Minimally Anterior Medial Maxillary Approach (MAMMA): a novel technique for a wide access to the maxillary sinus.

PURPOSE: To describe a novel endoscopic technique to approach the maxillary sinus (MS), the Modified Anterior Medial Maxillary Approach (MAMMA), preserving the inferior turbinate (IT) and the nasolacrimal duct (NLD). To perform radiological measurements and describe a case series to study the feasibility and limits of MAMMA. METHODS: Computed tomography (CT) scans (n = 150 nasal cavities) were used to calculate areas of the MAMMA to define surgical limits and extensions. Measurement of distances to critical anatomy landmarks and total area for the MAMMA were calculated. An instructional case illustrating the surgical technique and outcome was also included. RESULTS: Radiological analysis showed a mean distance from the Piriform Aperture (PA) to the anterior limit of the NLD of 1.03 ± 0.18 cm (range 0.59-1.48) and a mean distance from de PA to the posterior limit of the NLD of 1.57 ± 0.22 cm (range 1.02-2.11). The mean distance from the nasal floor to the Hasner's valve was 1.61 ± 0.27 cm (range 1.06-2.52) and the distance from the nasal floor to the insertion of the IT was 2.20 ± 0.36 cm (range 1.70-3.69). Finally, the mean total area for the MAMMA was 4.04 ± 0.52 cm2 (range 3.17-5.53). No complications or recurrence of the pathology were observed in operated patients. CONCLUSION: The MAMMA provides a wide surgical field of the MS walls comparable to more aggressive techniques, with preservation of the sinonasal and lacrimal function. MAMMA is an effective alternative to treat different MS pathologies including benign recurrent maxillary sinus tumors.

Effect of reproductive management programs that prioritized artificial insemination at detected estrus or timed artificial insemination on the reproductive performance of primiparous Holstein cows of different genetic merit for fertility.

Our objective was to compare reproductive outcomes of primiparous lactating Holstein cows of different genetic merit for fertility submitted for insemination with management programs that prioritized artificial insemination (AI) at detected estrus (AIE) or timed AI (TAI). Moreover, we aimed to determine whether subgroups of cows with different fertility potential would present a distinct response to the reproductive management strategies compared. Lactating primiparous Holstein cows (n = 6 commercial farms) were stratified into high (Hi-Fert), medium (Med-Fert), and low (Lo-Fert) genetic fertility groups (FG) based on a Reproduction Index value calculated from multiple genomic-enhanced predicted transmitting abilities. Within herd and FG, cows were randomly assigned either to a program that prioritized TAI and had an extended voluntary waiting period (P-TAI; n = 1,338) or another that prioritized AIE (P-AIE; n = 1,416) and used TAI for cows, not AIE. Cows in P-TAI received first service by TAI at 84 ± 3 d in milk (DIM) after a Double-Ovsynch protocol, were AIE if detected in estrus after a previous AI, and received TAI after an Ovsynch-56 protocol at 35 ± 3 d after a previous AI if a corpus luteum (CL) was visualized at nonpregnancy diagnosis (NPD) 32 ± 3 d after AI. Cows with no CL visualized at NPD received TAI at 42 ± 3 d after AI after an Ovsynch-56 protocol with progesterone supplementation (P4-Ovsynch). Cows in P-AIE were eligible for AIE after a PGF2α treatment at 53 ± 3 DIM and after a previous AI. Cows not AIE by 74 ± 3 DIM or by NPD 32 ± 3 d after AI received P4-Ovsynch for TAI at 74 ± 3 DIM or 42 ± 3 d after AI. Binary data were analyzed with logistic regression, count data with Poisson regression, continuous data by ANOVA, and time to event data by Cox's proportional hazard regression. Pregnancy per AI (P/AI) to first service was greater for cows in the Hi-Fert (59.8%) than the Med-Fert (53.6%) and Lo-Fert (47.7%) groups, and for the P-TAI (58.7%) than the P-AIE (48.7%) treatment. Overall, P/AI for all second and subsequent AI combined did not differ by treatment (P-TAI = 45.2%; P-AIE = 44.5%) or FG (Hi-Fert = 46.1%; Med-Fert = 46.0%; Lo-Fert = 42.4%). The hazard of pregnancy after calving was greater for the P-AIE than the P-TAI treatment [hazard ratio (HR) = 1.27, 95% CI: 1.17 to 1.37)], and for the Hi-Fert than the Med-Fert (HR = 1.16, 95% CI: 1.05 to 1.28) and Lo-Fert (HR = 1.34, 95% CI: 1.20 to 1.49) groups. More cows in the Hi-Fert (91.2%) than the Med-Fert (88.4%) and Lo-Fert (85.8%) groups were pregnant at 200 DIM. Within FG, the hazard of pregnancy was greater for the P-AIE than the P-TAI treatment for the Hi-Fert (HR = 1.41, 95% CI: 1.22 to 1.64) and Med-Fert (HR = 1.28, 95% CI: 1.12 to 1.46) groups but not for the Lo-Fert group (HR = 1.13, 95% CI: 0.98 to 1.31). We conclude that primiparous Holstein cows of superior genetic merit for fertility had better reproductive performance than cows of inferior genetic merit for fertility, regardless of the type of reproductive management used. In addition, the effect of programs that prioritized AIE or TAI on reproductive performance for cows of superior or inferior genetic merit for fertility depended on the outcomes evaluated. Thus, programs that prioritize AIE or TAI could be used to affect certain outcomes of reproductive performance or management.

