Resonant dielectric multilayer with controlled absorption for enhanced total internal reflection fluorescence microscopy.

Total internal reflection fluorescence microscopy (TIRF-M) is widely used in biological imaging. Evanescent waves, generated at the glass-sample interface, theoretically strongly improve the axial resolution down to a hundred of nanometers. However, objective based TIRF-M suffers from different limitations such as interference fringes and uneven illumination, mixing both propagating and evanescent waves, which degrade the image quality. In principle, uneven illumination could be avoided by increasing the excitation angle, but this results in a drastic loss of excitation power. We designed dedicated 1D photonic crystals in order to circumvent this power loss by directly acting on the intensity of the evanescent field at controlled incident angles. In this framework, we used dedicated resonant multi-dielectric stacks, supporting Bloch surface waves and resulting in large field enhancement when illuminated under the conditions of total internal reflection. Here, we present a numerical optimization of such resonant stacks by adapting the resulting resonance to the angular illumination conditions in TIRF-M and to the fluorescence collection constraints. We thus propose a dedicated resonant structure with a control of the absorption during thin film deposition. A first experimental demonstration illustrates the concept with a 3-fold fluorescence enhancement in agreement with the numerical predictions.

Accuracy of CBCT images in the volumetric assessment of residual root canal filling material: Effect of voxel size.

AIMS: Our aim was to compare three different voxel sizes of CBCT images for the determination of residual filling material volume in root canals when compared with micro CT. MATERIAL AND METHODS: Forty-two root canals of 14 extracted human maxillary molar teeth were retreated by using ProFile® instruments. Images were obtained after retreatment by using ProMax 3D Max CBCT at 3 different voxel sizes (1) High resolution (0.1 mm); (2) High definition (0.15 mm); and (3) Normal resolution (0.2 mm). Two observers measured volumes of residual filling materials in exported CBCT images by means of 3D Doctor Software. Micro CT measurements were served as gold standard. Mann-Whitney U test and Wilcoxon Test were used for the comparison of CBCT and micro CT measurements. Statistical significance was set at P < 0.05. RESULTS: No statistically differences were found between the two observers for all measurements (P > 0.05). There were no significant differences among different CBCT voxel sizes used (0.1 mm, 0.15 mm, and 0.2 mm) (P > 0.05). The Spearman correlation coefficients between CBCT at different voxel sizes significantly highly correlated with micro CT measurements for each observer (P < 0.05). Furthermore, no significant differences were found between the measurements obtained by the two observers in consideration to root canal location (P > 0.05). CONCLUSION: CBCT images may provide useful information in the volumetric assessment of the amount of residual filling material in root canals for retreatment procedures.

Ability to detect endodontic complications using three different cone beam computed tomography units with and without artefact reduction modes: an ex vivo study.

AIM: To assess observer performance in detecting endodontic complications using three different cone beam computed tomography (CBCT) units with and without the application of artefact reduction modes. METHODOLOGY: The study involved 40 freshly extracted human mandibular teeth (n = 10 per group) and divided randomly into four endodontic complication groups. Group 1) Instrument fracture; Group 2) Strip perforation; Group 3) Canal underfilling; and Group 4) Canal overfilling. Images of each tooth were obtained using three different CBCT units offering artefact reduction algorithms: the ProMax 3D Max, the Pax Flex 3D and the Dentri S. Four observers evaluated the images for the presence/absence of the four simulated endodontic complications. Weighted kappa coefficients and intra-class correlation coefficients (ICCs) were calculated to reveal the intra- and inter-observer agreement for each imaging mode, respectively. Receiver operating characteristic (ROC) analysis was used to evaluate the observers' performance. DeLong tests were used to compare the results for each image mode and observer using a significance level of α = 0.05. RESULTS: In each of the four simulated endodontic complication groups, no significant differences were observed with and without application of artefact reduction for any of the three CBCT units tested. Only two significant differences were detected, and both were between the ProMax 3D Max at low mode AR and ProMax 3D Max without AR: observer 2 in group 1 (P = 0.0001) and observer 4 in group 4 (P = 0.0256). CONCLUSION: For each of the three CBCT units tested, application of artefact reduction for detecting endodontic complications is not recommended as a routine tool.

