Risk analysis and seroprevalence of bovine ephemeral fever virus in Punjab, Pakistan.

Bovine ephemeral fever (BEF) is a vector-borne viral disease caused by the RNA virus which belongs to the genus Ephemerovirus and the family Rhabdoviridae. To evaluate the effect of the risk factors like the breed of cattle and buffaloes, age, sex, lactation, housing and region on the bovine ephemeral fever virus (BEFV) prevalence, ELISA and virus neutralisation (VN) tests (n = 600) were performed for the BEFV prevalence. The seroprevalence in cattle was 45.6% and 42% by ELISA and VN, respectively (P = 0.001). The breed-wise seropositive ratio was (55-64%) in cattle and (22.5-18.3%) in buffaloes by VN and ELISA. The sex-wise prevalence was (40-49.4%) in females and (35.8-46%) in males by VN and ELISA in cattle and a similar prevalence was reported in buffaloes. The age-wise prevalence in bovines by ELISA was 5.33, 22.66 and 17.66% in the age group < 1 year, 1-3 years and > 3 years, respectively. The disease prevalence was higher in the age group of 1-3 years. The prevalence was higher during the 3rd lactation in bovines. The region-wise prevalence was higher in the 07 districts while lower (18-21%) in Rawalpindi District by VN and ELISA, respectively (P = 0.001). Commercial dairy farms of cattle showed a higher disease prevalence (52% and 44%) than non-commercial farms (38% and 36%) by ELISA and VN, respectively (P = 0.227). Exotic cows showed higher disease prevalence (76.67% and 70%) by ELISA and VN. The mortality in bovines was 5% (7.7% and 2.3%) in the cattle and buffaloes. The case fatality of BEFV in bovines was 12.25%. There was a significant effect of the risk factors like the breed, age, sex, lactation, housing and region on the BEFV prevalence. This is the first comprehensive study of BEFV in Pakistan.

Feasibility of half the recommended dose of IV contrast in DECT: image quality evaluation and diagnostic acceptability in cancer patients.

PURPOSE: To assess the quality of dual-energy computed tomography (DECT) images in patients receiving 50% of the recommended weight-based volume of iodinated intravenous contrast medium. METHODS: The study included cancer patients who previously underwent abdominal CT on a DECT scanner using a single source with the full recommended weight-based dose of Iohexol 350. Using the same scanner, the patients underwent a portovenous phase DECT scan following intravenous injection of half of the recommended weight-based dose. Monochromatic energy images were processed at 60 and 70kEv and compared to polychromatic 140kVp images. Three radiologists independently scored the images for overall diagnostic acceptability and image quality of solid organs and vasculature. Regions of interest were drawn on the portal vein, aorta, liver, and fat to calculate contrast to noise ratio (CNR) and signal to noise ratio (SNR). A multivariate ordinal generalized estimating equations model was used to assess image quality score. Pairwise comparisons were performed of the readers' scores, CNR, and SNR. Agreement with respect to quality score was calculated by using Fleiss's kappa value. RESULTS: Diagnostic acceptability was better for the SECT (120kVp) scans than for the 70 and 60kEv scans, and better for the 70 and 60kEv scans than for the 140kVp scans. Noise was subjectively rated as best on the 70kEv images. SNR of the liver was highest on 70kEv images. SNR of the liver on 70kEv images was significantly better than SECT images (p < 0.0001). Liver CNR was highest on SECT (120kVp) images. CONCLUSION: DECT with 50% reduction in the volume of intravenous contrast produces image quality comparable to that of SECT in cancer patients.

Prevalence of antibiotic resistance pattern in shigella isolates procured from pediatric patients at Faisalabad - Pakistan.

Shigella infection (shigellosis) is an intestinal disease caused by a shigella isolates belongs to a family Enterobacteriacea. Watery diarrhea, abdominal pain and tenesmus are the prominent symptoms of shigella infection. The present study was designed to determine period prevalence and antimicrobial susceptibility of Shigella species recovered from stool specimens obtained from diarrheal paediatric patients under 5 years of age. This cross-sectional study was carried out for a period of six months (Jan to June, 2016). All Shigella isolates were identified based on colony morphology, microscopic characteristics, and biochemical characteristics. After applying Kirby Baur disc diffusion method only 22 (18.96%) stool specimens were found positive for Shigella isolates among the 116 stool specimens. The isolates were also found susceptible to Levofloxacin (72.72%), Azithromycin (59.09%), and Cefotaxime (40.90%). However, the said isolates were resistant to Lincomycin (100%) and Penicillin-G (100%), followed by Amoxicillin (95.45%) and Oxacillin (95.45%). The chi-square test was used to check the close association among antimicrobial agents used and as highly significant (p-value < 2.2e-16). Based on antimicrobial susceptibility findings, Levofloxacin, Azithromycin and Cefotoxime were found effective for the control of shigellosis.

