A single administration of carbetocin before electroejaculation increases the insemination doses produced from each ejaculate in rams.

The aim of the study was to determine the effect of carbetocin administration (a long-acting analog of oxytocin) 20 or 10 min before electroejaculation (EE) on the duration of semen collection procedure, quantitative and qualitative characteristics of the ejaculate, and stress biomarkers in rams. Semen was collected from 12 Corriedale rams (age, 2.5-5.5 years old) with EE, in a Latin-square design, administrating carbetocin (0.2 mg/100 kg of body weight i.v.) 20 or 10 min before EE, or without carbetocin administration (CB-20, CB-10, and CON treatments, respectively). Each treatment was applied to different rams every 3-4 days, allowing all the rams to receive all three treatments. Carbetocin administered 20 or 10 min before EE increased the number of sperm ejaculated (P = 0.01), the semen concentration (P = 0.02), the number of insemination doses collected in a single collection (P = 0.01), and the number of insemination doses collected/electrical pulses administered (P = 0.05) compared to control rams. Carbetocin administered 20 or 10 min before semen collection prolonged the time required for EE and the number of pulses administered during EE compared to CON rams (P < 0.03 for both). The CB-10 rams required the administration of more electrical pulses during ejaculation than CON rams (P = 0.001), and CB-20 treatment tended to require more electrical pulses than CON rams (P = 0.06). The volume of the ejaculate was greater in CB-10 than in CON rams (P = 0.01), and that of CB-20 treatment tended to be greater than CON rams (P = 0.08). The percentage of sperm with intact membrane was greater in CB-20 than in CON rams (P = 0.01). Total protein, albumin, and globulin concentrations were lower immediately after carbetocin administration 20 or 10 min before EE. The treatments did not affect cortisol concentration, glycemia, rectal and surface temperatures, heart rate, and facial expressions. Carbetocin administration before EE of rams improved the quantitative and qualitative characteristics of the ejaculate, duplicating the number of insemination doses collected. It can be a promising treatment to obtain a greater quantity of doses to inseminate with a lower frequency of semen collections, reducing the negative impacts of EE on animal welfare.

Optogenetic manipulation of cardiac electrical dynamics using sub-threshold illumination: dissecting the role of cardiac alternans in terminating rapid rhythms.

Cardiac action potential (AP) shape and propagation are regulated by several key dynamic factors such as ion channel recovery and intracellular Ca2+ cycling. Experimental methods for manipulating AP electrical dynamics commonly use ion channel inhibitors that lack spatial and temporal specificity. In this work, we propose an approach based on optogenetics to manipulate cardiac electrical activity employing a light-modulated depolarizing current with intensities that are too low to elicit APs (sub-threshold illumination), but are sufficient to fine-tune AP electrical dynamics. We investigated the effects of sub-threshold illumination in isolated cardiomyocytes and whole hearts by using transgenic mice constitutively expressing a light-gated ion channel (channelrhodopsin-2, ChR2). We find that ChR2-mediated depolarizing current prolongs APs and reduces conduction velocity (CV) in a space-selective and reversible manner. Sub-threshold manipulation also affects the dynamics of cardiac electrical activity, increasing the magnitude of cardiac alternans. We used an optical system that uses real-time feedback control to generate re-entrant circuits with user-defined cycle lengths to explore the role of cardiac alternans in spontaneous termination of ventricular tachycardias (VTs). We demonstrate that VT stability significantly decreases during sub-threshold illumination primarily due to an increase in the amplitude of electrical oscillations, which implies that cardiac alternans may be beneficial in the context of self-termination of VT.

Daily variation of the cortisol and insulin concentration, glycemia, surface temperature, and behavior patterns due the administration of equine Chorionic Gonadotropin in rams.