Pregnancy After Liver Transplantation: Risks and Outcomes.

OBJECTIVE: The aim of this study was to evaluate the outcomes of liver transplant recipients who became pregnant after transplantation. METHODS: The clinical data of all patients who underwent liver transplantation between January 2007 and December 2016 in our liver transplantation institute were reviewed. The following data were analyzed: indications for transplantation, recipient age at the beginning of pregnancy, the interval between transplantation and pregnancy, maternal and fetal complications, type of delivery, the health condition of neonates, and modifications in immunosuppressive therapy. RESULTS: During the study period, 1890 patients underwent liver transplantation. There were 185 women (9.8%) in childbearing age (15-45 years old), and 18 (9.7%) of them became pregnant during the study period. There were a total of 26 pregnancies. The mean age of patients at the time of operation was 25.3 ± 5.2 years, and the mean interval between operation and conception was 32.7 ± 15.3 months. Seventeen pregnancies (65.4%) ended in a live birth in the study. Six pregnancies (23%) resulted with no maternal or fetal complications. The most frequent maternal complication during pregnancy was pregnancy-induced hypertension (n = 3; 16.6%). CONCLUSIONS: Despite advances in immunosuppressive therapy and increasing experience in the management of these patients, pregnancies in liver transplant recipients are still more risky than in the general population for both the mother and the fetus. Thus, the issues related to fertility should be comprehensively discussed with the patients and their partners, preferably before transplantation, and pregnancies in liver transplant recipients should be followed up more carefully by a multidisciplinary team.

Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen?

BACKGROUND: The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation. METHODS: In Inonu University's Liver Transplant Institute, 69 patients who made an emergency notice to the National Coordination Center for liver transplantation owing to FLF from January 2012 to December 2015 were included in the study. Patients were divided into 2 groups. Group 1 consisted of 52 patients who underwent liver transplantation and recovered normal brain function, and group 2 had 17 patients who underwent liver transplantation and did not recover normal brain function and had cerebral death. All patients were evaluated before surgery for clinical encephalopathy stage, light reflex, and convulsions. Groups were compared and assessed according to age (>40, 10-40 and <10 years), body mass index, etiologic factor, preoperative laboratory values, transplantation type, mortality, and encephalopathy level. Multivariate analysis was done for specific parameters. RESULTS: Prothrombin time (PT), international normalized ratio (INR), and total bilirubin values were significantly different between the groups. There was no significant difference between the groups regarding ammonia and lactate levels. There was a statistically significant difference between the groups regarding sodium and potassium levels from serum electrolytes. However, the averages of both groups were within normal limits. pH and total bilirubin levels were meaningful for multivariate analysis. CONCLUSIONS: HE reversibility, mortality, and morbidity are important in patients with HE who undergo liver transplantation. Therefore, West Haven clinical staging and serum INR, PT, and total bilirubin level may be helpful in predicting the reversibility of FLF patients with HE before liver transplantation. It was determined that West Haven encephalopathy grading is important in determining the reversibility of HE after transplantation in FLF; especially the probability of reversibility of stage 4 HE decreases significantly. High PT and INR levels, hyperbilirubinemia, and serum sodium and potassium concentrations were risk factors for the reversibility of HE in this study.

Histopathological Examination of Explanted Liver After Transplantation in Patients With Cryptogenic Cirrhosis.

