Prospective Observational Trial of a Nonocclusive Dilatation Balloon in the Management of Tracheal Stenosis.

OBJECTIVES: Tracheal stenosis is a debilitating condition that often presents as an emergency and is challenging to treat. Dilatation may avoid tracheostomy or costly tracheal resection and reconstruction. Traditional dilators cause complete occlusion, preventing oxygenation and ventilation, limiting the safe duration of dilatation, and increasing the risk of hypoxic injury or barotrauma. The study authors here assessed an innovative nonocclusive tracheal dilatation balloon, which may improve patient safety by allowing continuous gas exchange. DESIGN: A prospective observational study of 20 discrete dilatation procedures performed in 13 patients under general anesthesia. The primary outcomes were the ability to ventilate during dilatation and the preservation of peripheral oxygen saturation. Secondary outcomes included a measured reduction in stenosis, improvement in Cotton-Myer grading, and procedure-related adverse events. SETTING: At a single university (academic) hospital. PARTICIPANTS: Consenting adult patients with acquired tracheal stenosis. INTERVENTIONS: Access to the airway was maintained by a rigid bronchoscope or supraglottic airway device, as deemed appropriate. Continuous conventional ventilation was provided during 3-minute balloon dilatations. MEASUREMENTS AND MAIN RESULTS: Heart rate, airway pressure, end-tidal carbon dioxide partial pressure, and peripheral oxygen saturation were measured, and adverse events were recorded. Ventilation was satisfactory in all patients. Peripheral saturation remained greater than 94% in 19 of the 20 (95%) procedures. Stenosis internal diameter and grading were improved. Two patients had minor reversible adverse events (coughing and laryngospasm), which did not prevent completion of the procedure. CONCLUSIONS: The authors report the first human trial of the device, in which continuous conventional ventilation could be provided during all tracheal balloon dilatation procedures. Larger trials are needed to confirm improved patient safety and comparative efficacy.

Disease dynamics of red-spotted newts and their anuran prey in a montane pond community.

Long-term monitoring of amphibians is needed to clarify population-level effects of ranaviruses (Rv) and the fungal pathogen Batrachochytrium dendrobatidis (Bd). We investigated disease dynamics of co-occurring amphibian species and potential demographic consequences of Rv and Bd infections at a montane site in the Southern Appalachians, Georgia, USA. Our 3-yr study was unique in combining disease surveillance with intensive population monitoring at a site where both pathogens are present. We detected sub-clinical Bd infections in larval and adult red-spotted newts Notophthalmus viridescens viridescens, but found no effect of Bd on body condition of adult newts. Bd infections also occurred in larvae of 5 anuran species that bred in our fishless study pond, and we detected co-infections with Bd and Rv in adult newts and larval green frogs Lithobates clamitans. However, all mortality and clinical signs in adult newts and larval anurans were most consistent with ranaviral disease, including a die-off of larval wood frogs Lithobates sylvaticus in small fish ponds located near our main study pond. During 2 yr of drift fence monitoring, we documented high juvenile production in newts, green frogs and American bullfrogs L. catesbeianus, but saw no evidence of juvenile recruitment in wood frogs. Larvae of this susceptible species may have suffered high mortality in the presence of both Rv and predators. Our findings were generally consistent with results of Rv-exposure experiments and support the purported role of red-spotted newts, green frogs, and American bullfrogs as common reservoirs for Bd and/or Rv in permanent and semi-permanent wetlands.

Flexor carpi radialis surface electromyography electrode placement for evoked and voluntary measures.

INTRODUCTION: In this study we evaluated the reliability of bipolar electrode recordings, which allow for undistorted compound muscle action potentials (CMAPs) while minimizing cross-talk during voluntary contractions. METHODS: Twenty-four men completed maximal voluntary wrist flexion contractions in 4 test sessions. Compound muscle action potentials were also evoked during each session. Surface electromyography was recorded from the flexor carpi radialis (FCR) with the recording electrode (G1) placed on the motor point and a second recording electrode (G2) adjacent to G1. Reliability was assessed using intraclass correlational analysis of variance and standard error of measurement. RESULTS: Root-mean-square (RMS) amplitude and mean power frequency (MPF) were highly reliable (R = 0.89 and 0.84, respectively). The CMAPs also exhibited good reliability (R = 0.75). Normalization of RMS amplitude reduced the intraclass reliability coefficient (R = 0.85). CONCLUSION: The electrode placement resulted in reliable measures from voluntary contractions and CMAPs. Normalization can decrease reliability.

