Feasibility and complications after transoral endoscopic thyroidectomy via vestibular approach (TOETVA) - a single-center first experience case series.

BACKGROUND: This paper reports on the first experience after implementation of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) as an alternative to (partial) thyroidectomy or isthmusectomy in a single center. Feasibility, implementation and specific complications are addressed. METHODS: All patients who underwent a TOETVA procedure in our center between November 2019 and March 2023 were included. The surgical technique was performed as described by Anuwong et al. All procedures were performed by two dedicated head- and neck surgeons. RESULTS: A total of 20 patients were included. All patients underwent TOETVA surgery as planned and no conversions were needed. Observed complications were post-operative wound infections (POWI) (2/20; 10%), clinically significant seroma (1/20, 5%) and unilateral hemiparesis of the larynx (3/20; 15%). Permanent mental nerve damage was seen in 3/20 patients (15%), and 4 other patients (20%) experienced transient neuropraxia. CONCLUSIONS: TOETVA is a feasible alternative to (partial) thyroidectomy or isthmusectomy in selected patients. Special care should be taken when placing the trocars in the oral vestibulum to prevent mental nerve damage. Experience and training are essential for implementing the TOETVA procedure. TRIAL REGISTRATION: This study was registered to ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT05396703.

Pain and Cognition in Multiple Sclerosis.

OBJECTIVE: The goal of the present study was to examine the relationship between pain and cognition in patients with multiple sclerosis. DESIGN: Cross-sectional. SETTING: Nursing home and personal environment of the investigators. SUBJECTS: Two groups of participants were included: 91 patients with multiple sclerosis and 80 matched control participants. METHODS: The level of pain was measured by the following pain scales: Number of Words Chosen-Affective, Colored Analogue Scale for pain intensity and suffering from pain, and the Faces Pain Scale. Mood was tested by administering the Beck Depression Inventory and the Symptom Check List-90 anxiety and depression subscale. Global cognitive functioning was assessed by the Mini Mental State Examination. Memory and executive functions were assessed by several neuropsychological tests. RESULTS: Multiple sclerosis (MS) patients scored significantly lower than control participants on the majority of the neuropsychological tests. The MS patients experienced more pain compared with control participants, despite the fact that they were taking significantly more pain medication. No significant correlation was observed between cognition and pain in MS patients. Verbal working memory explained 10% of pain intensity (trend). Mood appeared to be a significant predictor of pain in patients with multiple sclerosis. CONCLUSION: The lack of a relationship between cognition and pain might be explained by the fact that, compared with control participants, patients with multiple sclerosis activate other non-pain-related areas to perform executive functions and memory tasks.

[Chronic traumatic encephalopathy: an old acquaintance in athletes]. / Chronische traumatische encefalopathie.

- Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease caused by repetitive head injuries like those seen in sports such as boxing, American football and soccer.- The clinical features of CTE are a range of cognitive, psychiatric and motor symptoms, and histopathology involves deposits of hyperphosphorylated tau protein and the presence of TAR DNA-binding protein (TDP-43) with relatively little beta-amyloid.- CTE is difficult to differentiate clinically from Alzheimer's disease, frontotemporal dementia and psychiatric disorders because of the major symptom overlap between these conditions.- The most important risk factors for developing CTE are the cumulative effect of repetitive head injuries, with or without clinical symptoms, and the duration of exposure to the repetitive injuries (the sporting career).- There is no treatment for CTE at present and the strategy must be primarily geared to prevention.- In view of the large number of people, including those in the Netherlands, who take part in sports in which head injuries may occur, research into CTE is of major societal importance.

Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial.

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability.

Radiography in acute ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision rules.

STUDY OBJECTIVE: We validate the Ottawa Ankle Rules and 2 Dutch ankle rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful ankle presenting to the emergency department. METHODS: This prospective comparison of 3 ankle rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared. RESULTS: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76). CONCLUSION: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.

Treatment of ruptures of the lateral ankle ligaments: a meta-analysis.

BACKGROUND: Ruptures of the lateral ankle ligaments are very common; however, treatment remains controversial. The aim of the current study was to perform a meta-analysis of randomized, controlled clinical trials of existing treatment strategies for acute ruptures of the lateral ankle ligaments. METHODS: Randomized, controlled trials reported between 1966 and 1998 were included if they involved acute ruptures of the lateral ankle ligaments. Randomized, controlled trials are defined as comparative studies with an intervention group and a control group in which the assignment of participants to a group is determined by the formal procedure of randomization. Summary measures of effectiveness were expressed as relative risks with use of random effects modeling. RESULTS: When analyzing the trials, we searched for comparable outcome measures in both short and long-term follow-up studies (studies with six months to 3.8 years of follow-up). This resulted in the analyses of three outcome measures: time lost from work, residual pain, and giving-way. This report summarizes the results of twenty-seven trials. With respect to giving-way, a significant difference was noted between operative treatment and functional treatment (relative risk, 0.23; 95 percent confidence interval, 0.17 to 0.31) in favor of operative treatment and a significant difference was also noted between functional treatment and treatment with a cast for six weeks (relative risk, 0.69; 95 percent confidence interval, 0.50 to 0.94) in favor of functional treatment. With respect to residual pain, no significant difference was found between operative and functional treatment and a significant difference was found between functional treatment and treatment with a cast for six weeks (relative risk, 0.67; 95 percent confidence interval, 0.50 to 0.90). We found minimal or no treatment to result in more residual pain (relative risk, 0.53; 95 percent confidence interval, 0.27 to 1.02) and giving-way (relative risk, 0.34; 95 percent confidence interval, 0.17 to 0.71) than did functional treatment. CONCLUSIONS: We concluded that a no-treatment strategy for ruptures of the lateral ankle ligaments leads to more residual symptoms. Operative treatment leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks.