OBJECTIVES: Cryptogenic cirrhosis is a common indication for liver transplantation. Diagnosis is made after exclusion of other causes of cirrhosis. In this study, the aim was to evaluate patients with cryptogenic cirrhosis after histopathological examination of explanted liver. MATERIALS AND METHODS: A retrospective histopathological chart review of 117 patients with cryptogenic cirrhosis who had liver transplantation between November 2009 and June 2014 was performed. Age, sex, operative features, survival rates, and preoperative and postoperative diagnosis were evaluated. RESULTS: During the study period, 123 liver transplantations were performed for these 117 patients. Deceased donor liver transplantations were performed in 23 (18.7%) of the cases. Retransplantations were performed in 5 patients. Median age was 48 years, and female-to-male ratio was 41:76. Hepatosteatosis were observed in 29 patients. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis were observed in 20 (12%) and 9 (7.7%) of these patients, respectively. Autoimmune hepatitis was observed in 2 patients. The definitive cause of cirrhosis was unclear in 68 (58%) of the patients. Incidental malignant and premalignant lesions were observed in 15 patients. CONCLUSIONS: Histopathological examination of the explanted liver after liver transplantation in those patients with cryptogenic cirrhosis may significantly help to diagnose the cause of cirrhosis, such as nonalcoholic steatohepatitis or autoimmune hepatitis, with using the scoring system developed by the International Autoimmune Hepatitis Workgroup. In addition, incidental malignant or premalignant lesions may be observed.

Chronic graft-versus-host disease after liver transplantation: a case report.

Graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but significant complication, occurring in 1%-2% of cases with a mortality rate of 85%- 90%. It occurs when donor passenger lymphocytes mount an alloreactive response against the host's histocompatibility antigens. It presents as fever, rash, and diarrhea with or without pancytopenia. Between March 2002 and September 2011, among 656 OLT patients 1 (0.15%) had acute GVHD. A biopsy at the 7th posttransplantation month revealed chronic GVHD. Consequently, in the cases that had fever, rash, and/or desquamation of the any part of body after liver transplantation, GVHD must be considered and skin biopsies must be planned for the diagnosis.

The effects of severe growth hormone deficiency on the skin of patients with Sheehan's syndrome.

BACKGROUND: Growth hormone (GH) may play an important role in the content and appearance of the skin. Dry, thin and pale skin has been described in hypopituitarism. Sheehan's syndrome is characterized by anterior pituitary dysfunction due to postpartum pituitary necrosis and GH is one of the hormones lost first. OBJECTIVE: The aim of this study was to examine the hydration of the skin of patients with Sheehan's syndrome using measurements of capacitance, sebum content, transepidermal water loss, pH and temperature. The data were compared with those of control subjects. METHODS: A total of 21 patients with Sheehan's syndrome and 20 women as control subjects were included in this blinded prospective study. Hormone deficiencies other than GH had been adequately replaced. The diagnosis of GH deficiency (GHD) was established by the insulin tolerance test (ITT). Skin properties were measured by non-invasive and well-established methods. RESULTS: The skin capacitance had decreased on the forehead and forearm and sebum content had decreased on the forehead of patients with Sheehan's syndrome when compared with control subjects. The pH, temperature and average transepidermal water loss (TEWL) of the skin of the patients were not statistically different from the controls. CONCLUSION: GHD results in a decrease in skin capacitance and sebum content indicating that GH and/or insulin-like growth factor-I (IGF-I) have an important role in skin function.

MR spectroscopy in a cervical abscess.

MR spectroscopy (MRS) has been used to analyse noninvasively tissues at a molecular level. Hydrogen and phosphorus MRS have been used for characterisation of intracranial solid and cystic masses, gynaecological tumours and lymph nodes. We report a cystic, tick-walled mass in the soft tissues of the neck. Single-voxel proton MRS revealed a prominent acetate peak at 1.92 ppm and a diagnosis of abscess was suggested. At operation a pyogenic neck abscess was confirmed, with culture of the pus.

A comparison of four intravenous sedation techniques and Bispectral Index monitoring in sinonasal surgery.