The effects of massed versus distributed contractions on the variability of maximal isometric force.

This study evaluated the effect of a massed versus distributed repetition schedule on the variability of force and surface electromyographic (sEMG) activity during maximal voluntary isometric elbow flexion contractions. The massed group (N = 13) performed 15 contractions on 1 day, while the distributed group (N = 13) performed 15 contractions across three consecutive days (five per day). Two retention tests (five contractions each) occurred 2 weeks and 3 months after the final trial of the initial test sessions. Force and sEMG of the biceps and triceps brachii muscles were recorded concurrently. Both groups had comparable increases in force and biceps brachii sEMG that continued over short- and longer-term retention tests (p < 0.05). Triceps brachii sEMG exhibited a more complicated pattern of successive decreases and increases (p < 0.05). The massed repetition schedule resulted in significantly (p < 0.05) less variability in maintaining a constant force [root mean square (RMS) error]. There was a significant decrease in the variability of the force-time and sEMG-time curves as assessed by the variance ratio (VR) (p < 0.05). Only biceps sEMG and VR correlated highly with force VR for the distributed group. Total (biceps + triceps) sEMG magnitude and variability correlated highly with both RMS error and force VR for the massed group. It was concluded that the massed contraction pattern allowed participants to learn how to regulate joint stiffness in addition to the variability of muscle activity. This allowed for greater decreases in RMS error than could be obtained by regulating the variability of muscle activity alone.

Feasibility and Acceptability of Web-Based Structured Oral Examinations for Postgraduate Certification: Mixed Methods Preliminary Evaluation.

BACKGROUND: The COVID-19 pandemic disrupted postgraduate certification examinations globally. The Colleges of Medicine of South Africa continued hosting certification examinations through the pandemic. This was achieved by effecting a rapid transition from in-person to web-based certification examinations. OBJECTIVE: This formative evaluation explored candidates' acceptability of web-based structured oral examinations (SOEs) hosted via Zoom (Zoom Communications Inc). We also reported the audiovisual quality and technical challenges encountered while using Zoom and candidates' overall experience with these examinations conducted during the early part of the COVID-19 pandemic. Additionally, performance in web-based certification examinations was compared with previous in-person certification examinations. METHODS: This mixed methods, single-arm evaluation anonymously gathered candidates' perceptions of web-based SOE acceptability, audiovisual quality, and overall experience with Zoom using a web-based survey. Pass rates of web-based and previous in-person certification examinations were compared using chi-square tests, with a Yates correction. A thematic analysis approach was adopted for qualitative data. RESULTS: Between June 2020 and June 2021, 3105 candidates registered for certification examinations, 293 (9.4%) withdrew, 2812 (90.6%) wrote, and 2799 (99.9%) passed, and 1525 (54.2%) were invited to a further web-based SOE. Examination participation was 96.2% (n=1467). During the first web-based examination cycle (2020), 542 (87.1%) of 622 web-based SOE candidates completed the web-based survey. They reported web-based SOEs as fair (374/542, 69%) and adequately testing their clinical reasoning and insight (396/542, 73.1%). Few would have preferred real patient encounters (173/542, 31.9%) or in-person oral examinations (152/542, 28%). Most found Zoom acceptable (434/542, 80%) and fair (396/542, 73.1%) for hosting web-based SOEs. SOEs resulted in financial (434/542, 80%) and time (428/542, 79%) savings for candidates. Many (336/542, 62%) supported the ongoing use of web-based certification examinations. Only 169 technical challenges in using Zoom were reported, which included connectivity-related issues, poor audio quality, and poor image quality. The thematic analysis identified 4 themes of positive and negative experiences related to web-based SOE station design and content, examination station environment, examiner-candidate interactions, and personal benefits for candidates. Our qualitative analysis identified 10 improvements for future web-based SOEs. Candidates achieved high pass rates in web-based certification examinations in 2020 (1583/1732, 91.39%) and 2021 (850/1067, 79.66%). These were significantly higher (2020: N=8635; χ21=667; P<.001; 2021: N=7988; χ21=178; P<.001) than the previous in-person certification examination pass rate of 58.23% (4030/6921; 2017-2019). CONCLUSIONS: Web-based SOEs conducted by the Colleges of Medicine of South Africa during the COVID-19 pandemic were well received by candidates, and few technical difficulties were encountered while using Zoom. Better performance was observed in web-based examinations than in previous in-person certification examinations. These early findings support the ongoing use of this assessment method.