Sex steroids can modulate the circadian rhythmicity of some physiological and behavioral functions of sheep. During the non-breeding season, Corriedale rams have a low testosterone concentration, but the administration of equine Chorionic Gonadotropin (eCG) stimulates its secretion. Therefore, the daily variation of cortisol and insulin concentrations, glycemia, behavioral pattern (eating, ruminating, standing, lying, and sleeping), and rostral and eye surface temperatures were compared in rams treated or not treated with eCG during the non-breeding season [between August (late winter) and September (early spring)]. Twenty Corriedale adult rams (BW 63.4 ± 7.3 kg; BCS: 3.5 ± 0.5; mean ± SD; age: 2-3 years old) were randomly assigned to 1 of 2 treatments: a) Treated: administration of 1000 IU of eCG intramuscularly and b) Control: control, without application of eCG. All the rams were managed under the same feeding and environmental conditions (individual pens outdoors). All variables were measured each hour for 26 h, except testosterone and insulin that were measured at 09:00, 10:00, 12:00, 15:00, 18:00, 21:00, 22:00, 24:00, 03:00, 06:00, 09:00 and 11:00 h. Testosterone and cortisol concentration were greater in Treated than Control rams (testosterone: 32.7 ± 0.7 nmol/L vs 5.8 ± 0.7 nmol/L; P <0.0001; cortisol: 11.3 ± 0.6 nmol/L vs 9.9 ± 0.6 nmol/L; P =0.02). The eye surface temperature was 0.9°C lower in the Treated than in the Control rams (P =0.004). The characteristics of the daily variation pattern of cortisol, glycemia, glycemia:insulin ratio, and surface temperature were not affected by the treatment, the acrophases being at ∼06:00 h, ∼18:00 h, ∼08:00 h, and ∼11:00 h, respectively. The acrophase of insulin concentration was observed earlier in Treated than in Control rams (13:02 ± 0:56 vs 15:47 ± 0:53; P =0.04). Additionally, the acrophase of the time spent eating was advanced in Treated rams (09:48 ± 00:16 vs 10:20 ± 00:16; P =0.04) and sleeping (21:39 ± 00:57 vs 02:02 ± 01:06; P <0.0001). Treated rams slept less time than Control rams (P =0.04). In conclusion, the administration of eCG modulated the daily variation pattern of insulin concentration and the behavioral pattern (period in which rams were observed eating and sleeping). Nevertheless, although there was a greater cortisol concentration and reduced eye surface temperature, the administration of eCG did not modify their daily variation pattern, suggesting that this is robust, limiting the effect of testosterone on their basal pattern.

Heat stress response in slick vs normal-haired Criollo Limonero heifers in a tropical environment.

To assess the effect of hair type on the heat stress response, 20 Criollo Limonero heifers with slick (n = 11) or normal hair (n = 9) were studied. Under a high temperature-humidity index (THI) environment, heat stress response was assessed through physiological variables that included respiration rate (RR), heart rate (HR), ruminal frequency (RMF), rectal temperature (RT), saliva pH (SPH), and lymphocyte count (LC) in the morning (5:00 AM, 27.4 °C, 64% relative humidity, THI = 77) and afternoon (1:00 PM, 34.5 °C, 70% relative humidity, THI = 88). A case-control study using a split plot design was used. Data were analyzed using ANOVA (PROC MIXED SAS 2010) and a statistical model comprising the fixed effects of hair length, sampling hour, interaction of hair length by sampling hour, and the random effect of animal nested within hair type on physiological variables associated with heat stress response. Sampling hour influenced (P < 0.0001) RR, RT, and (P < 0.003) SPH. Hair length influenced RR (P < 0.01) and RT (P < 0.04) and tended to influence LC (P < 0.07). The interaction of sampling hour by hair influenced RR (P < 0.04), RT (P < 0.0002), and both SPH and LC (P < 0.05). During afternoon hours, slick-haired heifers had lower values for RR (81 ± 4.2 vs 102 ± 4.7 bpm; P < 0.01), RT (39.5 ± 0.1 vs 40.3 ± 0.1 C°; P < 0.002), and LC (60 ± 3.2 vs 72.3 ± 3.6; P < 0.09) than normal-haired heifers. In normal-haired heifers, SPH increased during afternoon compared to morning-hours (8.66 ± 0.1 vs 9.11 ± 0.1; P < 0.04). It was concluded that slick-coated heifers exhibited an enhanced capability to cope with heat stress compared to normal-haired heifers likely due to an enhanced capacity for heat dissipation.