Symposium review: Use of multiple biological, management, and performance data for the design of targeted reproductive management strategies for dairy cows.

As the reproductive efficiency of dairy cattle continues to improve in response to better management and use of technology, novel reproductive management approaches will be required to improve herd performance, profitability, and sustainability. A potential approach currently being explored is targeted reproductive management. This approach consists of identifying cows with different reproductive and performance potential using multiple traditional and novel sources of biological, management, and performance data. Once subgroups of cows that share biological and performance features are identified, reproductive management strategies specifically designed to optimize cow performance, herd profitability, or alternative outcomes of interest are implemented on different subgroups of cows. Tailoring reproductive management to subgroups of cows is expected to generate greater gains in outcomes of interest than if the whole herd is under similar management. Major steps in the development and implementation of targeted reproductive management programs for dairy cattle include identification and validation of robust predictors of reproductive outcomes and cow performance, and the development and on-farm evaluation of reproductive management strategies for optimizing outcomes of interest for subgroups of cows. Predictors of cow performance currently explored for use in targeted management include genomic predictions; behavioral, physiological, and performance parameters monitored by sensor technologies; and individual cow and herd performance records. Once the most valuable predictive sources of variation are identified and their effects quantified, novel analytic methods (e.g., machine learning) for prediction will likely be required. These tools must identify groups of cows for targeted management in real time and with no human input. Despite some encouraging research evidence supporting the development of targeted reproductive management strategies, extensive work is required before widespread implementation by commercial farms.

Evaluation and characterization of estrus alerts and behavioral parameters generated by an ear-attached accelerometer-based system for automated detection of estrus.

Our objectives were to evaluate the performance of an ear-attached automated estrus detection (AED) system (Smartbow; Zoetis) that monitored physical activity and rumination time, and to characterize AED system estrus alert features (i.e., timing and duration). Lactating Holstein cows (n = 216) commenced a protocol for the synchronization of estrus at 50 ± 3 DIM or 18 ± 3 d after artificial insemination. For 7 d after induction of luteolysis with PGF2α (d 0), we used visual observation of estrous behavior (30 min, 2 times per day) and data from an automated mounting behavior monitoring system based on a pressure-activated tail-head sensor (HeatWatch; Cowchips LLC) as a reference test (RTE) to detect behavioral estrus. Concomitantly, estrus alerts and their features were collected from the AED system. Progesterone levels confirmed luteal regression, and transrectal ultrasonography confirmed the occurrence and timing of ovulation. Performance metrics for the AED system were estimated with PROC FREQ in SAS, using the RTE or ovulation only as a reference. Performance was also estimated after the removal of cows with a discrepancy between the RTE and ovulation. Continuous outcomes with or without repeated measurements were evaluated by ANOVA using PROC MIXED in SAS. Based on the RTE, 86.6% (n = 187) of the cows presented estrus and ovulated; 1.4% (n = 3) presented estrus and did not ovulate; 6.4% (n = 14) did not present estrus but ovulated; and 5.6% (n = 12) did not present estrus or ovulation. We found no difference in the proportion of cows detected in estrus and with ovulation for the AED system (83.4%) and the RTE (86.6%). Compared with estrus events as detected by the RTE, sensitivity for the AED was 91.6% (95% CI: 87.6-95.5) and specificity was 69.2% (95% CI: 51.5-87.0). Using ovulation as reference, sensitivity was 89.6% (95% CI: 85.3-93.8) and specificity was 86.7% (95% CI 69.5-100). For all cows with agreement between the RTE and ovulation, sensitivity was 92.5% (95% CI: 88.7-96.3) and specificity was 91.7% (95% CI: 76.0-100). The mean (±SD) interval from induction of luteolysis to estrus alerts, estrus alert duration, and the onset of estrus alerts to ovulation interval were 72.2 ± 18.1, 13.5 ± 3.8, and 23.8 ± 7.1 h, respectively. We concluded that an ear-attached AED system that monitored physical activity and rumination time was effective at detecting cows in estrus and generated few false positive alerts when accounting for ovulation, cow physiological limitations, and the limitations of the RTE.