Fighting to Breathe and Fighting for Health-Related Quality of Life: Measuring the Impact of Being Dependent on Technology for Breathing on the Child and Their Caregiver.

BACKGROUND AND OBJECTIVE: Medical advancement has enabled children to survive congenital airway anomalies, rare diseases and critical illnesses with medical technology including tracheostomies and long-term ventilation to support breathing. This study aimed to assess (1) the validity of the EQ-TIPS and EQ-5D-Y-3L in children dependent on technology and (2) the impact of caring for these children on the EQ-5D-5L and CarerQoL. METHODS: Caregivers of children aged 1 month to 18 years completed the EQ-TIPS or EQ-5D-Y-3L, Pediatric Quality of Life Inventory (PedsQL) and Paediatric Tracheostomy Health Status Instrument (PTHSI) to reflect the child's health. In addition, caregivers self-completed the EQ-5D-5L and CarerQoL. Reports of problems on EQ dimensions were compared across age groups with the Fisher's exact test. Spearman and Pearson's correlation coefficients and Kruskal-Wallis H-test were used to explore the association between caregiver and child scores, concurrent validity, and known-group validity of the EQ-TIPS and EQ-5D-Y-3L. RESULTS: Responses from 144 caregivers were collected, 66 for children aged 1 month to 4 years completing EQ-TIPS and 78 for children aged 5-18 years completing EQ-5D-Y-3L. The EQ-TIPS showed a higher report of no problems for social interaction for children aged 1-12 months (p = 0.040) than the older age groups, there were however no differences in the level sum score (LSS) or EQ Visual Analogue Scale scores between the age groups. The EQ-5D-Y-3L showed a significantly less report of problems for mobility (p = 0.013) and usual activities (p = 0.006) for children aged 5-7 years compared with children aged 8-12 and children aged 13-18 years. Similarly, the 5-7 years of age group had a significantly lower EQ-5D-Y-3L LSS compared with the older groups (H = 12.08, p = 0.002). The EQ-TIPS and EQ-5D-Y-3L showed moderate-to-strong associations with the PedsQL. EQ-TIPS median LSS was able to differentiate between groups on the clinical prognosis with a better health-related quality of life (HRQoL) in those where weaning from technology is possible compared with those where weaning is not possible (H = 18.98, p = 0.011). The EQ-5D-Y-3L can discriminate between breathing technology, where those with only a tracheostomy reported better HRQoL (H = 8.92, p = 0.012), and between mild and moderate clinical severity (H = 19.42, p < 0.001). Neither the PedsQL nor the PTHSI was able to discriminate between these groups across the age range. Caregiver and child HRQoL scores showed moderate-to-strong associations. CONCLUSIONS: The EQ-TIPS and EQ-5D-Y-3L showed good validity in children dependent on the technology for breathing. The EQ-TIPS and EQ-5D-Y-3L LSS were all able to differentiate between children with known clinical variables and outperformed both the PedsQL and PTHSI, making them preferable for intervention research. The caregiver scores are associated with the child HRQoL scores and thus a spill-over should be accounted for in any interventions targeting this cohort. It is recommended that future studies investigate the reliability and responsiveness of these measures in children dependent on technology for breathing.

Intestinal parasites of the gopher tortoise (Gopherus polyphemus) from eight populations in Georgia.

The gopher tortoise (Gopherus polyphemus), one of five tortoise species endemic in the USA, was recently classified as a candidate for federal listing as a threatened species. Fecal samples collected from 117 tortoises from eight sites in Georgia were examined for endoparasites using a combination of sedimentation and flotation. Samples from an island population were examined for parasitic oocysts and ova only by flotation, protozoan cysts by trichrome-stained direct smear, and Cryptosporidium by direct immunofluorescence assay and ProSpecT rapid assay. A total of 99 tortoises (85, range 0-100%) was infected with pinworms (Alaeuris spp.), 47 (40, 0-86%) with cestodes (Oochorstica sp.), 34 (41, 0-74%) with Chapiniella spp., 2 (3, 0-33%) with Eimeria paynei, and a single tortoise each with a capillarid and ascarid (1%). On the island, Entamoeba was detected in one tortoise (2%) while Cryptosporidium oocysts were detected in eight (17%). In conclusion, at least eight species of parasites were detected including Cryptosporidium, a possible pathogen of tortoises. Interestingly, we detected spatial variation in the distribution of several parasites among populations suggesting additional work should be conducted across a gradient of tortoise densities, land use, and habitat characteristics.