Metastasis in a benign duodenal stromal tumour.

Gastro-intestinal stromal tumour (GIST) is increasingly recognized as a distinct entity within the group of soft tissue tumours. Mostly, GIST arises from the muscular components of the stromal layer, but the tumour may also originate from the autonomic nerve system, recently designated as gastro-intestinal autonomic nerve tumour (GANT). The majority of GIST is located in the stomach and small intestine; only 4% of GIST is found in the duodenum. Clinical and pathological criteria to differentiate benign from malignant GIST are not well established. Tumour size and mitotic activity are commonly considered as important features, predicting biological behaviour and outcome. It has been suggested that the clinical course of the GANT-type tumours may be more aggressive. We present a case of a radically resected duodenal stromal tumour with benign features, in a young woman, with metastases to the liver and peritoneum occurring 8 years after the initial diagnosis.

Polybrominated biphenyl and diphenylether flame retardants: analysis, toxicity, and environmental occurrence.

Data on two classes of brominated polyaromatic flame retardants are reviewed with emphasis on analytical aspects, occurrence, fate, and toxicity in the environment. Concentrations of brominated fire retardants are quantified as equivalents of commercial mixtures. Because different congeners behave differently in the environment and show large differences in toxicity, future studies would benefit from the availability of analytical standards of individual congeners. The main environmental properties and mechanisms of toxicity of the PBBs and PBDEs are similar to those of the structurally related PCBs and dibenzodioxins. Although the present concentrations of brominated fire retardants do not yet appear to represent a major environmental risk in marine food chains, their replacement by environmentally less harmful alternatives is recommended.

HPLC determination of chloramphenicol degradation in eye drops.

An HPLC-method is described for the simultaneous determination of chloramphenicol and its most important degradation products. A 15 cm long C-18 reversed phase column was used with a mobile phase consisting of boric acid solution-acetonitrile (60 + 45) adjusted to a pH of 3. The amount of degradation of chloramphenicol eye drop solutions containing boric acid and borax, at pH 4.7 and 7.2 respectively, is determined at 4, 21, 100 and 120 degrees C. The solution of pH 7.2 is more stable than that of pH 4.7 at 4 and 21 degrees C, but is less stable at 100 and 120 degrees C. Preparation has to be accomplished in subdued light. The solutions have to be protected from light during storage.

Placental transfer and metabolism of purines and nucleosides in the pregnant guinea pig.

The placental transfer and metabolism of several purines and nucleosides have been investigated using an artificially perfused guinea-pig placenta. A model describing transfer and metabolism in the uteroplacental unit is constructed and applied. Measurements of oxypurines and guanine have been performed in vivo in the blood of pregnant guinea pigs and their fetuses. It appears that only the oxypurines and, to a lesser extent, guanine are present in the maternal and fetal circulations. These purines could be involved in transfer from mother to fetus and used for salvage in the fetal tissues.

Further investigations on the effects of ergometrine and other ergot derivatives following injection into the nucleus accumbens of the rat.

The influence of different pretreatments upon locomotor stimulation, induced by injection of ergometrine into the nucleus accumbens of rats, was investigated. The noradrenergic antagonists phenoxybenzamine and propranolol and the serotonin antagonist methysergide produced no clear changes. Reserpine, alone or in combination with alpha-MPT, considerably shortened the delay between injection of ergometrine and start of locomotor stimulation. Ro-DOPA, but not Ro-5-HTP, clearly antagonized the locomotor stimulation. The effect of ergometrine was strongly diminished following injection of haloperidol directly into the nucleus accumbens. A strong inhibition was also observedfollowing intracerebral administration of the imidazoline derivative (3,4-dihydroxy-phenylamino)-2-imidazoline (DPI), but not after injection of the structurally related compound clonidine. DPI by itself and also the ergot derivatives ergocornine, bromocryptine, LSD, dihydroergotamine and methysergide in doses 5--10 times as high as that of ergometrine failed to produce locomotor stimulation following injection into the nucleus accumbens. The results are discussed, especially with regard to the role of dopamine.