Effect of reproductive management programs for first service on replacement dairy heifer economics.

Our objective was to evaluate cash flow for dairy heifers managed for first service with programs that relied primarily on insemination at detected estrus (AIE), timed AI (TAI), or a combination of both. Holstein heifers from 2 commercial farms were randomized to receive first service with sexed semen after the beginning of the AI period (AIP) at 12 mo of age with 1 of 3 treatments: (1) PGF+AIE (n = 317): AIE after PGF2α injections every 14 d (up to 3) starting at the beginning of the AIP; heifers not AIE 9 d after the third PGF2α were enrolled in the 5d-Cosynch (5dCP) protocol; (2) ALL-TAI (n = 315): TAI after ovulation synchronization with the 5dCP protocol; and (3) PGF+TAI (n = 334): AIE after 2 PGF2α injections 14 d apart (second PGF2α at beginning of AIP). If not AIE 9 d after the second PGF2α, the 5dCP protocol was used for TAI. After first service heifers were AIE or received TAI after the 5dCP with conventional semen. Individual heifer cash flow (CF) for up to a 15-mo period (d 0 = beginning of AIP) was calculated using reproductive cost (rearing only), feed cost (rearing only), income over feed cost (lactation only), calf value, operating cost, and with or without replacement cost. A stochastic analysis with Monte Carlo simulation was used to estimate differences in CF for a range of market values for inputs and outputs. Time to pregnancy for up to 100 d after the beginning of the AIP was analyzed by Cox's proportional regression, binary data with logistic regression, and continuous outcomes by ANOVA. Time to pregnancy (hazard ratio and 95% CI) was reduced for the ALL-TAI versus the PGF+AIE treatment (1.20; 1.02-1.42), but it was similar for ALL-TAI and PGF+TAI (1.13; 0.95-1.33) and the PGF+AIE and PGF+TAI treatments (1.07; 0.91-1.25). The proportion of heifers not pregnant by 100 d did not differ (PGF+AIE = 7.0%; PGF+TAI = 6.5%; ALL-TAI = 6.8%). When including replacement cost, CF ($/slot per 15 mo) differences were $51 and $42 in favor of the PGF+TAI and ALL-TAI compared with the PGF+AIE treatment, and $9 in favor of the PGF+TAI compared with the ALL-TAI treatment but did not differ statistically. Excluding heifers that were replaced to evaluate the effect of timing of pregnancy differences only, the difference in CF between the PGF+AIE with the PGF+TAI and ALL-TAI treatment was the same (i.e., $15) and favored the programs that used more TAI, but also did not differ statistically. Stochastic simulation results were in line with those of the deterministic analysis confirming the benefit of the programs that used more TAI. We concluded that submission of heifers for first service with TAI only or TAI in combination with AIE generated numerical differences in CF of potential value to commercial dairy farms. Reduced rearing cost and increased revenue during lactation increased CF under fixed (not statistically significant) or simulated variable market conditions.

Reproductive performance of replacement dairy heifers submitted to first service with programs that favor insemination at detected estrus, timed artificial insemination, or a combination of both.