Pattern of clinical drug resistance and occurrence of Gram negative bacterial neonatal sepsis at a tertiary care hospital.

Sepsis is a leading cause of neonatal deaths across the world. Gram-negative rods such as Klebsiella and E. coli are major cause of sepsis in neonates. With a mortality rate of 1-4 deaths per thousand live births, sepsis is the second most important cause of neonatal deaths in the developing countries. The present study was designed to determine the occurrence of Gram-negative bacteria in neonatal sepsis and to find antibiotic susceptibility of isolated microbes. Blood samples of 100 neonates (1-89 days old) were sub cultured on MacConkey's and Blood agar for isolation of Gram-negative bacteria. A total of four bacterial species were isolated including Klebsiella (35.71%), E. coli (28.57%), Acinetobacter (21.42%) and Proteus (14.28%). Gram-negative bacteria were isolated more commonly from EOS (early onset sepsis) as compared to LOS (late onset sepsis). Klebsiella isolates from neonates showed sensitivity to imipenem (70%) followed by ceftazidime (40%) and cefotaxime (40%) and high resistance was shown by sulfamethoxazole (80%) and amikacin (70%). E. coli associated with neonatal sepsis were sensitive to imipenem (63%) while highly resistant to cefotaxime (75%) and ciprofloxacin (62%). For Acinetobacter high sensitivity was found for ceftazidime (50%) and resistance was shown to ciprofloxacin and sulfamethoxazole (100%). Proteus showed high sensitivity to amikacin (75%) and high resistance to imipenem and ciprofloxacin (75%). In conclusion, Gram-negative associated neonatal sepsis was found in the studied subjects and drug resistance was observed to clinically used antibiotics.

Middle Fossa Encephaloceles Treated via the Transmastoid Approach: A Case Series and Review of the Literature.

BACKGROUND: Middle fossa (MF) encephaloceles are rare lesions resulting from herniation through defects in the tegmen tympani or mastoideum. Underlying etiologies and clinical presentations are variable. Surgical goals include fistula obliteration, resection of nonfunctioning parenchyma, and dehiscence repair. The middle cranial fossa approach (MCFA), transmastoid approach (TMA), and combined (MCFA + TMA) approaches have been described. The minimally invasive TMA provides excellent exposure of the pathology and allows for ample working room to repair the defect. OBJECTIVE: To present short-term follow-up results in patients treated via the TM repair at our institution. METHODS: A retrospective review of patients with symptomatic encephaloceles treated via the TMA by our multidisciplinary team. Patient demographics, clinical presentations, intraoperative findings, repair technique, and outcomes were highlighted. RESULTS: A total of 16 encephaloceles in 13 patients were treated. Defect etiologies included spontaneous (50.0%), secondary to chronic infection (25.0%), or cholesteatoma (18.8%). Defects were most often within the tegmen mastoideum (68.8%). Average length of surgery was 3.3 h (95% CI: 2.86-3.67) and length of stay 3.9 d (95% CI: 3.09-4.79). On short-term follow-up (average 11.5 mo), no patients experienced postoperative cerebrospinal fluid leak or recurrence. The majority of patients (83.3%) experienced confirmed improvement or stabilization of hearing. CONCLUSION: MF encephaloceles present with various clinical manifestations and result from multiple underlying etiologies. The TMA is an alternative to craniotomy and our short-term results suggest that this approach may be utilized effectively in appropriately selected cases.

Socioeconomic Status and Survival in Nasopharyngeal Carcinoma: A Population-Based Study.