Cystic form of cervical lymphadenopathy in adults. Guidelines of the French Society of Otorhinolaryngology (short version). Part 2-etiological diagnosis procedure: Clinical and imaging assessment.

INTRODUCTION: The authors present the guidelines of the French Society of Otorhinolaryngology (SFORL) for clinical and radiological assessment of cystic neck lymphadenopathy of unknown primary in adults. Most cases concern head and neck carcinoma metastasis, often in the oropharyngeal area, or less frequently differentiated thyroid carcinoma or non-keratinizing nasopharyngeal carcinoma. METHODS: A multidisciplinary task force was commissioned to carry out a review of the literature on the etiological work-up in cystic neck lymphadenopathy in adults: clinical examination, conventional imaging (ultrasound, CT, MRI) and metabolic imaging. Guidelines were drafted based on the articles retrieved, and graded A, B, C or expert opinion according to decreasing level of evidence. RESULTS: Oriented clinical examination, cervical and thyroid ultrasound scan and contrast-enhanced neck and chest CT scan are recommended in the assessment of cystic neck lymphadenopathy of unknown primary in adult patients. PET-CT is recommended prior to panendoscopy, to identify the primary tumor. CONCLUSION: Clinical and radiological assessment is fundamental for etiologic diagnosis of cystic neck lymphadenopathy in adult patients, and should be completed by cytological examination before in initiating treatment.

Nodal metastases distribution in laryngeal cancer requiring total laryngectomy: Therapeutic implications for the N0 Neck.

OBJECTIVES: Neck dissection is a controversial surgical procedure in patients with squamous cell carcinoma of the Larynx free of any node metastasis detected in preoperative staging. The aim of this study was to investigate the distributions of lymph node metastases in laryngeal squamous cell carcinoma and improve the rationale for elective treatment of N0 neck. MATERIAL AND METHODS: Retrospective single-center series of Seventy-eight successive patients with laryngeal squamous cell carcinoma who underwent neck dissection between 2008 and 2015. RESULTS: Surgery was first-line treatment in 37 patients (47%) and for recurrent disease in 41 (53%). The rate of occult nodal metastasis was 14% (n=11): levels IIa and/or III were affected in 9 cases (11.5%) compared with single cases of IIb and IV involvement (1.3% each). The rate of occult nodal metastasis was significantly lower among patients operated on for recurrent disease after radiotherapy than in patients who never had any radiotherapy of the cervical lymph nodes (0% vs. 16.7%, P=0.03). CONCLUSIONS: Selective cervical lymph node dissection in levels IIa and III sparing levels IIb and IV seems to be ideal in total laryngectomy in patients with cN0 laryngeal squamous cell carcinoma. Omitting lymph node dissection altogether may be considered in total laryngectomy on a cN0 patient showing recurrence after radiotherapy.

Human protective response induced by meningococcus B vaccine is mediated by the synergy of multiple bactericidal epitopes.

4CMenB is the first broad coverage vaccine for the prevention of invasive meningococcal disease caused by serogroup B strains. To gain a comprehensive picture of the antibody response induced upon 4CMenB vaccination and to obtain relevant translational information directly from human studies, we have isolated a panel of human monoclonal antibodies from adult vaccinees. Based on the Ig-gene sequence of the variable region, 37 antigen-specific monoclonal antibodies were identified and produced as recombinant Fab fragments, and a subset also produced as full length recombinant IgG1 and functionally characterized. We found that the monoclonal antibodies were cross-reactive against different antigen variants and recognized multiple epitopes on each of the antigens. Interestingly, synergy between antibodies targeting different epitopes enhanced the potency of the bactericidal response. This work represents the first extensive characterization of monoclonal antibodies generated in humans upon 4CMenB immunization and contributes to further unraveling the immunological and functional properties of the vaccine antigens. Moreover, understanding the mechanistic nature of protection induced by vaccination paves the way to more rational vaccine design and implementation.