Our objective was to compare the insemination dynamics and time to pregnancy for up to 100 d after the beginning of the artificial insemination period (AIP) for heifers managed with first artificial insemination (AI) service programs that relied primarily on insemination at detected estrus (AIE) after PGF2α treatments, timed artificial insemination (TAI), or a combination of both. Holstein heifers were randomly assigned to receive first AI service with sex-selected semen after 368 ± 10 d of age with (1) AIE after synchronization of estrus with up to 3 PGF2α treatments every 14 d starting on the first day of the AIP (PGF+AIE; n = 317). Heifers not AIE up to 9 d after the third PGF2α received a 5-d Cosynch protocol with progesterone supplementation [GnRH + controlled internal drug release insert (CIDR)-5 d-CIDR removal and PGF2α-3 d-GnRH and TAI] before TAI. Heifers detected in estrus from CIDR removal and PGF2α until the day before TAI received AIE with no GnRH treatment; (2) 2 PGF2α treatments 14 d apart with the second treatment at the beginning of the AIP (PGF+TAI; n = 334). Heifers received AIE for up to 9 d after the second PGF2α treatment. Heifers not AIE received TAI after the 5-d Cosynch protocol and (3) TAI after the 5-d Cosynch protocol (ALL-TAI; n = 315). Heifers failing to conceive to a previous AI received a subsequent AI with conventional semen at detected estrus or TAI after the 5-d Cosynch protocol. Binomial outcomes were analyzed by logistic regression, whereas time to AI and pregnancy were analyzed with Cox's regression. The hazard of first AI up to 45 d of the AIP was greater for ALL-TAI than for PGF+AIE [hazard ratio (HR) = 1.72; 95% confidence interval (CI) =1.45 to 2.03] and PGF+TAI (HR = 1.51; 95% CI = 1.28 to 1.77), but similar for PGF+AIE and PGF+TAI (HR = 1.14; 95% CI = 0.97 to 1.33). A greater proportion of heifers received AIE in PGF+AIE (98.7%) than in PGF+TAI (78.5%). Overall, first service pregnancy per AI did not differ (PGF+AIE = 42.0%; PGF+TAI = 47.3%, ALL-TAI = 43.8%). Time to pregnancy was reduced for ALL-TAI compared with PGF+AIE (HR = 1.20, 95% CI = 1.02 to 1.42), but was similar to that of PGF+TAI (HR = 1.13, 95% CI = 0.96 to 1.33). Time to pregnancy did not differ for PGF+AIE and PGF+TAI (HR = 1.07, 95% CI = 0.91 to 1.25). Median days to pregnancy were 27, 23, and 21 for heifers in PGF+AIE, PGF+TAI, and ALL-TAI, respectively. We concluded that an ALL-TAI program for first service reduced time to pregnancy, albeit a relatively small reduction, when compared with a program that relied primarily on AIE after induction of estrus with PGF2α treatments. The program that combined synchronization of estrus and TAI (PGF+TAI) resulted in similar time to pregnancy than the predominant TAI and predominant AIE programs.

Effect of rumen-protected branched-chain amino acid supplementation on production- and energy-related metabolites during the first 35 days in milk in Holstein dairy cows.

Essential AA are critical for multiple physiological processes. Branched-chain AA (BCAA) supplementation has beneficial effects on body weight, lipogenesis, and insulin resistance in several species. The BCAA are used for milk and body protein synthesis as well as being oxidized by the tricarboxylic acid cycle to produce ATP during catabolic states. The objective was to evaluate the effect of rumen-protected BCAA (375 g of 27% l-Leu, 85 g of 48% l-Ile, and 91 g of 67% l-Val) with or without propylene glycol (PG) oral administration on milk production, dry matter intake, nonesterified fatty acids, ß-hydroxybutyrate, and plasma urea nitrogen during the first 35 d in milk (DIM) in dairy cattle. Multiparous Holstein cows were enrolled in blocks of three 28 d before expected calving and assigned randomly to either the control or 1 of 2 treatments. The control (n = 26) received 200 g/d of dry molasses, the BCAA treatment (n = 23) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM, and the BCAA plus PG (BCAAPG) treatment (n = 25) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM plus 300 mL of PG once daily from calving until 7 DIM. Postpartum, dry matter intake least squares means (LSM; 95% confidence interval) were 20.7 (19.9, 21.7), 21.3 (20.4, 22.3), and 21.9 (20.9, 22.8) kg for control, BCAA, and BCAAPG, respectively. Milk yield (1-35 DIM) LSM were 41.7 (39.4, 44.0), 42.7 (40.3, 45.0), and 43.7 (41.4, 46.0) kg for control, BCAA, and BCAAPG, respectively. Energy-corrected milk LSM were 50.3 (46.8, 53.7), 52.4 (48.9, 55.8), and 52.9 (49.5, 56.4) kg for control, BCAA, and BCAAPG, respectively. Milk urea nitrogen LSM in milk for control, BCAA, and BCAAPG were 8.60 (8.02, 9.22), 9.70 (9.01, 10.45), and 9.75 (9.08, 10.47) mg/dL. Plasma urea nitrogen concentrations LSM for control, BCAA, and BCAAPG were 8.3 (7.7, 8.9), 10.1 (9.4, 10.9), and 9.6 (9.4, 10.3) mg/dL, respectively. The numbers of plasma samples classified as hyperketonemia were 77, 44, and 57 in control, BCAA, and BCAAPG, respectively. The BCAA supplementation increased plasma urea nitrogen and milk urea nitrogen, free valine concentration in plasma, and decreased hyperketonemia events during the postpartum period.

Resynchronization of ovulation protocols for dairy cows including or not including gonadotropin-releasing hormone to induce a new follicular wave: Effects on re-insemination pattern, ovarian responses, and pregnancy outcomes.

