The Use of Antioxidants in the Prevention and Treatment of Noise-Induced Hearing Loss.

As of today, there are no therapeutic measures for the prevention or treatment of noise-induced hearing loss (NIHL). The current preventative measures, including avoidance and personal protective hearing equipment, do not appear to be sufficient because there is an increasing number of people with NIHL, especially in the adolescent population. Therefore, we must find a therapy that prevents the impact of noise on hearing. Antioxidants are a promising option in preventing the damaging effects of noise by targeting free radicals but further studies are needed to confirm their efficacy in humans.

Granulomatosis with Polyangiitis as a Cause of Sudden-Onset Bilateral Sensorineural Hearing Loss: Case Report and Recommendations for Initial Assessment.

Granulomatosis with polyangiitis (GPA) is a severe systemic vasculitis that commonly affects the paranasal sinuses, upper and lower respiratory tracts, and kidneys. GPA has also been associated with sensorineural hearing loss (SNHL), through inflammation of the cochlear apparatus. Early recognition, diagnostic laboratory evaluation, and appropriate treatment are essential to improve outcomes and achieve remission for patients with GPA. Here, we present a case of bilateral sudden sensorineural hearing loss (SSNHL) and distal symmetric polyneuropathy as the first presenting signs of GPA. A specific diagnostic work-up to rule out autoimmune inner-ear disease in patients with bilateral SSNHL is not clearly stated in the clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery. The aim of this paper is to delineate an appropriate diagnostic work-up for patients with bilateral SSNHL when there is concern for autoimmune disease.

Aortic adventitial thickness as a marker of aortic atherosclerosis, vascular stiffness, and vessel remodeling in systemic lupus erythematosus.

INTRODUCTION: There is limited human imaging data on the association of adventitial thickness (AT) with arterial disease. Systemic lupus erythematosus (SLE) is a prototypical disease model for studying markers of premature arterial disease. OBJECTIVE: To determine if increased aortic AT is associated with aortic atherosclerosis [increased intima media thickness (IMT) or plaques], stiffness [increased pressure-strain elastic modulus (PSEM)], and vessel remodeling. METHODS: In total, 70 SLE patients and 26 age- and sex-matched controls underwent transesophageal echocardiography (TEE). Two-dimensional guided M-mode images were obtained to assess AT, IMT, and plaques, and PSEM at the proximal, mid, and distal thoracic aorta. Images were interpreted by 3 observers unaware of the subjects' clinical data and each other's measurements. Abnormal aortic AT, IMT, and PSEM were defined as > 2SD above the overall mean values in controls and corresponded to > 1 mm, > 1 mm, and > 10.6 Pascal units, respectively. Plaques were defined as focal-protruding IMT > 50% of the surrounding vessel wall. RESULTS: Abnormal aortic AT, atherosclerosis, and abnormal stiffness were more frequent in SLE patients than in controls (all p ≤ 0.02). In SLE patients, abnormal AT combined with atherosclerosis was associated with larger aortic end-diastolic diameters than in controls (p ≤ 0.05). In SLE patients, aortic AT was greater in patients with atherosclerosis and in those with abnormal stiffness than in patients without these abnormalities (all p ≤ 0.02). In patients with abnormal AT, the degree of aortic stiffness was similar to those with atherosclerosis (p = 0.22). CONCLUSION: In patients with SLE, increased aortic AT is associated with aortic atherosclerosis, abnormal stiffness, and eccentric vessel remodeling. Key Points • In patients with SLE, abnormal aortic adventitial thickness is associated with aortic atherosclerosis, abnormal stiffness, and eccentric vessel remodeling. • In patients with SLE, aortic adventitial thickening may contribute to the extent of aortic atherosclerosis, abnormal aortic stiffness, and vessel remodeling. • To our knowledge, this is the first human imaging study to characterize the aortic adventitial layer and delineate its association with aortic disease.

Can Diagnostic and Therapeutic Arthrocentesis Be Successfully Performed in the Flexed Knee?