This study was performed to investigate the quality of different intravenous sedation techniques, and the correlation between the Bispectral Index (BIS) values and the Observer's Assessment of Alertness/Sedation (OAA/S) scores. Eighty patients undergoing sinonasal surgery were randomly assigned to one of four groups. Group MF received midazolam and fentanyl, group PF received propofol and fentanyl, group MR received midazolam and remifentanil, and group PR received propofol and remifentanil. Heart rate and mean arterial pressure values were not different among the groups. SpO2 decreased only after intravenous medication in groups MF and MR (P < 0.017). Emesis was less common with propofol. A positive relationship existed between the BIS values and OAA/S scores during the operation in all groups and the strongest correlation was observed in group PR (r = 0.565 and P < 0.001). In conclusion, these four intravenous sedation techniques did not change mean arterial pressure, heart rate or SpO2 clinically and produced a similar level of light sedation. The BIS was useful for monitoring of sedation during sinonasal surgery under local anaesthesia with intravenous sedation.

Vice president Al Gore's health care agenda and the utilization of medical services: An empirical analysis.

OBJECTIVE: To estimate the impact of Vice President Al Gore's healthcare agenda on the utilization of physician and hospital services among 4 uninsured target populations: parents of publicly insured children; near elderly adults, ages 55-64; employed adults with disabilities; and adults employed in small firms or self-employed. METHODS: From the 1993 National Health Interview Survey, we select 4 representative samples of uninsured adults, ages 18-64, corresponding to the target groups described in Gore's healthcare agenda. For each adult in these samples, we estimate the change in medical service utilization caused by becoming insured using results from Craig and Ko.[1] The weighted average of these estimates represents the expected change in medical service utilization attributable to insurance. RESULTS: The increase in the utilization caused by insurance depends on the target group and the service in question. The increase in utilization of physician visits is 16% among parents of publicly insured children, 37% among the near elderly, 8% among the employed, disabled adults, and 21% among the self-employed. This effect is small compared with the increase in surgical procedures (31%, 110%, 316%, and 101%, respectively). However, given the size of the US healthcare system, this amounts to about a 0.5% increase in the production of medical services. Even if a universal coverage plan were instated in place of Gore's incremental coverage plan, production would increase by about 2%. CONCLUSIONS: Points 2 through 5 of Vice President Al Gore's healthcare agenda have an impact on the utilization of medical care by the 4 target populations. However, this impact varies by service and population, and its system-wide impact on the production of care is minor.

Postoperative hypertension effect of carotid sinus denervation.

Postoperative arterial blood pressures were monitored in 43 patients who had undergone bilateral neck dissection during a 6-week period at Ankara Numune Hospital's IInd Otorhinolaryngology Department. During the first operations, all cases received carotid sinus denervation, whereas no denervation was done for the opposite side dissections held 6 weeks later. Study and control groups were composed of the same patients to achieve an objective outcome for the risk of postoperative hypertension. Hypertension was observed in 10 (23%) of 43 patients after the first operations and 12 (28%) of 43 patients after the opposite side dissections, for which no carotid denervation was done. The difference between the rates was insignificant statistically.

[Isolated unilateral otitis with facial nerve paralysis as initial symptom of Wegener granulomatosis. An unusual clinical course]. / Isolierte einseitige Otitis mit Fazialisparese als Erstsymptom bei Wegener-Granulomatose. Ein ungewöhnlicher klinischer Verlauf.