Our objectives were to evaluate the pattern of re-insemination, ovarian responses, and pregnancy per artificial insemination (P/AI) of cows submitted to different resynchronization of ovulation protocols. The base protocol started at 25 ± 3 d after artificial insemination (AI) and was as follows: GnRH, 7 and 8 d later PGF2α, GnRH 32 h after second PGF2α, and fixed timed AI (TAI) 16 to 18 h after GnRH. At 18 ± 3 d after AI, cows were randomly assigned to the G25 (n = 1,100) or NoG25 (n = 1,098) treatments. The protocol for G25 and NoG25 was the same, except that cows in NoG25 did not receive GnRH 25 ± 3 d after AI. At nonpregnancy diagnosis (NPD), 32 ± 3 d after AI, cows from G25 and NoG25 with a corpus luteum (CL) ≥15 mm in diameter and a follicle ≥10 mm completed the protocol (G25 CL = 272, NoG25 CL = 194), whereas cows from both treatments that did not meet these criteria received a modified Ovsynch protocol with P4 supplementation [controlled internal drug release insert plus GnRH, controlled internal drug release insert removal, and PGF2α 7 and 8 d later, GnRH 32 h after second PGF2α, and TAI 16 to 18 h after GnRH (G25 NoCL = 53, NoG25 NoCL = 78)]. Serum concentrations of progesterone (P4) were determined and ovarian ultrasonography was performed thrice weekly from 18 ± 3 d after AI until 1 d after TAI (G25 = 46, NoG25 = 44 cows). A greater percentage of NoG25 cows were re-inseminated at detected estrus (NoG25 = 53.5%, G25 = 44.6%), whereas more cows had a CL at NPD in G25 than NoG25 (83.7 and 71.3%). At 32 d after AI, P/AI was similar for G25 and NoG25 for inseminations at detected estrus (38.4 and 42.9%), TAI services for cows with no CL (40.4 and 36.7%), and for all services combined (39.6 and 39.0%). However, P/AI were greater for cows with a CL in G25 than NoG25 (40.6 and 32.8%) that received TAI. More cows ovulated spontaneously or in response to GnRH for the G25 than the NoG25 treatment (70 and 36%) but a similar proportion had an active follicle at NPD (G25 = 91% and NoG25 = 96%). The largest follicle diameter at NPD (G25 = 15.0 ± 0.4 mm, NoG25 = 16.5 ± 0.6 mm) and days since it reached ≥10 mm (G25 = 4.0 ± 0.3 d, NoG25 = 5.8 ± 0.6 d) were greater for the NoG25 than G25 treatment. For cows with a CL at NPD, CL regression after NPD, ovulation after TAI, and ovulatory follicle diameter did not differ. In conclusion, removing the first GnRH of a modified Resynch-25 protocol for cows with a CL at NPD and a modified Ovsynch protocol with P4 supplementation for cows without a CL at NPD resulted in a greater percentage of cows re-inseminated at detected estrus and a similar proportion of cows pregnant in spite of reduced P/AI for cows with a CL at NPD.

Intravaginal instillation of gonadotropin-releasing hormone analogues with an absorption enhancer induced a surge of luteinizing hormone in lactating dairy cows.

Our objectives were to evaluate circulating LH concentrations after intravaginal (IVG) instillation of GnRH analogs in lactating dairy cows. In 2 experiments, lactating Holstein cows (experiment 1: n = 32; experiment 2: n = 47) received the experimental treatments 48 h after the first of 2 PGF2α treatments given 12 h apart and 7 d after a modified Ovsynch protocol (GnRH at -7 d, PGF2α at -24 h, PGF2α at -56 h, GnRH at 0 h). In experiment 1, cows were stratified by parity and randomly allocated to receive the following treatments: 2 mL of saline IVG (SAL, n = 6), 100 µg of gonadorelin (Gon) i.m. (G100-IM, n = 5), and 100 (G100, n = 7), 500 (G500, n = 8), or 1,000 µg of Gon IVG (G1000, n = 7). In experiment 2, treatments were SAL (n = 8), G100-IM (n = 8), G1000 (n = 7), 1,000 µg of Gon plus 10% citric acid (CA) IVG (G1000CA, n = 8), 80 µg of buserelin IVG (B80, n = 8), and 80 µg of buserelin plus 10% CA IVG (B80CA, n = 8). In both experiments, blood was collected every 15 min from -15 min to 4 h, and every 30 min from 4 to 6 h after treatment. Data for area under the curve (AUC), mean LH concentrations, and time to maximum LH concentration were analyzed by ANOVA with (mean LH only) or without repeated measures using PROC MIXED of SAS (version 9.4, SAS Institute Inc., Cary, NC). The proportion of cows with a surge of LH was evaluated with Fisher's exact test using PROC FREQ of SAS. In both experiments, LH concentrations were affected by treatment, time, and the treatment by time interaction. In experiment 1, the AUC for LH and maximum LH concentration were greatest for the G100-IM treatment and were greater for the G1000 than for the SAL and G500 treatments. The proportion of cows with an observed surge of LH was 100 and 0% for cows that received Gon i.m. and IVG, respectively. In experiment 2, the AUC and maximum LH concentrations were greater for the G100-IM, G1000CA, and B80CA treatments than for the other IVG treatments. The proportion of cows with a surge of LH differed by treatment (SAL = 0%, G100-IM = 100%, G1000 = 14%, G1000CA = 88%, B80 = 13%, and B80CA = 100%). For the treatments with a surge of LH, time to maximum concentration of LH was the shortest for the G100-IM treatment, intermediate for the G1000CA treatment, and the longest for cows in the B80CA treatment. In conclusion, Gon (up to 1,000 µg) absorption through intact vaginal epithelium after a single IVG instillation was insufficient to elicit a surge of LH of normal magnitude. Conversely, IVG instillation of 1,000 µg of Gon and 80 µg of buserelin with the addition of citric acid as absorption enhancer resulted in a surge of LH of similar characteristics than that induced after i.m. injection of 100 µg of Gon.