Effects of chemical stimulation of the mesolimbic dopamine system upon locomotor activity.

The effects of local injections of drugs into terminal areas of the mesolimbic dopamine system were investigated. Bilateral administration of dopamine, but not of noradrenaline and serotonin, into the nucleus accumbens of non-pretreated rats resulted in stimulation of locomotor activity. No clear or only minor effects were seen after injections of the dopamine metabolites 3-methoxytyramine, DOPAC and HVA and after injections of media with different pH and osmolality. d-Amphetamine proved more effective than dopamine in producing locomotor stimulation, whereas both stimulant and depressant effects were observed following injection of apomorphine into the nucleus accumbens. ET 495 and the noradrenaline agonists clonidine, phenylephrine and isoprenaline did not enhance locomotor activity, but theophylline was effective. Pretreatment with haloperidol, but not with clozapine, significantly reduced the effects of dopamine and theophylline. Locomotor stimulation was also found following bilateral administration of dopamine, d-amphetamine and apomorphine into the tuberculum olfactorium, whereas noradrenaline, serotonin and ET 495 produced no, or rather depressant effects. These results provide further evidence for an important role of the mesolimbic dopamine system with respect to locomotor activity.

The nucleus accumbens of rats and dopaminergic mechanisms regulating locomotor behaviour.

Dopamine and (3,4-dihydroxyphenylamino)-2-imidazoline (DPI) were injected into the nucleus accumbens of rats locally pretreated with ergometrine. The results show that the ergometrine-induced locomotor activity is inhibited by both compounds suggesting that ergometrine inhibits certain types of dopamine receptors. The data are discussed in terms of distinct types of dopamine receptors.

The effect of microinjections of amphetamine into the neostriatum and the nucleus accumbens on self-stimulation behaviour.

The effect of micro-injections of dexamphetamine chloride into the neostriatum, the nucleus accumbens, the anterior hypothalamus, and the ventricular system on self-stimulation with electrodes in the ventral tegmentum was studied. Unilateral injections of 10 mug into the anterior hypothalamus produced no effect. Injections into the neostriatum tended to depress the self-stimulation rate, whereas injections into the nucleus accumbens increased the rate markedly. Bilateral injections (2 times 2.5 mug and 2 times 5 mug amph.) into the nucleus accumbens were more effective than unilateral injections and were as effective as systemic injections of 1 mg/kg amphetamine (i.p.). Bilateral injections into the neostriatum also increased the self-stimulation rate. Injections of 10 mug into the ventricular system resulted in a smaller increase which was not statistically significant. These results are discussed in relation to the involvement of the dopaminergic system in the maintenance of self-stimulation behaviour.

Inhibition of d-amphetamine-induced locomotor activity by injection of haloperidol into the nucleus accumbens of the rat.

The effect of intracerebral administraton of antagonists of dopamine and noradrenaline upon the locomotor stimulation induced by intraperitoneal injection of d-amphetamine sulfate in rats was investigated. Inj ection of low doses of the dopamine antagonist haloperidol (2.5 mug and 5 mug) bilaterally into the nucleus accumbens antagonized the locomotor stimulation following d-amphetamine. No significant inhibition was observed following administration of the alpha-adrenergic antagonist phentolamine or thhe beta-adrenergic antagonist propranolol into the nucleus accumbens. Injection of the dame doses of haloperidol into the caudate nucleus did not inhibit the d-amphetamine induced locomotor activity in contrast to the effects seen following injection into the nucleus accumbens. The results confirm the significance of dopaminergic mechanisms for the locomotor stimulant effect of d-amphetamine and indicate that the mesolimbic dopamine system plays an important role in this respect.

Effects of antagonists upon locomotor stimulation induced by injection of dopamine and Noradrenaline into the nucleus accumbens of nialamide-pretreated rats.

The effects of injections of monoamines, alone and in combination with different antagonists, bilaterally into the nucleus accumbens of nialamide-pretreated rats were investigated. Dopamine was found to produce a stronger stimulation of locomotor activity than noradrenaline, whereas serotonin was effective only in a small number of animals, in which the duration of locomotor stimulation was shorter than after dopamine or noradrenaline. The effects of both dopamine and noradrenaline were completely antagonized by administration of a small dose of the dopamine antagonist haloperidol, administered bilaterally 15 min after the catecholamines. The alpha-adrenergic antagonist phentolamine did not inhibit the effect of noradrenaline but, on the contrary potentiated and considerably prolonged the duration of locomotor stimulation. Aslo, the effect of dopamine was potentiated and prolonged by phentolamine. Bilateral injection of phentolamine alone had no influence upon locomotor activity. The effect of noradrenaline was not clearly inhibited nor potentiated by the beta-adrenergic antagonist propranolol. It is suggested that the stimulation of locomotor activity induced by injection of noradrenaline into the uncleus accumbens of nialamide-pretreated rats is brought about via dopaminergic mechanisms.