OBJECTIVES/HYPOTHESIS: To evaluate survival for nasopharyngeal carcinoma in relation to socioeconomic status. STUDY DESIGN: Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) Census Tract-level Socioeconomic Status Database (2000-2016). METHODS: Patients with nasopharyngeal carcinoma diagnosed between 2000 and 2016 were identified. Data were stratified based on socioeconomic status, divided into three groups: group 1 being the poorest and group 3 the wealthiest. Univariate analysis as well as multivariate Cox regression analysis adjusted for individual variables was performed. RESULTS: A total of 5,527 patients were included in the study, with 33% in group 1, 34% in group 2, and 33% in group 3. There was a significant difference between groups in regard to age at diagnosis, race, histologic subtype, overall stage, tumor stage, nodal stage, and whether or not they received radiation. Patients in group 1, the poorest socioeconomic status, were more likely to be young (P = .003), black (P < .0001), present with higher overall stage (P = .009), tumor stage (P = .01), and nodal stage (P = .02), and less likely to receive radiation (P = .005). In multivariate analysis, there was a significant difference in survival between the groups, with group 1 patients less likely to survive compared to group 3 (hazard ratio = 1.28; 95% CI 1.07-1.57). CONCLUSIONS: Patients in the poorest socioeconomic status presented with more advanced nasopharyngeal cancer and were less likely to receive radiation when compared with individuals of higher socioeconomic status. The poorest socioeconomic status groups were less likely to survive from their disease when controlling for other variables. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2719-2723, 2021.

COVID-19 and comorbidities of hepatic diseases in a global perspective.

The worldwide outbreak of coronavirus disease 2019 (COVID-19) has challenged the priorities of healthcare system in terms of different clinical management and infection transmission, particularly those related to hepatic-disease comorbidities. Epidemiological data evidenced that COVID-19 patients with altered liver function because of hepatitis infection and cholestasis have an adverse prognosis and experience worse health outcomes. COVID-19-associated liver injury is correlated with various liver diseases following a severe acute respiratory syndrome-coronavirus type 2 (SARS-CoV-2) infection that can progress during the treatment of COVID-19 patients with or without pre-existing liver disease. SARS-CoV-2 can induce liver injury in a number of ways including direct cytopathic effect of the virus on cholangiocytes/hepatocytes, immune-mediated damage, hypoxia, and sepsis. Indeed, immediate cytopathogenic effects of SARS-CoV-2 via its potential target, the angiotensin-converting enzyme-2 receptor, which is highly expressed in hepatocytes and cholangiocytes, renders the liver as an extra-respiratory organ with increased susceptibility to pathological outcomes. But, underlying COVID-19-linked liver disease pathogenesis with abnormal liver function tests (LFTs) is incompletely understood. Hence, we collated COVID-19-associated liver injuries with increased LFTs at the nexus of pre-existing liver diseases and COVID-19, and defining a plausible pathophysiological triad of COVID-19, hepatocellular damage, and liver disease. This review summarizes recent findings of the exacerbating role of COVID-19 in pre-existing liver disease and vice versa as well as international guidelines of clinical care, management, and treatment recommendations for COVID-19 patients with liver disease.

Myxoid Liposarcoma With Skeletal Metastases: Pathophysiology and Imaging Characteristics.

Liposarcoma is a commonly occurring soft tissue sarcoma that can be divided into 4 subtypes. Myxoid and round cell liposarcoma (MRCL) represent one of these subtypes and are classified together due to their shared chromosomal translocation. Histologic analysis of MRCL reveals a myxoid matrix with a delicate capillary network and dispersed lipoblasts. Varying degrees of round cell component are also observed, with greater amounts of round cells indicating a higher histologic grade and poorer prognosis. MRCL has a unique pattern of spread due to its initial tendency to spread to extrapulmonary sites. Additionally, skeletal metastases are frequently found in cases of MRCL. While various imaging techniques are used to visualize MRCL and metastases, magnetic resonance imaging is generally the preferred method. This article reviews the pathophysiology and imaging features of MRCL as well as the imaging characteristics, advantages, and drawbacks of multiple imaging modalities for visualizing bone metastases.

Effect of sarcopenia on systemic targeted therapy response in patients with advanced hepatocellular carcinoma.