Preventing Future Harm: Identifying the Drivers of an Unsafe Discharge to Improve Safety on an Inpatient Oncology Service.

Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.This article describes the care of a young patient with aggressive breast cancer, declining performance status, and multiple hospital admissions who died shortly after being discharged home without essential medications or an adequate plan for follow-up. The patient's death due to her malignancy was unavoidable, but she had inadequate resources before her death, leading to avoidable suffering. This outcome resulted from a series of minor errors attributable to inadequate handoffs, challenges establishing realistic goals of care, and hierarchy within and between medical teams that resulted in major lapses at the time of discharge. We explore these issues and discuss how this case led to the establishment of programs designed to empower health care providers and increase engagement of outpatient oncologists at critical points of patients' disease courses.

Low incidence of pulmonary hypertension in children with suspected obstructive sleep apnea: A prospective observational study.

OBJECTIVES: Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity. METHODS: A prospective study of children aged 1-13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1-2 (mild-moderate) and MOS 3-4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded. RESULTS: One hundred and seventy children median age 3.8 years (IQR 2.7-6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH. CONCLUSION: PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.

Clinical correlations to distinguish severe from milder forms of obstructive sleep apnoea syndrome using overnight oximetry for prioritising adenotonsillectomy in a limited-resource setting.

BACKGROUND: In resource-poor settings with limited surgical services, it is essential to identify and prioritise children with severe and very severe obstructive sleep apnoea syndrome (OSAS) to expedite surgery. McGill's Oximetry Score (MOS) has been validated against polysomnography for OSAS and is affordable and easy to use. AIMS: The aim of this study was to assess the correlation of tonsillar size and clinical symptoms with MOS grade 3 or 4, to identify who requires overnight oximetry and who to prioritise for adenotonsillectomy. METHODS: Children with suspected OSAS were recruited from the otolaryngology clinic at the Red Cross War Memorial Children's Hospital. Demographics, symptom screening scores (SSS), patient characteristics, overnight oximetry (OO), echocardiography and MOS scores (graded 1-4) were recorded. Multivariate modified-Poisson regression models were used to examine correlations of patient characteristics 'with grade 3 or 4 MOS. RESULTS: One-hundred-and-three children were analysed, 38% were female, and median (IQR) age was 3.8 (2.5-5.3) years. Increased tonsil size was associated with a 60% increased risk of grade 3 or 4 MOS, risk ratio (RR) 1.59, 95% CI 1.10-2.29 (p = 0.014). Children with witnessed apnoeic events during sleep had 1.3 times increased risk of MOS Grade 3 or 4, RR 1.31, 95% CI (p = 0.033). A significant correlation was shown with grade 3 or 4 MOS, RR 1.15, 95% CI 1.03-1.27 (p = 0.010) by combining tonsillar size with the following symptoms: apnoeic events; struggling to breathe during sleep and needing to stimulate the child to breathe. CONCLUSION: Identifying children with suspected OSAS who require overnight oximetry can be performed using a simple 3-question screening tool: witnessed apnoeic events, struggling to breathe and the need to shake them awake to breathe. This is more precise with an additional clinical finding of grade 3 or 4 tonsils. These children should have surgery expedited. Any child with a MOS 3 or 4 score on OO needs to have expedited surgery.

Amelanotic/hypopigmented melanoma in a sibship with oculocutaneous albinism.