Lymph-node metastasis following total laryngectomy and total pharyngolaryngectomy for laryngeal and hypopharyngeal squamous cell carcinoma: Frequency, distribution and risk factors.

OBJECTIVES: To evaluate the prevalence and distribution of lymph-node metastasis after total laryngectomy or total pharyngolaryngectomy. MATERIAL AND METHODS: Retrospective single-center series of 136 successive patients undergoing total laryngectomy or total pharyngolaryngectomy with neck dissection for squamous cell carcinoma of the larynx or hypopharynx. RESULTS: The primary site was laryngeal in 110 cases and hypopharyngeal in 26. In 63 patients, surgery was first-line treatment; 73 were operated on for recurrence. The lymph-node metastasis rate, confirmed on histology, was 44.8% regardless of primary site. Hypopharyngeal location was a risk factor for lymph-node metastasis (73.1%, P=0.002) as was the supraglottic subsite (64.3%, P=0.039). Levels IIa and III were invaded in 28.7% and 25.7% of cases, respectively. Level VIb lymph-node involvement was 23.8% in patients who underwent level VIb neck dissection. Lymph-node recurrence rate was 10.3% in levels II to IV and 13.2% in VIb. CONCLUSIONS: Whatever the tumor site, levels IIa and III were most frequently invaded. The high rate of histological involvement of level VIb and of recurrence argues for systematic elective bilateral neck dissection of these territories in some primary sites.

Outcomes of septorhinoplasty: a new approach comparing functional and aesthetic results.

The aim of this study was to compare objective and subjective functional results of septorhinoplasty with subjective aesthetic results. A prospective study was performed including global and subgroup analyses (primary versus secondary septorhinoplasty). Three instruments were used to evaluate pre- and postoperative results: rhinomanometry for the objective functional analysis, the Nasal Symptom Obstruction Evaluation (NOSE) scale for the subjective functional analysis, and the Rhinoplasty Outcome Evaluation (ROE) scale for the subjective aesthetic analysis. A septorhinoplasty was performed in all cases. Thirty-five patients were included (22 female), of whom 74% underwent primary septorhinoplasty. The correlation between rhinomanometry, NOSE and ROE scores was analysed. Mean resistance of the two nasal cavities was 4.9 (standard deviation (SD) 8.35) sPa/ml before surgery and 0.8 (SD 0.7) sPa/ml after surgery. NOSE and ROE scores were, respectively, 72.5/100 (SD 21.7) and 7.5/24 (SD 11.3) before surgery and 22/100 (SD 20.6) and 18/24 (SD 17.3) after surgery. Patients complaining of postoperative nasal obstruction had a worse aesthetic evaluation. Correction of the functional disease appears to be as important as aesthetic correction. This study comparing functional and aesthetic results after septorhinoplasty could provide a basis for future studies.

Non-destructive and direct determination of the degree of substitution of carboxymethyl cellulose by HR-MAS 13C NMR spectroscopy.

We report on the direct assessment of the degree of substitution (DS) of carboxymethyl cellulose (CMC) by High Resolution Magic Angle Spinning (HR-MAS) 13C NMR spectroscopy. The method is applied to industrial CMCs with low and high viscosity and nominal DS, purified and technical samples, and from cellulose linters or wood. The preparation of a set of purified CMC working standards with accurate DS values for the method validation is also described. The DS values determined via HR-MAS 13C NMR on the industrial samples are critically compared to the corresponding values achieved through the USP 37 〈281〉 method (ASH method) and the HPLC method, and the advantages and limitations of the HR-MAS NMR method highlighted. Finally, the HR-MAS NMR approach allowed the accurate DS assessment in CMC with low DS, characterized by a non-negligible fraction of non-functionalized cellulose. The proposed "effective DS" accounts for the DS of the solvent-exposed CMC.