PURPOSE: Sarcopenia is an independent prognostic indicator for hepatocellular carcinoma (HCC). Our objective was to determine the effect of sarcopenia on response to systemic targeted therapy in patients with advanced HCC. MATERIALS AND METHODS: This was a retrospective, Institutional Review Board approved study of 36 patients on systemic targeted therapy with immune checkpoint blockade (n = 25) or tyrosine kinase inhibitor (n = 11) for biopsy-proven advanced HCC. Skeletal muscle index (SMI) was calculated from erector spinae muscle area (SMA) at the level of T12 on pretreatment CT: [SMI = SMA (cm2)/height (m2)]. SMI was compared to treatment response defined as overall survival ≥ 1 year (nonsurgical patients) or > 50% HCC necrosis (surgical patients). Receiver operating characteristic curve and area under the curve was used for analysis with p < 0.05 for statistical significance. RESULTS: Median age of men and women was 66.5 years (range 32-83) and 70 years (range 54-78), respectively. Liver disease etiology was nonalcoholic steatohepatitis (n = 9), hepatitis C (n = 10), hepatitis B (n = 5), alcohol (n = 3) and unknown (n = 9). Mean (± SD) height and SMI for men were 1.7 m (± 0.1) and 11.4 (± 3.6); values for women were 1.7 m (± 0.1) and 8.2 (± 1.9). Treatment was withdrawn in five patients due to treatment intolerance. Response occurred in 10/31 (32.3%) patients (23 men, 8 women). T12SMI correlated with treatment response using a threshold of 7.21-8.23 for women (AUC = 1; p = 0.037), and 11.47 for men (AUC = 0.83; p = 0.015); correlation was increased for men ≥ 60 years, (AUC = 0.87; p = 0.023). CONCLUSION: Sarcopenia was associated with reduced survival and HCC necrosis in patients treated with systemic targeted therapy. CLINICAL RELEVANCE: Sarcopenia may help in predicting outcomes to targeted therapy in advanced HCC.

Dermatofibrosarcoma Protuberans: Pathological and Imaging Review.

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-to-intermediate grade sarcoma that typically arises in the dermis and infiltrates subcutaneous tissue. Due to superficial appearance of DFSP, imaging techniques are not always utilized. However, they may be useful in large or atypical cases. The standard treatment for DFSP is excision of the lesion. In this article, we review the role of different imaging modalities in the assessment and management of DFSP.

Phylogeny of hospital acquired MRSA, and its comparative phenotypic clinico-epidemiology with vancomycin resistant S. aureus (VRSA).

Staphylococcus aureus is emerging as complicated pathogen because of its wide-ranging origin, multiple variants, and compromised antibiotic susceptibilities. Current study was planned to find lineage of hospital acquired methicillin resistant Staphylococcus aureus (HA-MRSA), and its comparative phenotypic clinico-epidemiology with vancomycin resistant S. aureus (VRSA). A total of (n = 200) samples were aseptically collected from wound, nose, and cerebrospinal fluid of patients from metropolitan and rural background hospitals along with on spot filling in of questionnaire. Phylogenetic analysis of HA-MRSA was identified by targeting mecA gene in S. aureus. At optimal tree branch length of 1.91 and evolutionary distance 0.1, high level sequence similarity (97%-99%) was observed with different strains of S. aureus isolated from both human and animal. Non-descriptive statistics at 5% probability found 61% S. aureus, while 43.44% of them were HA-MRSA, 92.62% VRSA, and 42.62% were both MRSA and VRSA. Among assumed risk factors, use of antibiotics, venous catheterization, chronic disease, pre-hospital visits, and ICU admitted patients showed significant association (p<0.05) with pathogen. HA-MRSA was 37.50%, 80%, and 37.50% sensitive to chloramphenicol, gentamicin, and oxacillin, respectively. While <50% of VRSA were sensitive against oxacillin, enoxacin, and chloramphenicol. A significant difference (p<0.05) of percentage responses of MRSA and VRSA at resistant, intermediate, and sensitive cadre against all antibiotics except chloramphenicol was obvious in this study. The Current study concluded higher prevalence of MRSA & VRSA, significant association of risk factors, limiting antibiotic susceptibility profile, and genetic transfer at animal-human interface which suggests further studies cum preventive strategies to be planned.

Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review.

BACKGROUND: Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation. METHODS: A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Search terms included combinations of keywords including medical tourism and plastic surgery and other related nomenclature. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined. RESULTS: We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twenty-five of 26 listed patients (96%) were female (age range 33-62 years). Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death. CONCLUSIONS: We present the first study to systematically review the complications associated with medical tourism for facial rejuvenation. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to help inform patients who seek facial rejuvenation procedures abroad and to better understand the health system implications associated with cosmetic tourism for facial rejuvenation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Primary Osteosarcoma of the Breast: Pathophysiology and Imaging Review.

