Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered.

OBJECTIVES: To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort. DESIGN: A retrospective case-series between 2006 and 2019. SETTING: All patient care was undertaken at a regional skull base referral centre. PARTICIPANTS: Twenty-one male patients with a median age of 18 (range 16-45 years). MAIN OUTCOME MEASURES: Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence. RESULTS: The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence. CONCLUSIONS: MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

Mobile app increases vegetable-based preparations by low-income household cooks: a randomized controlled trial.

OBJECTIVE: We built an app to help clients of food pantries. The app offers vegetable-based recipes, food tips and no-cost strategies for making mealtimes healthier and for bargain-conscious grocery shopping, among other themes. Users customize materials to meet their own preferences. The app, available in English and Spanish, has been tested in a randomized field trial. DESIGN: A randomized controlled trial with repeated measures across 10 weeks. SETTING: Clients of fifteen community food pantry distributions in Los Angeles County, USA.ParticipantsDistributions were randomized to control and experimental conditions, and 289 household cooks and one of their 9-14-year-old children were enrolled as participants. Experimental dyads were given a smartphone with our app and a phone use-plan, then trained to use the app. 'Test vegetables' were added to the foods that both control and experimental participants received at their pantries. RESULTS: After 3-4 weeks of additional 'test vegetables', cooks at experimental pantries had made 38 % more preparations with these items than control cooks (P = 0·03). Ten weeks following baseline, experimental pantries also scored greater gains in using a wider assortment of vegetables than control pantries (P = 0·003). Use of the app increased between mid-experiment and final measurement (P = 0·0001). CONCLUSIONS: The app appears to encourage household cooks to try new preparation methods and widen their incorporation of vegetables into family diets. Further research is needed to identify specific app features that contributed most to outcomes and to test ways in which to disseminate the app widely.

The Potential of Information Technology to Navigate Caregiving Systems: Perspectives from Dementia Caregivers.

Technologies designed to support caregivers of adults with Alzheimer's disease and related dementias (AD/RD) have been developing at an increasingly rapid pace. However, little remains known about caregivers' perspectives on how technologies can and should help them navigate larger service systems they interact with to engage in caregiving. This study involved in-depth interviews and a beta test of an AD/RD caregiver app to learn more about how they currently use technologies and how potential technological features and functions can best meet their needs. Thematic findings suggest a conceptual model for designing AD/RD caregiver technologies. The findings suggest that eHealth and individual technologies may not fully meet the needs of caregivers as they navigate the larger systems within which they provide care. Findings highlight the need to develop technologies for caregivers that are effective, easy to use, and more widely disseminated - especially for caregivers from disadvantaged backgrounds.

Autosis is a Na+,K+-ATPase-regulated form of cell death triggered by autophagy-inducing peptides, starvation, and hypoxia-ischemia.

A long-standing controversy is whether autophagy is a bona fide cause of mammalian cell death. We used a cell-penetrating autophagy-inducing peptide, Tat-Beclin 1, derived from the autophagy protein Beclin 1, to investigate whether high levels of autophagy result in cell death by autophagy. Here we show that Tat-Beclin 1 induces dose-dependent death that is blocked by pharmacological or genetic inhibition of autophagy, but not of apoptosis or necroptosis. This death, termed "autosis," has unique morphological features, including increased autophagosomes/autolysosomes and nuclear convolution at early stages, and focal swelling of the perinuclear space at late stages. We also observed autotic death in cells during stress conditions, including in a subpopulation of nutrient-starved cells in vitro and in hippocampal neurons of neonatal rats subjected to cerebral hypoxia-ischemia in vivo. A chemical screen of ~5,000 known bioactive compounds revealed that cardiac glycosides, antagonists of Na(+),K(+)-ATPase, inhibit autotic cell death in vitro and in vivo. Furthermore, genetic knockdown of the Na(+),K(+)-ATPase α1 subunit blocks peptide and starvation-induced autosis in vitro. Thus, we have identified a unique form of autophagy-dependent cell death, a Food and Drug Administration-approved class of compounds that inhibit such death, and a crucial role for Na(+),K(+)-ATPase in its regulation. These findings have implications for understanding how cells die during certain stress conditions and how such cell death might be prevented.