Nasotracheal prolonged safe extubation in acute respiratory failure post-thyroidectomy: An efficacious technique to avoid tracheotomy? A retrospective analysis of a large case series.

BACKGROUND: Acute respiratory failure is a rare life threatening complication following thyroid surgery and its incidence is reported as high as 0.9%. Clinical presentation of severe acute respiratory failure is characterized by dyspnea, inspiratory airways distress, hypoxia and its standard current management is the orotracheal intubation and safe extubation. In case of persistent distress, tracheotomy is mandatory. The Authors, analysing a large acute respiratory failure clinical series, describe an innovative treatment of this severe condition: the nasotracheal prolonged safe extubation. METHODS: Patients treated at our Intensive Care Unit for acute respiratory failure following thyroid surgery from January 2004 to December 2013, were reviewed. Demographic data including gender, age, clinical presentation, laryngoscopic findings, management and outcome during a 24-months follow-up after treatment were collected and evaluated. Moreover, the strategy for prolonged nasotracheal safe extubation was carefully described. RESULTS: Nineteen out of the 2853 patients scheduled for thyroid surgery (0.66%) at our University Hospital, developed post-operative acute respiratory failure. All of them were treated by nasotracheal prolonged safe extubation. The success rate in avoiding highly invasive treatment was of 84.2%, since only 3 patients needed definitive tracheotomy (15.7%). CONCLUSIONS: In our series, the prolonged safe extubation reduced the almost totality of expected tracheotomies in patients with acute respiratory failure following thyroid surgery (84.2%), demonstrating its feasibility and efficacy. It was a well tolerated and minimal invasive procedure that allowed a good respiratory ability and a fast clinical resolution of the laryngeal functional impairment.

The MiRa scale, a new standardised scale for evaluating nasal deformities before and after septorhinoplasty: A prospective study comparing patient satisfaction and the surgeon's assessment.

OBJECTIVES: The objective was to assess the reliability of a new standardised scale for evaluating nasal anomalies in order to compare the surgeon's assessment and patient satisfaction. DESIGN: Monocentric prospective cohort study. SETTINGS: First, we validated the reliability of the MiRa scale; then, we compared the surgeon's assessment and patient satisfaction. PARTICIPANTS: Fifty-two patients underwent septorhinoplasty surgery and gave their written consent before inclusion. MAIN OUTCOME MEASUREMENTS: Primary outcome measurement was to validate the reliability of the MiRa scale: two observers analysed all records twice. Intra-observer reproducibility and interobserver reproducibility were evaluated using the intraclass correlation coefficient (ICC). Secondary outcome measurement was to compare the surgeon's assessment and patient satisfaction: MiRa and ROE (Rhinoplasty Outcome Evaluation) scores were established for each patient prior to and 6 months after surgery. RESULTS: Using the MiRa scale, ICC for intra- and interobserver reproducibility was, respectively, 95.4% and 96%, showing no statistical difference (P=.70, P=.45). Good correlation scores were, respectively, 93% and 92%. Mean ROE scores were 7.1/24 (SD=11.3) before and 19.3/24 (SD=17.3) after surgery (P<.05). We found an increase in MiRa and ROE scores of +19.75% and +51.25% (P<.05), respectively. The average postoperative ROE score in the primary septorhinoplasty group was 20.4 (SD=14.4) and 17.2 (SD=23.1) in the secondary septorhinoplasty group (P<.05). CONCLUSION: MiRa scale is a reliable, standardised tool to evaluate surgical outcome in septorhinoplasty surgery. It provides an objective and reproducible score. The surgeon's assessment was more critical than patient satisfaction. Patient satisfaction is more difficult to achieve in cases involving a secondary septorhinoplasty.