BACKGROUND/OBJECTIVE: The objective of this study was to determine whether the extended or flexed knee positioning was superior for arthrocentesis and whether the flexed knee positioning could be improved by mechanical compression. METHODS: Fifty-five clinically effusive knees underwent arthrocentesis in a quality improvement intervention: 20 consecutive knees in the extended knee position using the superolateral approach, followed by 35 consecutive knees in the flexed knee position with and without an external compression brace placed on the suprapatellar bursa. Arthrocentesis success and fluid yield in milliliters were measured. RESULTS: Fluid yield for the extended knee was greater (191% greater) than the flexed knee (extended knee, 16.9 ± 15.7 mL; flexed knee, 5.8 ± 6.3 mL; P < 0.007). Successful diagnostic arthrocentesis (≥2 mL) was 95% (19/20) in the extended knee and 77% (27/35) in the flexed knee (P = 0.08). After mechanical compression was applied to the suprapatellar bursa and patellofemoral joint of the flexed knee, fluid yields were essentially identical (extended knee, 16.9 ± 15.7 mL; flexed knee, 16.7 ± 11.3 mL; P = 0.73), as were successful diagnostic arthrocentesis (≥2 mL) (extended knee 95% vs. flexed knee 100%, P = 0.12). CONCLUSIONS: The extended knee superolateral approach is superior to the flexed knee for conventional arthrocentesis; however, the extended knee positioning and flexed knee positioning have identical arthrocentesis success when mechanical compression is applied to the superior knee. This new flexed knee technique for arthrocentesis is a useful alternative for patients who are in wheelchairs, have flexion contractures, cannot be supine, or cannot otherwise extend their knee.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa.

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Improvement in diagnostic and therapeutic arthrocentesis via constant compression.

We hypothesized that constant compression of the knee would mobilize residual synovial fluid and promote successful arthrocentesis. Two hundred and ten knees with grade II-III osteoarthritis were included in this paired design study: (1) conventional arthrocentesis was performed with manual compression and success and volume (milliliters) determined; and (2) the intra-articular needle was left in place, and a circumferential elastomeric brace was tightened on the knee to provide constant compression. Arthrocentesis was attempted again and additional fluid volume was determined. Diagnostic procedural cost-effectiveness was determined using 2017 US Medicare costs. No serious adverse events were noted in 210 subjects. In the 158 noneffusive (dry) knees, sufficient synovial fluid for diagnostic purposes (≥ 2 ml) was obtained in 5.0% (8/158) without compression and 22.8% (36/158) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis fluid obtained without compression was 0.28 ± 0.79 versus 1.10 ± 1.81 ml with compression (293% increase, p = 0.0001). In the 52 effusive knees, diagnostic synovial fluid (≥ 2 ml) was obtained in 75% (39/52) without compression and 100% (52/52) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis without compression was 14.7 ± 13.8 versus 25.3 ± 15.5 ml with compression (72.1% increase, p = 0.0002). Diagnostic procedural cost-effectiveness was $655/sample without compression and $387/sample with compression. The new technique of constant compression via circumferential mechanical compression mobilizes residual synovial fluid beyond manual compression improving the success, cost-effectiveness, and yield of diagnostic and therapeutic arthrocentesis in both the effusive and noneffusive knee.

Ventricular Septal Defect from Aortic Regurgitation Jet Lesion in Aortic Valve Infective Endocarditis.

Aortic valve infective endocarditis (IE) can be complicated with severe aortic regurgitation (AR) jet-related lesions such as vegetations, pseudoaneurysms, aneurysms or perforations on the anterior mitral leaflet. Herein is reported the case of a 69-year-old male with culture-negative aortic valve endocarditis complicated with aortic valve perforations resulting in severe and eccentric AR and an AR jet-related ventricular septal defect (VSD). Neither transthoracic echocardiography (TTE) nor two-dimensional transesophageal echocardiography (2D-TEE) were unable to clearly discriminate an aorto-right ventricular fistula from a VSD. By contrast, three-dimensional TEE (3D-TEE) demonstrated multiple aortic valve vegetations, aortic valve perforations, severe AR, and an AR jet-related VSD. The 3D-TEE findings were confirmed at surgery, the aortic valve was replaced with a bioprosthetic valve, and the VSD was repaired with a pericardial patch. To the authors' knowledge, this is the first case of a VSD resulting from an AR jet lesion to be detected and characterized using 3D-TEE. The accurate preoperative diagnosis and characterization of the VSD with 3D-TEE contributed to successful surgery and the patient's short- and long-term survival. Video 1A: This four-chamber transthoracic echocardiography (TTE) view with color Doppler shows a color-Doppler jet traversing the basal interventricular septum (IVS) into the right ventricle, predominantly during systole. However, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. A mild to moderate degree of tricuspid regurgitation is also noted. Video 1B: Close-up view of the basal IVS demonstrates a color Doppler jet traversing the IVS, predominantly during systole and apparently originating in the left ventricular outflow tract side, as illustrated by a color Doppler acceleration zone. However, and as in Fig. 1A, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. Video 1C: Color Doppler two-dimensional TEE view longitudinal to the aortic valve and aortic root, showing a predominantly systolic color Doppler jet originating in the left ventricular outflow tract and/or aorta and crossing the anterior and basal IVS defect into the right ventricle. Videos 1D: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1E: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1F: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D.