Calcium-mediated signaling and calmodulin-dependent kinase regulate hepatocyte-inducible nitric oxide synthase expression.

BACKGROUND: Induced nitric oxide synthase (iNOS) is induced in hepatocytes by shock and inflammatory stimuli. Excessive NO from iNOS mediates shock-induced hepatic injury and death, so understanding the regulation of iNOS will help elucidate the pathophysiology of septic shock. In vitro, cytokines induce iNOS expression through activation of signaling pathways including mitogen-activated protein kinases and nuclear factor κB. Cytokines also induce calcium (Ca(2+)) mobilization and activate calcium-mediated intracellular signaling pathways, typically through activation of calmodulin-dependent kinases (CaMK). Calcium regulates NO production in macrophages but the role of calcium and calcium-mediated signaling in hepatocyte iNOS expression has not been defined. MATERIALS AND METHODS: Primary rat hepatocytes were isolated, cultured, and induced to produce NO with proinflammatory cytokines. Calcium mobilization and Ca(2+)-mediated signaling were altered with ionophore, Ca(2+) channel blockers, and inhibitors of CaMK. RESULTS: The Ca(2+) ionophore A23187 suppressed cytokine-stimulated NO production, whereas Ethylene glycol tetraacetic acid and nifedipine increased NO production, iNOS messenger RNA, and iNOS protein expression. Inhibition of CaMK with KN93 and CBD increased NO production but the calcineurin inhibitor FK 506 decreased iNOS expression. CONCLUSIONS: These data demonstrate that calcium-mediated signaling regulates hepatocyte iNOS expression and does so through a mechanism independent of calcineurin. Changes in intracellular calcium levels may regulate iNOS expression during hepatic inflammation induced by proinflammatory cytokines.

Prevention and Management of Complications in Nasal Reconstruction.

Nasal reconstruction is a challenging practice with the potential for complications. Surgeons can prevent complications through preoperative optimization of patient factors, refinement of intraoperative surgical techniques, and postoperative surgical and nonsurgical wound care. Preoperatively, optimization of modifiable and recognition of nonmodifiable risk factors is paramount. Intraoperatively, meticulous flap design and surgical technique promote healing. In the postoperative setting, attentive wound care, adjuvant therapies, and close follow-up for consideration of additional procedures enhance outcomes. By anticipating potential complications across perioperative settings, surgeons can prevent common complications in nasal reconstruction and more effectively manage those complications that arise.

Trends in Emergency Department Computed Tomography Usage for Diagnosis of Peritonsillar Abscess.

OBJECTIVES: Peritonsillar abscess (PTA) is the most common deep neck space infection and a frequent cause for otolaryngology consultation. Patients often undergo computed tomography (CT) scan for confirmation in addition to physical examination. Our aims were to determine whether patients unnecessarily undergo CT scans in the emergency department (ED) when presenting with sore throat and identify physical examination characteristics that predict PTA. METHODS: The electronic medical records of all patients (>18 years) presenting to an ED between June 2014 and June 2015 with a primary diagnosis of acute pharyngitis, acute tonsillitis, or PTA were reviewed for presenting symptoms and diagnostic imaging use. RESULTS: Four hundred eight patients met inclusion criteria; 21 were diagnosed with PTA, including 13 based on history and physical alone. A total of 21 CT scans were ordered, 11 (52.3%) of which did not demonstrate abscess. Soft palatal fullness, uvular deviation, drooling, and muffled voice were all significantly associated with increased CT usage (all P values <.02). Rising subjective pain scores were associated with increased use of CT imaging (P = .029). Multivariable analyses revealed that soft palatal fullness, uvular deviation, and drooling were all significant predictors of PTA (all P values <.001). CONCLUSIONS: Patients with severe symptoms of PTA, including uvular deviation, drooling, and soft palatal fullness, were most likely to undergo CT imaging. Given the high likelihood of PTA, patients presenting with these symptoms could forego CT imaging, reducing exposure to ionizing radiation.

Telemedicine in Otolaryngology During COVID-19: An Exploratory Assessment of Provider and Patient Attitudes.

OBJECTIVE: To determine provider and patient attitudes toward telemedicine in Otolaryngology-Head and Neck Surgery (OHNS). METHODS: Otolaryngology practitioners conducting outpatient clinics at an academic tertiary referral center were provided with a pre-Study Provider Perception Questionnaire (pre-PPQ) designed to evaluate pre-study perception of telemedicine in otolaryngology. A post-study Provider Perception Questionnaire (post-PPQ) designed to evaluate elements similar to those constituting the PrePPQ was completed at 6 weeks. Additionally, following each visit, providers and patients completed Individual Encounter Survey Questionnaires (IESQ) to evaluate the virtual clinical encounter experience. RESULTS: The pre-PPQ was completed by 29 providers, while the post-PPQ was completed by 12 providers. A total of 236 post-visit provider IESQs were completed, of which 208 were deemed successful. Audio/visual (AV) difficulties and limited server connectivity for the patient were most common causes for unsuccessful encounters. Providers reported that the most appropriate use of telemedicine, on both pre-PPQ and post-PPQ, was triaging patients to determine the need for in-person visits. The inability to perform a physical exam was rated as the primary barrier to telemedicine in OHNS on both pre-PPQ and post-PPQ. Patients strongly agreed with the statements, "My healthcare provider was able to understand my healthcare condition" and, "I felt comfortable communicating with my healthcare provider" 92.0% and 95.4% of the time, respectively. CONCLUSION: Both providers and patients demonstrated an overall positive attitude toward the use of telemedicine in the provision of otolaryngologic care.

Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer.

PURPOSE OF REVIEW: Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population. RECENT FINDINGS: Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients. SUMMARY: With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.