How Do Cooks Actually Cook Vegetables? A Field Experiment With Low-Income Households.

Vegetables in the diet contribute to disease prevention. However, low-income households underconsume fresh vegetables, perhaps because of cost and of unavailability at nearby stores. A third reason may lurk behind those barriers: cooks' unfamiliarity with various and appealing ways to prepare vegetables. To illuminate that possibility and to suggest interventions that could be designed more effectively to boost vegetable consumption, this study took the novel step of providing ample, if temporary, supplies of a fresh vegetable to random sets of clients of food pantries. A week later, telephone interviews obtained details about preparations of meals and snacks that household cooks had made with their unexpected bounty. Among the experiment's 10 vegetables, some were used twice as often as others. Even more striking, cooks practiced a narrow repertoire of preparation methods, dominated by boiling and steaming, across most of the vegetables. Fats and salt were often added to boiled and steamed preparations. Implications are drawn to suggest kinds of recipes-pairings of vegetables and of vegetables with underused means of preparation-that could expand cooks' repertoires and add variety in flavors, appearances of dishes, meal textures, and aromas.

Managing the Unstable Mandibular Complete Denture ­ Tooth Placement and the Polished Surface.

Constructing satisfactory conventional mandibular complete dentures is often challenging in comparison to the upper counterpart partially due to differences in the anatomy of the denture-bearing area. This problem is exaggerated in the atrophic mandible, where supporting structures are frequently ill-defined and suboptimal in quality. Implant-retained prostheses offer well recognized benefits but are not always a feasible options, so conventional methods must be relied upon. The importance of impression quality and registration has been reviewed previously. This article aims to discuss the influence of tooth placement, the polished surfaces and the neutral zone on the success of lower dentures. Clinical relevance: This article highlights the importance that polished surface contouring and tooth prescription can have on the outcome of lower dentures. Techniques for assessing and recording the neutral zone are explained, along with alternative occlusal schemes.

Testing the Shifting Persistence Niche Concept: Plant Resprouting along Gradients of Disturbance.

Plant resprouting after disturbance confers community resilience because individuals persist through trade-offs in resources for buds versus those required to produce seeds. However, repeated disturbance may deplete bud banks, and population persistence may become increasingly reliant on regeneration from seed. Theory predicts a shift in community assemblage from species with a strategy of persistence by resprouting (persistence niche) to one of regeneration from seed (regeneration niche) as the disturbance frequency increases. We tested, for the first time, the shifting persistence niche concept in a model system at local and regional community scales using a phylogenetically diverse floristic assemblage. Persistence traits of vascular plants were modeled as a function of dry-down frequency in wetlands. Resprouting species occupying the persistence niche were more common in stable wetlands than in those more frequently disturbed by dry downs. The patterns of resprouting species in standing vegetation and in seed banks provide strong support for the shifting persistence niche model involving trade-offs between resprouting (clonality) and sexual reproduction.

Dying neurons in thalamus of asphyxiated term newborns and rats are autophagic.

OBJECTIVE: Neonatal hypoxic-ischemic encephalopathy (HIE) still carries a high burden by its mortality and long-term neurological morbidity in survivors. Apart from hypothermia, there is no acknowledged therapy for HIE, reflecting the lack of mechanistic understanding of its pathophysiology. (Macro)autophagy, a physiological intracellular process of lysosomal degradation, has been proposed to be excessively activated in excitotoxic conditions such as HIE. The present study examines whether neuronal autophagy in the thalamus of asphyxiated human newborns or P7 rats is enhanced and related to neuronal death processes. METHODS: Neuronal autophagy and cell death were evaluated in the thalamus (frequently injured in severe HIE) of both human newborns who died after severe HIE (n = 5) and P7 hypoxic-ischemic rats (Rice-Vannuci model). Autophagic (LC3, p62), lysosomal (LAMP1, cathepsins), and cell death (TUNEL, caspase-3) markers were studied by immunohistochemistry in human and rat brain sections, and by additional methods in rats (immunoblotting, histochemistry, and electron microscopy). RESULTS: Following severe perinatal asphyxia in both humans and rats, thalamic neurons displayed up to 10-fold (p < 0.001) higher numbers of autophagosomes and lysosomes, implying an enhanced autophagic flux. The highly autophagic neurons presented strong features of apoptosis. These findings were confirmed and elucidated in more detail in rats. INTERPRETATION: These results show for the first time that autophagy is enhanced in severe HIE in dying thalamic neurons of human newborns, as in rats. Experimental neuroprotective strategies targeting autophagy could thus be a promising lead to follow for the development of future therapeutic approaches.