Oculocutaneous albinism (OCA) is a rare condition characterized by hypopigmentation. A female proband and her sister, both with primary amelanotic/hypopigmented melanoma, underwent three-dimensional total-body photography and dermoscopy. Both sisters had exome sequencing along with their brother, who had OCA but no history of melanoma. Imaging analysis was consistent with OCA in terms of individual typology angle scores, degree of sun damage, and high naevus counts. Exome data filtered for variants in known OCA and melanoma/naevi susceptibility genes (n = 98) found all siblings were compound heterozygous for TYR mutations (Arg402Ter and Val275Phe), previously reported as causative OCA variants. A rare missense variant in PARP1 (p.Pro377Ser) was solely present in the melanoma-unaffected brother, which is noteworthy as this was previously reported as potentially protective in a familial melanoma pedigree positive for CDKN2A mutations. Evaluation and confirmation of functional impact in larger cohorts could personalize melanoma screening in OCA.

Effects of the Proprioceptive Neuromuscular Facilitation Contraction Sequence on Motor Skill Learning-Related Increases in the Maximal Rate of Wrist Flexion Torque Development.

Background: The proprioceptive neuromuscular facilitation (PNF) reciprocal contraction pattern has the potential to increase the maximum rate of torque development. However, it is a more complex resistive exercise task and may interfere with improvements in the maximum rate of torque development due to motor skill learning, as observed for unidirectional contractions. The purpose of this study was to examine the cost-benefit of using the PNF exercise technique to increase the maximum rate of torque development. Methods: Twenty-six participants completed isometric maximal extension-to-flexion (experimental PNF group) or flexion-only (control group) contractions at the wrist. Ten of the assigned contractions were performed on each of three sessions separated by 48-h for skill acquisition. Retention was assessed with 5 contractions performed 2-weeks after acquisition. Torque and surface electromyographic (sEMG) activity were analyzed for evidence of facilitated contractions between groups, as well as alterations in muscle coordination assessed across test sessions. The criterion measures were: mean maximal isometric wrist flexion toque; the maximal rate of torque development (dτ/d t m a x ); root-mean-square error (RMSE) variability of the rate of torque versus torque phase-plane; the rate of wrist flexion muscle activation (Q 30); a coactivation ratio for wrist flexor and extensor sEMG activity; and wrist flexor electromechanical delay (EMD). Results: There were no significant differences between groups with respect to maximal wrist flexion torque, dτ/d t m a x or RMSE variability of torque trajectories. Both groups exhibited a progressive increase in maximal strength (+23.35% p < 0.01, η 2 = 0.655) and in dτ/d t m a x (+19.84% p = 0.08, η 2 = 0.150) from the start of acquisition to retention. RMSE was lowest after a 2-week rest interval (-18.2% p = 0.04, η 2 = 0.198). There were no significant differences between groups in the rate of muscle activation or the coactivation ratio. There was a reduction in coactivation that was retained after a 2-week rest interval (-32.60%, p = 0.02, η 2 = 0.266). Alternatively, EMD was significantly greater in the experimental group (Δ 77.43%, p < 0.01, η 2 = 0.809) across all sessions. However, both groups had a similar pattern of improvement to the third consecutive day of testing (-16.82%, p = 0.049, η 2 = 0.189), but returned close to baseline value after the 2-week rest interval. Discussion: The wrist extension-to-flexion contraction pattern did not result in a greater maximal rate of torque development than simple contractions of the wrist flexors. There was no difference between groups with respect to motor skill learning. The main adaptation in neuromotor control was a decrease in coactivation, not the maximal rate of muscle activation.

The assessment of quality of life in children with tracheostomies and their families in a low to middle income country (LMIC).

INTRODUCTION: The Breatheasy© Tracheostomy Program based at the Red Cross War Memorial Children's Hospital, Cape Town, manages children mostly from poor socio-economic backgrounds. In our resource-limited setting, it is unclear how these families cope with the demands of a tracheostomised child. We aim to assess the quality of life (QOL) of tracheostomised children and their families as the first study of its kind in a low-resource setting. METHODS: A descriptive, observational study was done to assess the QOL of tracheostomised children managed by the Breatheasy© Program over 10 months. Children with tracheostomies for longer than 6 months, complex syndromic children, and home ventilated children were included. The validated Paediatric Tracheotomy Health Status Instrument (PTHSI) was utilised, where a higher score implied a better outcome. RESULTS: A total of 68 families were recruited. In 57 (85.1%) of the carers, the highest level of education achieved was primary or high school. Twenty-seven (42%) families reported having an annual household income of less than $675 US Dollars (

Does Thyroid Gland Preserving Total Laryngectomy Affect Oncological Control in Laryngeal Carcinoma?