BACKGROUND: Wegener's granulomatosis is an immunepathogenic disease of unknown origin. The histopathological picture shows granulomatous inflammation with epitheloid cells, granulomas, and general vasculitis. The diagnosis of Wegener's granulomatosis is made on the basis of the clinical picture, serum cANCA, and histologic examination of biopsies. PATIENT: We present the case of a 57-year-old white male patient who was admitted to our ENT Hospital with a six weeks' history of otalgia and incomplete ipsilateral facial palsy since the day before admission. The patient had clinical features of acute otitis media without signs of mastoiditis. Despite a ten days' course of intravenous antibiotic treatment, the intensity of facial palsy progressed and the general condition of the patient worsened. A mastoidectomy and decompression of the facial nerve were performed, demonstrating sclerosis of the mastoid cells. Three weeks after release from the hospital, the patient was admitted again with recurrent fever, cephalea, loss of weight, and arthritic pain. There were no signs of recurrent otitis media or mastoiditis, and sigmoid sinus thrombosis was ruled out. Even under aggressive, intravenous antibiotic treatment the general physical condition continued to worsen; septic temperatures and signs of beginning renal failure occurred. The patient was transferred to the ICU with the diagnosis of sepsis of unknown origin. There bloodtests were positive for cANCA, which is highly specific for Wegener's granulomatosis. Under therapy with cyclophosphamide and i.v. corticosteroid, the patient recovered with 14 days. CONCLUSION: The lack of symptoms in the upper respiratory tract in our patient was unusual, indicating that in patients with recurrent otitis media, facial palsy, mastoiditis, or external otitis Wegener's granulomatosis should be ruled out as differential diagnosis.

Tracheal reconstruction with a vascularized cartilage flap in rabbits.

The relative merits of a vascularized autogenous cartilage flap (VACF) are discussed in reconstruction of tracheal defects in rabbits. Sixteen albino Vienna rabbits were divided into two groups of eight animals each. In all rabbits, a rectangular tracheal defect was created. In the experimental group, a VACF was designed on the left auricle. This island flap was then transposed through a subcutaneous tunnel to the trachea and used to repair the defect. In the control group, tracheal defects were reconstructed with free cartilage grafts. In histologic evaluations, it was found that the reconstructed site showed a greater degree of vascularization when a VACF was used, and the gap between the trachea and flap was filled with new cartilage tissue, to a much greater extent than with the free cartilage grafts. It is concluded that use of the VACF is a relatively safe and effective procedure for repairing tracheal defects.

The use of preoperative lidocaine to prevent stridor and laryngospasm after tonsillectomy and adenoidectomy.

The most important complications from tonsillectomy and adenoidectomy are bleeding, stridor, and laryngospasm. This controlled, double-blind study was designed to investigate the effects of topical and intravenous lidocaine on stridor and laryngospasm. A total of 134 patients scheduled for elective tonsillectomy and/or adenoidectomy were randomly separated into four groups. In the topical lidocaine group 4 mg/kg of 2% lidocaine was applied to subglottic, glottic, and supraglottic areas before endotracheal intubation. Normal saline solution was used topically for the first control group. In the intravenous lidocaine group, patients were given 1 mg/kg of 2% lidocaine before extubation, and the same amount of 0.9% NaCl was given to the second control group. Postoperative stridor, laryngospasm, cyanosis, bleeding, sedation degree, and respiratory depression were observed, and plasma lidocaine levels were measured. Both topical and intravenous lidocaine groups revealed less stridor and laryngospasm than the control groups, and no difference was found between the topical and intravenous lidocaine groups except the higher sedation scores in the early postoperative period for the intravenous lidocaine group.

Role of suprahyoid neck dissection in the treatment of squamous cell carcinoma of the lower lip.

Treatment of squamous cell carcinoma of the lip is primarily surgical. Unlike other oral lesions, lower lip cancers do not metastasize to lower cervical lymph nodes without invading submental and submandibular lymph nodes. This study presents 30 patients with N0 lower lip carcinoma who were treated by en bloc resection of the tumor with suprahyoid neck dissection. Occult metastasis was found in 4 patients (13%). Four patients, 3 of whom had no occult metastases, died of local or regional uncontrollable disease. Suprahyoid or modified radical neck dissection appears to be beneficial, even in small tumors of the lower lip, in detecting occult metastases.

Postoperative hypertension after radical neck dissection.

Postoperative hypertension after radical neck dissection was detected in 20.2% of 109 neck dissections in our department between 1989 and 1993. It was probably caused by carotid sinus denervation and appeared after the vasodilation generated by anesthesia had subsided. If postoperative hypertension was encountered after the first operation, the risk of such hypertension after surgery on the contralateral side significantly increased.