Utility of Platelet Count for Predicting Cirrhosis in Alcoholic Liver Disease: Model for Identifying Cirrhosis in a US Population.

BACKGROUND: Thrombocytopenia has been shown to be the single most useful laboratory investigation for identifying subclinical cirrhosis of varying etiologies. However, alcohol per se can result in thrombocytopenia, and hence it is unclear whether platelet count can identify cirrhosis in patients who are alcoholic. OBJECTIVES: To characterize the utility of clinical predictors, especially platelet count, for identifying the presence of cirrhosis in alcoholics. To develop a simple, objective model for identifying cirrhosis in alcoholics. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 2,471 consecutive hospitalized patients with abnormal liver enzyme levels were screened, from which 272 patients with a history of recent and ongoing alcohol intake, negative diagnostic studies for alternative etiologies of chronic liver disease, and recent liver imaging with ultrasound or CT scan were included. MAIN MEASURES: Results of liver imaging and admission laboratory studies including liver enzymes, coagulation studies, and blood counts. KEY RESULTS: One hundred twenty-nine patients (47%) had cirrhosis based on imaging; 143 patients (53%) had no cirrhosis. A pre-sobriety platelet count (during ongoing alcohol intake) of less than 70*10(3) cells/mm(3) was effective for ruling in cirrhosis (positive likelihood ratio [LR] 6.8, 95% CI: 3.4, 14); platelet count greater than 200*10(3) was useful for ruling out cirrhosis in alcoholics (negative LR 0.18, 95% CI: 0.10, 0.35). Multivariate logistic regression analysis identified international normalized ratio (INR) (p < 0.01) and pre-sobriety platelet count (p < 0.01) as independent predictors of cirrhosis. A Model for identifying Cirrhosis in Alcoholic Liver Disease (MCALD) was developed using the INR and pre-sobriety platelet count; it had an area under the receiver operating characteristic curve of 0.89 and Hosmer-Lemeshow goodness of fit chi(2) (p value) of 8.9 (0.35) for predicting cirrhosis in alcoholics. A MCALD score > 5.5 corresponded to an increased likelihood of cirrhosis (LR: 6.5, 95% CI: 4.3, 11.0) and a MCALD score < 5.5 corresponded to decreased likelihood of cirrhosis in alcoholics (LR: 0.25, 95% CI: 0.19, 0.36). Sobriety platelet count (after alcohol abstinence) at a cutoff of 160*10(3) had positive LR of 7.9 (95% CI: 4.4, 14) and negative LR of 0.42 (95% CI: 0.34, 0.52) for predicting cirrhosis in alcoholics. CONCLUSIONS: A simple model of platelet count and INR has good diagnostic accuracy for identifying cirrhosis in alcoholics.

Seasonality and facilitation drive tree establishment in a semi-arid floodplain savanna.

A popular hypothesis for tree and grass coexistence in savannas is that tree seedlings are limited by competition from grasses. However, competition may be important in favourable climatic conditions when abiotic stress is low, whereas facilitation may be more important under stressful conditions. Seasonal and inter-annual fluctuations in abiotic conditions may alter the outcome of tree-grass interactions in savanna systems and contribute to coexistence. We investigated interactions between coolibah (Eucalyptus coolabah) tree seedlings and perennial C4 grasses in semi-arid savannas in eastern Australia in contrasting seasonal conditions. In glasshouse and field experiments, we measured survival and growth of tree seedlings with different densities of C4 grasses across seasons. In warm glasshouse conditions, where water was not limiting, competition from grasses reduced tree seedling growth but did not affect tree survival. In the field, all tree seedlings died in hot dry summer conditions irrespective of grass or shade cover, whereas in winter, facilitation from grasses significantly increased tree seedling survival by ameliorating heat stress and protecting seedlings from herbivory. We demonstrated that interactions between tree seedlings and perennial grasses vary seasonally, and timing of tree germination may determine the importance of facilitation or competition in structuring savanna vegetation because of fluctuations in abiotic stress. Our finding that trees can grow and survive in a dense C4 grass sward contrasts with the common perception that grass competition limits woody plant recruitment in savannas.