Prevalence of obstructive sleep apnoea syndrome following oropharyngeal cancer treatment: A prospective cohort study.

OBJECTIVES: To evaluate the prevalence of obstructive sleep apnoea syndrome (OSAS) in a population of patients treated for an advanced oropharyngeal cancer (AJCC Stage III or IV), depending on treatment strategy, and to evaluate its impact on quality of life. DESIGN: Prospective cohort study. SETTING: University Teaching Hospital of La Conception, Marseille, France. PARTICIPANTS: Fifty-one disease-free patients were included. Forty-one patients received a combined chemoradiotherapy, while 10 patients were treated by surgery followed by chemoradiotherapy. MAIN OUTCOME MEASURES: Every patient underwent a formal sleep consultation and was asked to complete the Epworth Sleepiness Scale and EORTC QLQ C-30 and the EORTC H&N 35 questionnaires. A home overnight respiratory polygraphy was performed in every subject. RESULTS: The mean time between the end of cancer treatment and the OSAS analysis was 54.04 months [20; 84]. An OSAS was found in 25.49% of our patients. There was no significant difference between patients treated with either surgery (30%) or CRT (24.39%), P=.79. The EORTC QLQ C-30 questionnaire showed a significant difference between positive and negative OSAS groups in the Global Health Status Scale (50.64 vs 67.11, P=.02) and in the fatigue item (35.04 vs 17.25, P=.03). CONCLUSIONS: Our population with advanced oropharyngeal cancer, whatever the treatment strategy it may be, was at risk of developing OSAS with negative impact on quality of life. A routine screening and treatment of OSAS seems necessary to improve the quality of life of patients treated for advanced oropharyngeal cancer.

Preclinical studies on new proteins as carrier for glycoconjugate vaccines.

Glycoconjugate vaccines are made of carbohydrate antigens covalently bound to a carrier protein to enhance their immunogenicity. Among the different carrier proteins tested in preclinical and clinical studies, five have been used so far for licensed vaccines: Diphtheria and Tetanus toxoids, the non-toxic mutant of diphtheria toxin CRM197, the outer membrane protein complex of Neisseria meningitidis serogroup B and the Protein D derived from non-typeable Haemophilus influenzae. Availability of novel carriers might help to overcome immune interference in multi-valent vaccines containing several polysaccharide-conjugate antigens, and also to develop vaccines which target both protein as well saccharide epitopes of the same pathogen. Accordingly we have conducted a study to identify new potential carrier proteins. Twenty-eight proteins, derived from different bacteria, were conjugated to the model polysaccharide Laminarin and tested in mice for their ability in inducing antibodies against the carbohydrate antigen and eight of them were subsequently tested as carrier for serogroup meningococcal C oligosaccharides. Four out of these eight were able to elicit in mice satisfactory anti meningococcal serogroup C titers. Based on immunological evaluation, the Streptococcus pneumoniae protein spr96/2021 was successfully evaluated as carrier for serogroups A, C, W, Y and X meningococcal capsular saccharides.

Extraordinary range expansion in a common bat: the potential roles of climate change and urbanisation.

Urbanisation and climate change are two global change processes that affect animal distributions, posing critical threats to biodiversity. Due to its versatile ecology and synurbic habits, Kuhl's pipistrelle (Pipistrellus kuhlii) offers a unique opportunity to explore the relative effects of climate change and urbanisation on species distributions. In a climate change scenario, this typically Mediterranean species is expected to expand its range in response to increasing temperatures. We collected 25,132 high-resolution occurrence records from P. kuhlii European range between 1980 and 2013 and modelled the species' distribution with a multi-temporal approach, using three bioclimatic variables and one proxy of urbanisation. Temperature in the coldest quarter of the year was the most important factor predicting the presence of P. kuhlii and showed an increasing trend in the study period; mean annual precipitation and precipitation seasonality were also relevant, but to a lower extent. Although urbanisation increased in recently colonised areas, it had little effect on the species' presence predictability. P. kuhlii expanded its geographical range by about 394 % in the last four decades, a process that can be interpreted as a response to climate change.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications.