Extraskeletal osteosarcoma are rare malignant mesenchymal neoplasms of soft tissues representing around 1% of all soft tissue. The exact mechanism of tumorigenesis of primary breast osteosarcoma is still unclear. However, most of the cases develop without a recognized etiologic factor. Primary osteosarcoma of the breast is often initially misdiagnosed as breast fibroadenoma. Different imaging modalities and pathology play important role in differentiating breast osteosarcoma from other benign and malignant lesions of the breast resulting in dramatic change in the management.

Locally advanced prostate cancer imaging findings and implications for treatment from the surgical perspective.

The anatomy of the prostate is reviewed in the context of discussing the staging of prostate cancer and patterns of tumor spread. The utility of prostate magnetic resonance imaging along with new advancements in tumor staging are discussed specifically in locally advanced disease. What should be included in the radiology report carries a substantial weight to formulate the urologist's decision in regards to the selection of surgical candidates, preoperative planning and avoiding postoperative complications.

Tumor necrosis factor-α triggers opposing signals in head and neck squamous cell carcinoma and induces apoptosis via mitochondrial- and non-mitochondrial-dependent pathways.

Head and neck squamous cell carcinoma (HNSCC) remains one of the most common malignancies worldwide. Although the treatment outcomes of HNSCC have improved in recent years, the prognosis of patients with advanced-stage disease remains poor. Current treatment strategies for HNSCC include surgery as a primary therapy, while radio-, chemo-, and biotherapeutics can be applied as second-line therapy. Although tumor necrosis factor-α (TNF-α) is a potent tumor suppressor cytokine, the stimulation of opposing signals impairs its clinical utility as an anticancer agent. The aim of this study was to elucidate the mechanisms regulating TNF-α­induced opposing signals and their biological consequences in HNSCC cell lines. We determined the molecular mechanisms of TNF-α-induced opposing signals in HNSCC cells. Our in vitro analysis indicated that one of these signals triggers apoptosis, while the other induces both apoptosis and cell survival. The TNF-α-induced survival of HNSCC cells is mediated by the TNF receptor-associated factor 2 (TRAF2)/nuclear factor (NF)-κB-dependent pathway, while TNF-α-induced apoptosis is mediated by mitochondrial and non-mitochondrial-dependent mechanisms through FADD-caspase-8-caspase-3 and ASK-JNK-p53-Noxa pathways. The localization of Noxa protein to both the mitochondria and endoplasmic reticulum (ER) was found to cause mitochondrial dysregulation and ER stress, respectively. Using inhibitory experiments, we demonstrated that the FADD­caspase-8­caspase-3 pathway, together with mitochondrial dysregulation and ER stress-dependent pathways, are essential for the modulation of apoptosis, and the NF-κB pathway is essential for the modulation of anti-apoptotic effects/cell survival during the exposure of HNSCC cells to TNF-α. Our data provide insight into the mechanisms of TNF-α-induced opposing signals in HNSCC cells and may further help in the development of novel therapeutic approaches with which to minimize the systemic toxicity of TNF-α.

Heterotopic ossification: radiological and pathological review.

Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.

Surgical Approaches in the Treatment of Intracranial Complications of Paranasal Sinus Disease: A Review of the Literature.

BACKGROUND: Intracranial extension of frontal or ethmoid sinusitis carries a high morbidity and mortality if not treated aggressively. With the emergence of endoscopic sinus surgery (ESS), we questioned whether these approaches have supplanted traditional transcranial procedures for intracranial extension of sinus disease, and whether ESS approaches had a difference in patient outcomes. METHODS: Studies reporting surgical management and outcomes of frontal sinus disease with intracranial extension were queried using the United States National Library of Medicine at the National Institutes of Health PubMed database. We also queried common internet search engines. We included studies regarding sinogenic intracranial suppurative infections treated surgically with ESS and neurosurgical approaches. Studies with insufficient data regarding specific treatment methods and studies that included populations of medically treated infections were excluded. RESULTS: A total of 108 cases were identified in which patients with intracranial sinogenic disease were treated via ESS alone (morbidity: 43.5%, mortality: 0.9%), 47 cases via transcranial intervention alone (morbidity: 33.2%, mortality: 7.8%), and 43 cases via simultaneous neurosurgical and ESS approaches (morbidity: 16.3%, mortality: 6.4%). Complex sinus disease with posterior table compromise in the absence of intracranial extension treated via ESS alone was reported in 164 cases with a morbidity and mortality of 3.8% and 0%, respectively. CONCLUSIONS: Combined ESS and transcranial approaches achieve definitive control of sinogenic and intracranial disease, whereas either modality alone carries a potential risk for higher morbidity and mortality. The use of ESS alone may have use in the treatment of sinusitis with posterior table erosion prior to intracranial extension.