Using a rainforest-flame forest mosaic to test the hypothesis that leaf and litter fuel flammability is under natural selection.

We used a mosaic of infrequently burnt temperate rainforest and adjacent, frequently burnt eucalypt forests in temperate eastern Australia to test whether: (1) there were differences in flammability of fresh and dried foliage amongst congeners from contrasting habitats, (2) habitat flammability was related to regeneration strategy, (3) litter fuels were more flammable in frequently burnt forests, (4) the severity of a recent fire influenced the flammability of litter (as this would suggest fire feedbacks), and (5) microclimate contributed to differences in fire hazard amongst habitats. Leaf-level comparisons were made among 11 congeneric pairs from rainforest and eucalypt forests. Leaf-level ignitability, combustibility and sustainability were not consistently higher for taxa from frequently burnt eucalypt forests, nor were they higher for species with fire-driven recruitment. The bulk density of litter-bed fuels strongly influenced flammability, but eucalypt forest litter was not less dense than rainforest litter. Ignitability, combustibility and flame sustainability of community surface fuels (litter) were compared using fuel arrays with standardized fuel mass and moisture content. Forests previously burned at high fire severity did not have consistently higher litter flammability than those burned at lower severity or long unburned. Thus, contrary to the Mutch hypothesis, there was no evidence of higher flammability of litter fuels or leaves from frequently burnt eucalypt forests compared with infrequently burnt rainforests. We suggest the manifest pyrogenicity of eucalypt forests is not due to natural selection for more flammable foliage, but better explained by differences in crown openness and associated microclimatic differences.

Neuroscience, quantum indeterminism and the Cartesian soul.

Quantum indeterminism is frequently invoked as a solution to the problem of how a disembodied soul might interact with the brain (as Descartes proposed), and is sometimes invoked in theories of libertarian free will even when they do not involve dualistic assumptions. Taking as example the Eccles-Beck model of interaction between self (or soul) and brain at the level of synaptic exocytosis, I here evaluate the plausibility of these approaches. I conclude that Heisenbergian uncertainty is too small to affect synaptic function, and that amplification by chaos or by other means does not provide a solution to this problem. Furthermore, even if Heisenbergian effects did modify brain functioning, the changes would be swamped by those due to thermal noise. Cells and neural circuits have powerful noise-resistance mechanisms, that are adequate protection against thermal noise and must therefore be more than sufficient to buffer against Heisenbergian effects. Other forms of quantum indeterminism must be considered, because these can be much greater than Heisenbergian uncertainty, but these have not so far been shown to play a role in the brain.

Skull base surgery for malignant tumors: The 2nd international collaborative study (1995-2015).

BACKGROUND: The current study presents the effort of a global collaborative group to review the management and outcomes of malignant tumors of the skull base worldwide. PATIENTS AND METHODS: A total of 28 institutions contributed data on 3061 patients. Analysis evaluated clinical variables, survival outcomes, and multivariable factors associated with outcomes. RESULTS: The median age was 56 years (IQR 44-67). The open surgical approach was used in 55% (n = 1680) of cases, endoscopic resection was performed in 36% (n = 1087), and the combined approach in 9.6% (n = 294). With a median follow-up of 7.1 years, the 5-year OS DSS and RFS were 65%, 71.7% and 53%, respectively. On multivariable analysis, older age, comorbidities, histology, dural/intracranial involvement, positive margins, advanced stage, and primary site were independent prognostic factors for OS, DSS, and RFS. Adjuvant RT was a protective prognostic factor. CONCLUSION: The progress across various disciplines may have contributed to improved OS and DSS in this study compared to previous reports.