INTRODUCTION: Thyroid lobectomy is recommended with total laryngectomy in the National Comprehensive Cancer Network guidelines. However, it is associated with a 32% to 89% risk of hypothyroidism, which is a problem for patients without access to thyroid hormone monitoring and replacement. A number of studies have reported a low incidence of thyroid gland involvement and recommended preserving the thyroid gland in favorable cases. Yet there are no studies that report whether thyroid preserving laryngectomy for laryngeal cancer adversely affects oncologic outcomes compared to patients who have undergone thyroid lobectomy. OBJECTIVES: To determine whether patients who underwent thyroid gland preserving laryngectomy had higher local recurrence rates or poorer disease-free survival. METHOD: A retrospective folder review of patients who underwent a total laryngectomy over a 12-year period was conducted. Local recurrence and disease-free survival were determined for patients who had both their thyroid lobes preserved and compared with those who had a thyroid lobectomy. RESULTS: Sixty-nine patients had thyroid preserving laryngectomy and 73 patients had a thyroid lobectomy. The duration of follow-up was 18 to 132 months (median, 30; IQR, 30). There was no significant difference in local recurrence rates (P = .76) or survival curves between the two groups. CONCLUSION: Thyroid preserving laryngectomy in selected patients with advanced laryngeal carcinoma does not increase local recurrence rates, nor does it negatively affect disease-free survival. Thyroid preservation is appropriate when intraoperative inspection of the larynx shows no extralaryngeal extension or when paratracheal nodal metastases are not a concern. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 130:1465-1469, 2020.

Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery.

BACKGROUND: Surgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA). METHODS: JNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed. RESULTS: Homologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia. CONCLUSIONS: Perioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.

Snake fungal disease caused by Ophidiomyces ophiodiicola in a free-ranging mud snake (Farancia abacura).

Snake fungal disease is an emerging infectious disease caused by the fungus Ophidiomyces ophiodiicola leading to severe dermatitis and facial disfiguration in numerous free-ranging and captive snakes. A free-ranging mud snake (Farancia abacura) from Bulloch County, Georgia, was presented for autopsy because of facial swelling and emaciation. Extensive ulceration of the skin, which was especially severe on the head, and retained shed were noted on external examination. Microscopic examination revealed severe heterophilic dermatitis with intralesional fungal hyphae and arthroconidia consistent with O. ophiodiicola A skin sample incubated on Sabouraud dextrose agar yielded a white-to-tan powdery fungal culture that was confirmed to be O. ophiodiicola by polymerase chain reaction and sequence analysis. Heavy infestation with adult tapeworms (Ophiotaenia faranciae) was present within the intestine. Various bacterial and fungal species, interpreted to either be secondary invaders or postmortem contaminants, were associated with oral lesions. Although the role of these other organisms in the overall health of this individual is not known, factors such as concurrent infections or immunosuppression should be considered in order to better understand the overall manifestation of snake fungal disease, which remains poorly characterized in its host range and geographic distribution.

Task complexity and maximal isometric strength gains through motor learning.

This study compared the effects of a simple versus complex contraction pattern on the acquisition, retention, and transfer of maximal isometric strength gains and reductions in force variability. A control group (N = 12) performed simple isometric contractions of the wrist flexors. An experimental group (N = 12) performed complex proprioceptive neuromuscular facilitation (PNF) contractions consisting of maximal isometric wrist extension immediately reversing force direction to wrist flexion within a single trial. Ten contractions were completed on three consecutive days with a retention and transfer test 2-weeks later. For the retention test, the groups performed their assigned contraction pattern followed by a transfer test that consisted of the other contraction pattern for a cross-over design. Both groups exhibited comparable increases in strength (20.2%, P < 0.01) and reductions in mean torque variability (26.2%, P < 0.01), which were retained and transferred. There was a decrease in the coactivation ratio (antagonist/agonist muscle activity) for both groups, which was retained and transferred (35.2%, P < 0.01). The experimental group exhibited a linear decrease in variability of the torque- and sEMG-time curves, indicating transfer to the simple contraction pattern (P < 0.01). The control group underwent a decrease in variability of the torque- and sEMG-time curves from the first day of training to retention, but participants returned to baseline levels during the transfer condition (P < 0.01). However, the difference between torque RMS error versus the variability in torque- and sEMG-time curves suggests the demands of the complex task were transferred, but could not be achieved in a reproducible way.