Single Versus Simultaneous Double Free Flaps for Head and Neck Reconstruction: Comparison of Flap Outcomes and Donor-Site Morbidity.

INTRODUCTION: Ablative procedures of the head and neck often result in substantial defects that require large-volume tissue transfer for restoration of form and function. Multiple simultaneous free flaps may be required for complex defects, but these procedures are often avoided because of the perception of an increase in associated surgical complications and morbidity. We present our experience with the use of simultaneous multiple free flaps as compared with single free flaps (SFFs) for head and neck reconstruction. METHODS: Thirty-seven patients with a history of head and neck malignancy underwent SFF reconstruction, and 21 patients underwent double free flap (DFF) reconstruction. Statistical analysis was conducted comparing demographics, comorbidities, etiology of disease, and surgical outcomes between the 2 patient groups. RESULTS: Operative time and length of hospital stay were both significantly longer in the DFF group versus the SFF group. Despite significantly higher rates of preoperative radiation, osteoradionecrosis, and operation for secondary malignancy in DFF group, no significant differences in flap survival, partial flap loss, recipient site complications, or donor site complications were found. Overall flap-related reoperation rates were low, as were total flap losses. There were 10 complications (24%) that required reoperation in the DFF group, and 1 total flap loss (2.4%), on per-flap basis. There were 10 complications (27%) that required reoperation in the SFF group and 3 total flap losses (8.1%). Per-flap incidence of donor site morbidity in the DFF group was significantly lower than that in the SFF group (23.8% vs 56.8%, respectively, P = 0.011). CONCLUSIONS: The use of multiple free flaps for reconstruction of major head and neck tissue defects is sometimes necessary to achieve adequate reconstructive results. These procedures have no significant associated increase in overall flap-related complications. Our findings suggest that donor site morbidity can be minimized in double-flap reconstructions by thoughtful flap selection.

The effects of granulocyte colony-stimulating factor on MR images of bone marrow.

Granulocyte colony-stimulating factor (G-CSF) analogs such as filgrastim/pegfilgrastim are increasingly used to enhance neutrophilic recovery after chemotherapy. It is widely known that, physiologically, pegfilgrastim stimulates marrow mitotic activity and induces marrow reconversion from fatty to cellular. However, there is limited literature discussing the effects of pegfilgrastim on musculoskeletal magnetic resonance imaging, with the consensus that marrow reconversion secondary to pegfilgrastim therapy is easily confounded with a malignant process, especially in patients with a history of cancer. We attempt to discuss the expected changes and MRI findings after pegfilgrastim therapy through a summary of current literature. Additionally, we provide images from our own practice to support the previously established findings. G-CSF-stimulated reconversion can appear as patchy expansions of baseline hematopoietic marrow, but can also appear to be diffusely homogeneous, adding to its ambiguity. We conclude that using a baseline MRI, clinical information, and assessing sequential MRI changes in conjunction with pegfilgrastim therapy may aid the differentiation between benign and pathological change. We expand our discussion to include the effects of novel technologies, such as whole-body MRI, chemical shift imaging, and contrast agents in helping the distinction.

Locally advanced asymptomatic papillary thyroid cancer presenting with retropharyngeal lymph node metastasis symptoms.

Papillary thyroid cancer (PTC) rarely metastasizes to the retropharyngeal lymph nodes. Managing patients with locally advanced primary PTC and metastasis located in distant anatomical areas is challenging. Herein, we report a 56-year-old patient with locally advanced asymptomatic PTC, who presented with obstructive airway symptoms due to the metastatic retropharyngeal lymph node. The patient underwent simultaneous total thyroidectomy, central lymph node dissection, en bloc resection of strap muscle and left laryngeal nerve via cervical approach and transoral resection of the metastatic retropharyngeal lymph node. Metastatic PTC should be included in the differential diagnosis of a retropharyngeal masses. Simultaneous total thyroidectomy of the primary thyroid cancer via a cervical approach and transoral resection of an isolated retropharyngeal metastasis is safe and feasible.