated at lower power densities to minimize thermal injury to adjacent tissue. OBJECTIVE: The purpose of this study was to determine the efficacy and safety of blue laser for treatment of VF vascular lesions using low power densities, and to compare outcomes of blue laser with those of KTP laser. METHODS: Adult voice patients who underwent blue laser treatment of VF vascular lesions in the operating room at the lowest power densities that appeared clinically to cause the effect desired were included in this retrospective study. Baseline lesion characteristics and postoperative outcomes were assessed with a model that we had described previously. Postoperative outcomes were compared to those of previously reported KTP laser. RESULTS: Thirty-one subjects (54 VFs treated) underwent blue laser vaporization of VF vascular lesions (average age was 40.63 ± 17.51). Data were compared to those of 66 subjects (100 VFs) who had undergone KTP laser vaporization of VF vascular lesions. There were no significant differences in subject demographics, past medical or surgical history, or preoperative location or severity of vascular lesions. Surgical success for blue laser at the low power densities used was 3.74 ± 0.50, 3.55 ± 0.94, 3.90 ± 0.94, and 3.70 ± 1.11 (out of 5) at postoperative visits 1-4, respectively. Surgical objective score was significantly greater following KTP laser at every postoperative visit. Treatment with KTP laser resulted in significantly greater generalized postoperative edema, and blue laser resulted in significantly greater localized edema at postoperative visits one and two. At visit three and four, there are no significant differences. VF stiffness following blue laser was 2.41 ± 0.67, 1.91 ± 0.69, 1.33 ± 0.47, and 1.10 ± 0.18 (out of 4) at postoperative visits 1-4, respectively. Postoperative VF stiffness did not differ significantly from KTP laser. Postoperative hemorrhage severity after blue laser was 1.79 ± 0.54, 1.59 ± 0.48, 1.15 ± 0.25, and 1.14 ± 0.26 (out of 4) at postoperative visits 1-4, respectively. Blue laser resulted in significantly less VF hemorrhage than KTP laser at the first (1.79 ± 0.54 versus 2.26 ± 0.83) and second (1.59 ± 0.48 versus 1.98 ± 0.72) postoperative visits. Vascular lesions treated with low-power-density blue laser were significantly more likely to recur than those treated with KTP laser (40.74% versus 10.00%). New vascular malformations were significantly more likely to form after blue laser than KTP (24.07% versus 6.00%). Subjects treated with low-power-density blue laser were significantly more likely to undergo repeat surgery than those treated with KTP (31.48% versus 14.00%). Significant predictors for the need for repeat blue laser included lesion recurrence, a lower surgical objective score at the third or fourth postoperative visit and a higher baseline lesion severity grade. CONCLUSION: Blue laser is an effective tool for the surgical management of VF vascular lesions. Although overall surgical success ratings were inferior to KTP laser at the power densities used, the severity of postoperative edema and VF hemorrhage were significantly less with blue laser. Re-evaluation of blue laser using higher power densities is in progress.

Examination of care processes and treatment optimization for head and neck cancer patients in a community setting "hub and hub" model.

Objective: To examine referral pattern, the timing of diagnostic/staging processes, and treatment initiation for new head and neck cancer patients in a community setting. Methods: Patients with a newly diagnosed previously untreated diagnosis of head neck cancer managed at Asplundh Cancer Pavilion/Abington Memorial Hospital from October 2018 to March 2020. Source of referral and preceding workup were examined as well as intervals between initial head and neck consult and various timepoints of treatment initiation. Results: One hundred and five patients were included in the study. The primary referral sources were external general otolaryngology (56.3%). Oral surgery and dermatology obtained tissue biopsy approximately 80% of the time before referral. The average time from the ordering of initial staging positron emission tomography/computed tomography to finalized results was 14 days (range: 10-25 days). Patients referred from dermatology and oral surgery were more likely to require single modality care, namely definitive surgical management. Time to treatment initiation average was 37 days (range: 29-41 days). Patients with longer treatment times noted significantly higher times to both radiation and medical oncology consults (48.42 vs. 18.13 days; P < 0.001). Conclusions: No notable differences in treatment initiation times were identified based on referral source or extent of workup performed before head/neck surgery consult. It appears the largest opportunities for improvement in terms of reducing overall treatment length exist in the optimization of radiation initiation time.

Timing of Martian Core Formation from Models of Hf-W Evolution Coupled with N-body Simulations.