Outcome of radiosurgery treatment with a linear accelerator in patients with trigeminal neuralgia. / Resultados de la aplicación de radiocirugía con acelerador lineal en pacientes con neuralgia del trigémino.

INTRODUCTION: An overview of the effectiveness of radiosurgery in patients diagnosed with trigeminal neuralgia with an analysis of potential predictors of good outcome. METHODS: All patients treated with linear accelerator radiosurgery between 2004 and 2011 were analysed. A dose of 60Gy dose was administered 1 to 2mm from the root entry zone with a maximum isodose of 20% delivered to the brainstem. Clinical results for pain control and any side effects were analysed at 12 and 36 months (BNI score). RESULTS: The study included 71 patients (mean follow-up 50.5 months). Pain improvement at 12 months was observed in 68.11% of the total (28.98% with BNI score i-ii; 39.12% with BNI score iii) and at 36 months in 58.21% (23.88% BNI score i-ii; 34.32% BNI score iii). Average recovery time was 3.69 months and the relapse rate was 44.68%. Patients with typical pain displayed statistically significant differences in improvement rates at 12 and at 36 months (P<047 and P<.002). Onset of improvement was analysed using Kaplan-Meyer plots. Statistically significant differences were observed between patients with typical and atypical pain at 36 months (P<.012) in Kaplan-Meyer plots. Side effects were recorded in 15 patients (20.89%), including 9 cases of facial numbness (13.43%); only 2 cases were clinically relevant (2.98%). CONCLUSION: According to our results, radiosurgery is an effective treatment for trigeminal neuralgia, with few side effects. Typical pain seems to be a good predictor of pain relief.

Prevalence of pulmonary hypertension in children with obstructive sleep apnea living at high altitude.

Introduction: The prevalence of obstructive sleep apnea (OSA) is 1-4 %. Some reports describe its association with pulmonary hypertension (PH), but its prevalence is unknown. No studies at high altitude have determined the relationship between OSA and PH. The aim of this study was to establish the prevalence of PH in children diagnosed with OSA living in a high-altitude city at 2640 m above sea level. Methods: Children between 2 and 16 years of age referred to the Sleep Laboratory of the Fundación Neumológica Colombiana in Bogotá with a positive polysomnogram for OSA were included, and a two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate PH. Statistical analysis was performed using median, interquartile range, chi-squared test, and Kruskall-Wallis test. Results: Of the 55 patients (n: 55), 63.6 % were male, with a median age of 6 years, 14 children (25.5 %) were overweight; 12 children (21.8 %) had mild OSA, 12 (21.8 %) had moderate OSA and 31 (56.4 %) severe OSA. In patients with severe OSA, the minimum saturation during events was 78 % with a desaturation index (DI) of 33.8/hour (p < 0.01). T90 and T85 increased proportionally with OSA severity (p < 0.05). Of the 55 patients with OSA, none had PH according to echocardiography; 4 patients (7.2 %) had pulmonary artery systolic pressure (PASP) at the upper limit of normal (ULN), and it was not related to a higher body mass index (BMI). Conclusions: We found no association between OSA and PH in children with OSA at high altitude.

Divergent Genital Morphologies and Female-Male Covariation in Watersnakes.