Functional Outcomes Following Delayed Laryngeal Reinnervation Of Patients with Vagal Paralysis After Paraganglioma and Schwannoma Surgery.

PURPOSE: We present a prospective case series that aimed to report the functional (voice and swallowing) outcomes of delayed laryngeal reinnervation following vagal interruption by resection of vagal paraganglioma and schwannoma. MATERIALS AND METHODS: A dedicated, anonymized database was established in 2012 with a minimum eighteen-month follow up set for this report. Internationally validated self- and observer-reported measures were recorded preoperatively and at six, 12 and, 18 months together with demographics, diagnoses, and operative details. RESULTS: A total of eight patients with a median age of 46 (37-54) underwent excision of vagal paraganglioma (five) and schwannoma (three) with few mild complications. Three underwent selective and five non selective reinnervation. Seven out of eight patients underwent synchronous injection medialization. The voice handicap index (VHI-30) improved from a baseline median 83 (range 52-102) to 7.5 (5-58) at 18 months; maximum phonation time improved from median 8 (range 5-15) to 10.5 (8.5-11); voice grade ("G" in grade, roughness, breathiness, asthenia, and strain [GRBAS] scoring) improved from median three (severe impairment, range 0-3) to one (mild impairment, 0-2); Eating Assessment Tool (EAT-10) score improved from median 12 (range 3.5-27) preoperatively to one (0-16); and reflux symptom index (RSI) improved from median 25 (range 17-36) to 7 (0-36). One patient exhibited no discernible reinnervation, while the remainder exhibited good cord bulk and tone, though without purposive abduction. CONCLUSION: Delayed laryngeal reinnervation for high vagal paralysis is a safe technique associated with good voice and swallowing outcomes by 12-18 months. Potential confounders in this small series and the absence of a control arm both limit conclusions, but this study suggests that further prospective, controlled studies, and/or case registration are merited.

Developing a Memory and Communication App for Persons Living With Dementia: An 8-Step Process.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3928/19404921-20210825-02.

The limits of brain determinacy.

The genes do not control everything that happens in a cell or an organism, because thermally induced molecular movements and conformation changes are beyond genetic control. The importance of uncontrolled events has been argued from the differences between isogenic organisms reared in virtually identical environments, but these might alternatively be attributed to subtle, undetected differences in the environment. The present review focuses on the uncontrolled events themselves in the context of the developing brain. These are considered at cellular and circuit levels because even if cellular physiology was perfectly controlled by the genes (which it is not), the interactions between different cells might still be uncoordinated. A further complication is that the brain contains mechanisms that buffer noise and others that amplify it. The final resultant of the battle between these contrary mechanisms is that developmental stochasticity is sufficiently low to make neurobehavioural defects uncommon, but a chance component of neural development remains. Thus, our brains and behaviour are not entirely determined by a combination of genes-plus-environment.

Evaluation of swallowing by Sydney Swallow Questionnaire (SSQ) in oral and oropharyngeal cancer patients treated with primary surgery.

This work aimed at evaluating patients' swallowing functions by a newly validated swallow-specific questionnaire, the Sydney Swallow Questionnaire (SSQ), in a cohort of oral and oropharyngeal cancer patients. Mean/median SSQ scores were calculated and compared with study variables using the Mann-Whitney U test and Kruskal-Wallis test. The mean composite SSQ scores (SD) for the base of tongue, oral tongue, and tonsillar cancer patients were 663.8 (382.8), 456.2 (407.6), and 283.0 (243.1), respectively (p = 0.005); for advanced vs. early T stage disease they were 918.1 (319.5) vs. 344.8 (292.1) (p ≤ 0.001); for patients <60 years vs. ≥60 years they were 549.3 (415.1) vs. 314.0 (247.3) (p = 0.02); and for patients with reconstruction vs. without reconstruction they were 676.5 (410.5) vs. 331.9 (286.5) (p = 0.002). SSQ is a useful tool for evaluation of swallowing in head and neck cancer patients. Site of cancer, T stage, patient's age, and reconstruction directly affect post-treatment swallow outcome.