Determining how and when Mars formed has been a long-standing challenge for planetary scientists. The size and orbit of Mars are difficult to reproduce in classical simulations of planetary accretion, and this has inspired models of inner solar system evolution that are tuned to produce Mars-like planets. However, such models are not always coupled to geochemical constraints. Analyses of Martian meteorites using the extinct hafnium-tungsten (Hf-W) radioisotopic system, which is sensitive to the timing of core formation, have indicated that the Martian core formed within a few million years of the start of the solar system itself. This has been interpreted to suggest that, unlike Earth's protracted accretion, Mars grew to its modern size very rapidly. These arguments, however, generally rely on simplified growth histories for Mars. Here, we combine likely accretionary histories from a large number of N-body simulations with calculations of metal-silicate partitioning and Hf-W isotopic evolution during core formation to constrain the range of conditions that could have produced Mars. We find that there is no strong correlation between the final masses or orbits of simulated Martian analogs and their 182W anomalies, and that it is readily possible to produce Mars-like Hf-W isotopic compositions for a variety of accretionary conditions. The Hf-W signature of Mars is very sensitive to the oxygen fugacity (fO2) of accreted material because the metal-silicate partitioning behavior of W is strongly dependent on redox conditions. The average fO2 of Martian building blocks must fall in the range of 1.3-1.6 log units below the iron-wüstite buffer to produce a Martian mantle with the observed Hf/W ratio. Other geochemical properties (such as sulfur content) also influence Martian 182W signatures, but the timing of accretion is a more important control. We find that while Mars must have accreted most of its mass within ~5 million years of solar system formation to reproduce the Hf-W isotopic constraints, it may have continued growing afterwards for over 50 million years. There is a high probability of simultaneously matching the orbit, mass, and Hf-W signature of Mars even in cases of prolonged accretion if giant impactor cores were poorly equilibrated and merged directly with the proto-Martian core.

Immediate and Short-term Effects of Straw Phonation in Air or Water on Vocal Fold Vibration and Supraglottic Activity of Adult Patients with Voice Disorders Visualized with Strobovideolaryngoscopy: A Pilot Study.

Purpose The first purpose of this study was to investigate and compare the short-term effects after a semi-occluded vocal tract (SOVT) therapy session consisting of straw phonation (SP) in air or water on vocal fold vibration and supraglottic activity of adult patients with voice disorders, visualized with strobovideolaryngoscopy (SVL). The second purpose of this study was to investigate and compare immediate changes in the patients' vocal fold vibration and supraglottic activity during SP in air or water, visualized with SVL. Methods Twelve adult patients with voice disorders (eight women and four men, mean age 52 years) were assigned randomly to one of two study groups: SP in air or SP in water. Immediately before and after a therapy session of 15 min, participants underwent a rigid SVL to determine the short-term effects of the SP session. At the posttherapy examination, flexible SVL while performing SP was added to determine the effects occurring during SP. The visual-perceptual ratings were performed blindly and in random order by three laryngologists, using the Voice-Vibratory Assessment with Laryngeal Imaging rating form for stroboscopy. ResultsShort-term effects after SP: After the SP-in-air session, the supraglottic mediolateral compression decreased significantly. The SP-in-water session led to significantly increased left vibrational amplitude. Immediate effects during SP: During SP in air, a significantly increased left amplitude and mucosal wave, and significantly decreased mediolateral supraglottic activity, were found. SP in water tended to decrease the vibrational amplitude during performance of the task. A trend toward higher anteroposterior supraglottic compression was observed during both SP in air and water, being more prominent in the latter. Conclusion SP in air led to less false vocal fold adduction and consequently less hyperfunction. The small increment in anteroposterior supraglottic activity during SP in air and water might be related to epilarynx narrowing, an economic phenomenon associated with SOVT exercises. The effects on vibrational amplitude were rather ambiguous. The small reduction in amplitude during SP in water is expected to diminish vocal fold impact stress and therefore creates an ideal basis for voice therapy. The increment in amplitude and mucosal wave during SP in air might indicate insufficient supraglottic pressure to obtain the favorable effects of semi-occlusion. Whether or not the rise in amplitude after the SP-in-water session is due to voice efficiency or voice fatigue remains unknown. Future larger-scale investigation in subgroups of voice patients is needed to explore these hypotheses.

Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision.

OBJECTIVE: To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis. METHODS: Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice. RESULTS: Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05). CONCLUSION: This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.

Evaluation of stapes mobilization in the 21st century for conductive hearing loss in the otosclerotic ear.

PURPOSE: Compare outcomes of stapes mobilization and stapedectomy performed by a single surgeon for the otosclerosis. MATERIALS AND METHODS: A retrospective chart review of adult patients who underwent stapes mobilization or stapedectomy for otosclerosis was performed. Operative notes reviewed; patients included if diagnosed with otosclerosis without another otologic disease that could contribute to their hearing loss and all required data were available. Pre-and post-operative audiograms at 1, 6, and 12-months were evaluated to compare the air-bone gaps between the mobilization and stapedectomy procedures. The rates of sensorineural hearing loss also were compared. Student t-tests and multiple regression models were used to ascertain the association between improvement in post-operative air-bone gaps, sensorineural hearing loss, and the procedure undertaken. RESULTS: Sixty-seven (n = 67) patients with 108 procedures were included for analysis. No substantial difference between the surgical subgroups was found when comparing stapes mobilization to stapedectomy, and there was no evidence to suggest that either surgical procedure was superior to the other based on the data obtained and analyzed. Improvements in air-bone gap averaged 15.79 dB for stapes mobilization and 19.23 dB for stapedectomy. The results of the study showed no evidence of post-operative sensorineural hearing loss or change in air-bone gaps when comparing virgin to "revision" stapedectomy largely in patients who had failed previous mobilization. CONCLUSION: Stapes mobilization provides a conservative approach to otosclerosis patients suffering from conductive hearing loss. Stapedectomy can be used to correct failed mobilization.

Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database.

BACKGROUND: This study compares outcomes of conventional and less-invasive (LI) approaches for aortic valve replacement (AVR) using The Society of Thoracic Surgeons database. METHODS: Between 2011 and 2017, we identified 122,474 patients undergoing isolated primary AVR. Patients were categorized into 3 groups: (1) full sternotomy (FS) (n = 98,549; 78%), (2) partial sternotomy (PS) (n = 17,306; 15%), and (3) right thoracotomy (RT) (n = 6619; 7%). RESULTS: The rate of LI-AVR increased from 17% in 2011 to 23% in 2016 (P < .001). Femoral cannulation was used in 1.5% of FS, 5.4% of PS, and 71% of RT patients (P < .001). Full sternotomy patients were older and had higher rates of preoperative renal failure, atrial fibrillation, and stroke, and had a higher NYHA function class, lower ejection fraction, and higher STS risk score. Total operative, cardiopulmonary bypass, and cross-clamp time were longest in RT-AVR patients and shortest in those who had FS-AVR. Overall, unadjusted operative mortality was 1.9% (1.05% among low-risk patients) and was not different among the 3 groups (1.97% FS, 1.77% PS, and 1.90% RT; P = .4). The rate of postoperative stroke was 1.2% and was not different among the 3 groups (1.2% FS, 1.3% PS, and 1.1% RT; P = .3). After risk adjustment, these differences remained nonsignificant. After risk adjustment, prolonged ventilation and atrial fibrillation were less common in PS-AVR patients. The adjusted risk for blood transfusion was lower in RT-AVR patients, as was the incidence of renal failure. Femoral cannulation was not associated with increased risk for stroke or mortality after LI-AVR. CONCLUSIONS: Less-invasive AVR is associated with an operative mortality and postoperative stroke rate similar to that of FS. Less-invasive AVRs should serve as a benchmark for comparison between transcatheter aortic valve replacement and surgical AVR in low-risk patients.

Adult-Onset Leukoencephalopathy With Axonal Spheroids and Pigmented Glia: Review of Clinical Manifestations as Foundations for Therapeutic Development.

A comprehensive review of published literature was conducted to elucidate the genetics, neuropathology, imaging findings, prevalence, clinical course, diagnosis/clinical evaluation, potential biomarkers, and current and proposed treatments for adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP), a rare, debilitating, and life-threatening neurodegenerative disorder for which disease-modifying therapies are not currently available. Details on potential efficacy endpoints for future interventional clinical trials in patients with ALSP and data related to the burden of the disease on patients and caregivers were also reviewed. The information in this position paper lays a foundation to establish an effective clinical rationale and address the clinical gaps for creation of a robust strategy to develop therapeutic agents for ALSP, as well as design future clinical trials, that have clinically meaningful and convergent endpoints.

Golf-Related Craniofacial Injuries in Adults: A NEISS Database Study.

INTRODUCTION: Despite its popularity, there have been no reports outlining adult craniofacial trauma in the setting of golf injuries. Our main objective was to identify and describe trends in head and neck injuries incurred while participating in golf including injury type, anatomic location, and patient disposition. METHODS: A retrospective cohort analysis of the National Electronic Injury Surveillance System (NEISS) was conducted from 2009-2018. Population characteristics of golf-related injuries were recorded, including, age, sex, and race distributions. Distribution of injury anatomic location, injury type, distribution of fracture location, patient disposition was further analyzed. A one way ANOVA was utilized to obtain the mean ages for all injuries and compare them for any statistical difference. To identify statistical significance, a Fisher exact test with a Monte Carlo simulation was performed. RESULTS: A total of 509 golf-related injuries (national estimate 24,425 cases) were recorded over the study period. Lacerations were the most common injury overall (54.2%), while contusions and abrasions were the next most common injuries (27.3%). The most common fracture subtype observed was midface (40.43%), followed by nasal bone (27.66%), mandible (12.77%), skull (12.77%), and cervical spine (6.38%). The highest proportion of patients admitted for further treatment were individuals >70 years of age. Fractures had the highest rate of admission (29.8%). CONCLUSIONS: A better understanding of golf injuries can allow for rapid detection and appropriate treatment when encountered. This knowledge can also help to develop safety precautions by potentially reforming rules and regulations as well as protective equipment.