Genital evolution can be driven by diverse selective pressures. Across taxa we see evidence of covariation between males and females, as well as divergent genital morphologies between closely related species. Quantitative analyses of morphological changes in coevolving male and female genitalia have not yet been shown in vertebrates. This study uses 2D and 3D geometric morphometrics to quantitatively compare the complex shapes of vaginal pouches and hemipenes across three species of watersnakes (the sister taxa Nerodia fasciata, N. sipedon, and a close relative N. rhombifer) to address the relationship between genital morphology and divergence time in a system where sexual conflict may have driven sexually antagonistic coevolution of genital traits. Our pairwise comparisons of shape differences across species show that the sister species have male and female genitalia that are significantly different from each other, but more similar to each other than to N. rhombifer. We also determine that the main axes of shape variation are the same for males and females, with changes that relate to deeper bilobation of the vaginal pouch and hemipenes. In males, the protrusion of the region of spines at the base of the hemipene trades off with the degree of bilobation, suggesting amelioration of sexual conflict, perhaps driven by changes in the relative size of the entrance of the vaginal pouch that could have made spines less effective.

Influence of the environment on the characteristics of asthma.

Few studies have compared the prevalence of asthma in urban and rural settings or explored the issue of whether these two manifestations of the disease may represent different phenotypes. The aim of this study was: (a) to establish whether the prevalence of asthma differs between rural and urban settings, and b) to identify differences in the clinical presentation of asthma in these two environments. Descriptive epidemiological study involving individuals aged 18 or over from a rural (n = 516) and an urban population (n = 522). In the first phase, individuals were contacted by letter in order to organize the administration of a first validated questionnaire (Q1) designed to establish the possible prevalence of bronchial asthma. In the second phase, patients who had presented association patterns in the set of variables related to asthma in Q1 completed a second validated questionnaire (Q2), designed to identify the characteristics of asthma. According to Q1, the prevalence of asthma was 15% (n = 78) and 11% (n = 59) in rural and urban populations respectively. Sixty-five individuals with asthma from the rural population and all 59 individuals from the urban population were contacted and administered the Q2. Thirty-seven per cent of the individuals surveyed had previously been diagnosed with bronchial asthma (35% in the rural population and 40% in the urban setting). In the urban asthmatic population there was a predominance of women, a greater personal history of allergic rhinitis and a family history of allergic rhinitis and/or eczema. Asthma was diagnosed in adulthood in 74.8% of the patients, with no significant differences between the two populations. Regarding symptoms, cough (morning, daytime and night) and expectoration were more frequent in the urban population. The prevalence of asthma does not differ between urban and rural settings. The differences in exposure that characterize each environment may lead to different manifestations of the disease and may also affect its severity.

Postoperative management of patients with pituitary tumors submitted to pituitary surgery. Experience of a Spanish Pituitary Tumor Center of Excellence.

There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.

[Microbiological and epidemiological evaluation of carbapenem-resistant Acinetobacter baumannii clones isolated at an intensive care unit of a University Hospital in Buenos Aires city]. / Evaluación microbiol6gica y epidemiológica de los clones de Acinetobacter baumannii resistentes a los carbapenemes aislados en la unidad de cuidados intensivos de un Hospital Universitario de la ciudad de Buenos Aires.

From June to December 2004, thirty-three carbapenem-resistant Acinetobacter baumannii isolates recovered from twenty nine patients at the intensive care unit in Hospital de Clínicas, Universidad de Buenos Aires, were studied. The isolates were categorized by molecular methods as: clone I (n = 14), clone IV (n = 7), clone III (n = 6), clone VI (n = 3), clone II (n = 2) and clone X (n = 1). Twenty one isolates were recovered from lower respiratory tract samples, 11 of which belonged to clone I. Clone III isolates were mainly recovered from non-respiratory samples (5/6). Clone IV isolates were recovered from patients not receiving previous imipenem therapy. The majority of the isolates belonging to clones I and IV were able to survive on inert materials for more than 5 days, whereas adhesion to catheters was observed in isolates belonging to clones I and III, especially in those related to bacteremia. Clone III isolates showed colistin, gentamicin and levofloxacin susceptibility, whereas clone I isolates and most from clone IV were only susceptible to colistin and tetracyclines.

[Techniques of endoscopic surgery in the pediatric cancer in a developing country]. / Técnicas de cirugía endoscópica para cáncer pediátrico en un país en vías de desarrollo.

The objective of the present study is to present our experience of introducing video-endoscopic surgical techniques applied to the diagnosis and treatment of pediatric cancer in the National Cancer Institute (NCI) of Bogota (Colombia), the reference state institution in this developing nation. The study is based on the large case load of the NCI, the considerable clinical experience of its healthcare professionals, and the availability of adequate material resources. This preliminary series comprises 11 pediatric patients who underwent surgery at the NCI between February 1 and 31 May 2007. Seven laparoscopies and four thoracoscopies were performed. The mean age of these patients was 8.8 years (range, 10 months to 17 years). The clinical characteristics of these patients are reported.

[Delayed vertigo after stapedotomy with good hearing results]. / Vértigo diferido tras estapedotomía con buen resultado auditivo.