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

Epistaxis: The role of arterial embolization.

Epistaxis is defined as flow of blood from the nasal fossae and is a common and benign disorder in the great majority of cases which does not require medical care. It may however become a genuine medical or surgical emergency because of the amount, repeated episodes or patient's medical vulnerability (such as coronary artery disease patients). Epistaxis may be either primary or a symptom of an underlying disease. Four levels of problems need to be answered faced with epistaxis: recognizing it, and in particular not missing "epistaxis" due to swallowed blood or venous hemorrhage, which falls outside of the scope of interventional radiology; establishing the amount and its repercussions, particularly as a decompensating factor in another disease; investigating its cause and in particular never missing a tumor (male adolescents); obtaining hemostasis. Epistaxis varies not only in type and cause but must be considered in its clinical context. Arterial embolization is a treatment of choice for severe refractory epistaxis and some hemorrhages. When carried out by trained operators, it is an effective method with few risks of complications and is increasingly being used in reference centers (Brinjikji et al.). It remains, however, a method which is less widely used than surgery, particularly in the United States where in a series of 69,410 patients treated over the last 10 years for refractory epistaxis, 92.6% underwent surgical ligation, 6.4% embolization and 1% combined treatments (Brinjikji et al.). Epistaxis is occasionally catastrophic and requires extremely urgent management. In each case, close collaboration with the surgeon, the presence of an intensive care anesthetist and at least sedation are all factors which improve management and therefore the results of embolization. All patients and/or their friends/close family should have given "reliable, clear and appropriate" information.

A pilot study about speech changes after partial Tucker's laryngectomy: the reduction of regressive voicing assimilation.

Partial frontolateral laryngectomy (PL) is performed to remove larynx tumor while preserving its main functions. So far, the speech changes induced by difficulties of voicing and the alterations to the vocal tract due to PL have been seldom addressed. The goal of our study was to make an acoustic analysis of regressive voicing assimilation (RVA) among patients after PL and to study the relationship with rates of speech. A retrospective study was conducted from January to April 2013. 11 subjects treated by partial frontolateral laryngectomy, and ten healthy subjects were included. Functional recordings of voice were analyzed and compared. For assimilation sequences we found a significant modification of voicing ratio in healthy subjects (p < 0.05) and PL patient at accelerated speaking rate only (p < 0.05). The vowel duration is significantly modified only for healthy subjects. For all subjects (PL patients and healthy) the duration of C1 consonant was not significantly modified. Our results highlight the presence of RVA in healthy subjects, but also in PL patients in the rapid speaking mode.

Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review.

Pancreatoduodenectomy is the gold standard operation for malignant and benign diseases of the pancreas and periampullary region. Even if improvements in intensive care management and surgical technique have dramatically reduced postoperative mortality after pancreatic surgery, morbidity remains high (30-50%), also in specialized pancreatic units. In order to reduce postoperative complications, particularly pancreatic fistula, different surgical techniques and their modifications have been proposed. In order to determine the better management of the pancreatic stump after pancreatoduodenectomy, the Authors analysed and compared derivative - pancreaticojejunal, pancreaticogastrostomy - vs no-derivative technique - pancreatic stump closure (duct ligation or mechanical suture, duct occlusion by fibrin glue or cyanoacrylate). A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, analysing the risk factors and the incidence of short-medium term postoperative complications. Up to now, even if derivative procedures are preferred as gold standard the best method to deal a pancreatic stump is still controversial and remains matter of research. Pancreatic surgeons must have more than one technique for managing the pancreatic remnant.