Effects of mycoplasmal upper-respiratory-tract disease on movement and thermoregulatory behavior of gopher tortoises (Gopherus polyphemus) in Georgia, USA.

Abstract From 2011-12, we studied a gopher tortoise (Gopherus polyphemus) population with a historically high prevalence of antibodies to Mycoplasma agassizii to assess long-term effects of upper-respiratory-tract disease (URTD) on tortoise behavior. We radiotracked 30 adult tortoises (16 males, 14 females) from a long-term study site with the use of mark-recapture methods to determine site fidelity and to compare home-range size to that of a study in 1997. An additional 10 tortoises (six males, four females) with severe clinical signs of URTD from elsewhere in the study area were radiotracked and compared to tortoises that were asymptomatic or had only mild clinical signs. We also monitored thermoregulatory behavior of tortoises with the use of data loggers affixed to the carapace. There was no significant difference in home-range size between the asymptomatic tortoises and those with mild symptoms. Home ranges of tortoises with severe URTD were significantly larger than asymptomatic or mildly affected tortoises. Tortoises with severe clinical signs moved long distances over short periods, contradicting a hypothesis that chronically infected tortoises are less likely to emigrate. Prevalence of M. agassizii antibodies was similar among the three groups (98% overall), but prevalence of antibodies to a second pathogen associated with URTD, Mycoplasma testudineum, was lower in the asymptomatic (n=14, 7%) and mild-symptoms (n=7, 14%) groups than the severe-symptoms group (n=8, 50%). Variation in the average carapacial temperatures of tortoises with severe URTD was significantly different from carapacial temperatures of mild and asymptomatic tortoises, suggesting differences in thermoregulatory behavior of severely ill tortoises. Our 15-yr recapture data suggest that, despite high prevalence of M. agassizii, population density has not decreased over time. However, emigration, especially of tortoises with severe clinical disease, may play an important role in dispersal and persistence of pathogens.

Surveillance for upper respiratory tract disease and Mycoplasma in free-ranging gopher tortoises (Gopherus polyphemus) in Georgia, USA.

Abstract Upper respiratory tract disease (URTD) in the gopher tortoise (Gopherus polyphemus) is highly contagious and has been implicated in the reduction of populations throughout the range. With the exception of a few limited studies, the prevalence of URTD in Georgia, USA tortoise populations is poorly known. We found that exposure to Mycoplasma agassizii and Mycoplasma testudineum, associated with URTD, varied geographically among 11 Georgia tortoise populations. The prevalence of antibodies to M. agassizii in individual populations was either very low (0-3%, n=7 populations) or very high (96-100%, n=4 populations), whereas there was variation in the prevalence of antibodies to M. testudineum among populations (20-61%, n=10) with only one site being negative. Five sites had tortoises with antibodies to both pathogens, and these were the only sites where we observed tortoises with clinical signs consistent with URTD. We did not find tortoises with clinical signs of URTD at sites with tortoises with antibodies only to M. testudineum, which provides evidence that this organism may be of limited pathogenicity for gopher tortoises. Collectively, these data indicate that both M. agassizii and M. testudineum are present in Georgia populations of gopher tortoises and that clinical disease is apparent in populations where both pathogens are present. Additional research is needed to better understand the role of these two pathogens, and other potential pathogens, in the overall health of tortoise populations, especially if future conservation efforts involve translocation of tortoises.

High occupancy of stream salamanders despite high ranavirus prevalence in a southern appalachians watershed.

The interactive effects of environmental stressors and emerging infectious disease pose potential threats to stream salamander communities and their headwater stream ecosystems. To begin assessing these threats, we conducted occupancy surveys and pathogen screening of stream salamanders (Family Plethodontidae) in a protected southern Appalachians watershed in Georgia and North Carolina, USA. Of the 101 salamanders screened for both chytrid fungus (Batrachochytrium dendrobatidis) and Ranavirus, only two exhibited low-level chytrid infections. Prevalence of Ranavirus was much higher (30.4% among five species of Desmognathus). Despite the ubiquity of ranaviral infections, we found high probabilities of site occupancy (≥0.60) for all stream salamander species.