Stapedial surgery is able to obtain excellent hearing results in the long-term in most otosclerotic patients. Nevertheless, some cases have vertigo and/or tinnitus after surgery, that may lead them to revision surgery. Out of a consecutive series on 115 patients, we present three cases (2,6%) with persistent vertigo after stapedotomy. These patients had residual unsteadiness despite good hearing after surgery, with a minimum follow-up of 12 months. Videonystagmography showed spontaneous nystagmus towards the contralateral ear in one case, whereas the other two had a canalicular paresis in the operated side, signs of vestibular hypofunction. After vestibular rehabilitation, unsteadiness resolved in all cases, with good spontaneous compensation, without any further surgery.

Minería de datos para la evaluación del riesgo de malignidad en pacientes con nódulos tiroideos con estudio citológico Bethesda IV / Risk of malignancy evaluation through data mining technic in patients with thyroid nodules with cytology study Bethesda IV

Introducción: en el campo de la salud, cada decisión representa datos, y las técnicas de minería de datos han empezado a ser una metodología prometedora para el análisis de esta información, especialmente en el diseño de los modelos predictivos. Métodos: estudio observacional analítico de pacientes mayores de 15 años, con reporte de punción de aspiración con aguja fina con estudio Bethesda IV, sometidos a manejo quirúrgico en el Hospital de San José de Bogotá. Los datos recogidos de los pacientes se incluyeron en tres grupos: la información sociodemográfica y clínica, los hallazgos en la citología y los reportes de la ecografía. Se realizó el análisis mediante Naive-Bayes, árbol de decisión y redes neuronales. Se usó la herramienta Weka versión 3.8.2. Resultados: de los 427 pacientes, 195 tuvieron resultados de patología de carcinoma de tiroides (45,6 %). Se evidenciaron mejores resultados usando la validación cruzada (10 fold) comparado con partición (66 %), la técnica de Bayes tuvo mejores resultados de clasificación correcta (91,1 %), comparado con la técnica de árbol (87,8 %) y la red neuronal (88,2 %). Conclusiones: el uso de la técnica de Naive Bayes muestra una importante exactitud para determinar la predicción de riesgo de malignidad en los pacientes con estudio citológico Bethesda IV, lo cual permitiría orientar de forma adecuada el manejo quirúrgico de los pacientes

Introduction: In the health field, each decision represents data, and data mining techniques have begun to be a promising methodology for the analysis of this information, especially in the design of predictive models. Methods: Analytical observational study; patients older than 15 years with a report of Bethesda IV after a fine needle aspiration biopsy that undergoing surgical management at the Hospital de San José in Bogotá. The data collected from those patients were included in three groups: sociodemographic-clinical information, cytology findings, and ultrasound reports. Analysis was performed using three technics: Naive Bayes, decision trees, and neural networks. Weka tool version 3.8.2 was used. Results: 195 patients out of 427, had a thyroid carcinoma pathology (45.6%). Better results were evidenced using cross-validation (10 fold) compared with a partition (66%), the Bayes technique had better results of correct classification (91.1%), than the tree technique (87.8%) and neural network (88.2%). Conclusions: The use of the Naive Bayes technique shows an important accuracy to determine the prediction of risk of malignancy in patients with a Bethesda IV cytological study, which would allow an adequate guide to the surgical management of patients.

[Kikuchi-Fujimoto disease: report of two cases]. / Enfermedad de Kikuchi-Fujimoto: descripción de dos casos.

Kikuchi-Fujimoto disease, described for the first time in 1972, is an unusual diagnosis that is characterized by lymph node enlargement and fever. Cervical lymph nodes are affected so often that ENT specialists should be aware of this entity during differential diagnosis. The diagnosis was done by histological features, necrotizing lymphadenitis. The disease is self-limited and it has good prognosis. We have reviewed two cases in our hospital. We report an aseptic meningoencephalitis as a rare complication.

[Pseudohypertrophy of the ventricular bands due to deformation of the thyroid cartilage]. / Pseudohipertrofia de bandas ventriculares por deformación del cartílago tiroides.

Hoarseness due to phonation by the false cords (dysphonia plicae ventricularis) is a common cause of functional dysphonia, in relation to excessive muscular tension in the larynx area. Nevertheless, a mechanic cause can be observed in some cases with dysphonia plicae ventricularis, which is usually due to deformation of the thyroid cartilage. We report a case with hypertrophy of the ventricular bands which was treated by vocal rehabilitation followed by suspension laryngoscopy with partial removal of the ventricular bands, without further improvement. This failure was related to a pseudohypertrophy of the ventricular bands, due to deformation of the thyroid cartilage, which was confirmed by computed tomography.