Animal displacement from marine energy development: Mechanisms and consequences.

For marine wave and tidal energy to successfully contribute to global renewable energy goals and climate change mitigation, marine energy projects need to expand beyond small deployments to large-scale arrays. However, with large-scale projects come potential environmental effects not observed at the scales of single devices and small arrays. One of these effects is the risk of displacing marine animals from their preferred habitats or their migration routes, which may increase with the size of arrays and location. Many marine animals may be susceptible to some level of displacement once large marine energy arrays are increasingly integrated into the seascape, including large migratory animals, non-migratory pelagic animals with large home ranges, and benthic and demersal mobile organisms with more limited ranges, among many others. Yet, research around the mechanisms and effects of displacement have been hindered by the lack of clarity within the international marine energy community regarding the definition of displacement, how it occurs, its consequences, species of concern, and methods to investigate the outcomes. This review paper leveraged lessons learned from other industries, such as offshore development, to establish a definition of displacement in the marine energy context, explore which functional groups of marine animals may be affected and in what way, and identify pathways for investigating displacement through modeling and monitoring. In the marine energy context, we defined displacement as the outcome of one of three mechanisms (i.e., attraction, avoidance, and exclusion) triggered by an animal's response to one or more stressors acting as a disturbance, with various consequences at the individual through population levels. The knowledge gaps highlighted in this study will help the regulatory and scientific communities prepare for mitigating, observing, measuring, and characterizing displacement of various animals around marine energy arrays in order to prevent irreversible consequences.

Novice Occupational Therapy Practitioners' Use of Occupation in Practice: A Scoping Review.

An occupation-centered perspective is a foundational component defining occupational therapy practice. A scoping review was conducted of research studies from 2002 - 2020 describing novice occupational therapy practitioners and occupation. Ten articles met the inclusion criteria. Novices acknowledged that using occupation was a source of professional tension, describing a mismatch between their education and workplace expectations. The cognitive load of occupation-centered practice influenced novices' avoidance of occupation. Few articles address novices' experiences using occupation in their practice. Existing research primarily addresses barriers limiting novices' use of occupation such as lack of supervision and confidence.

A retrospective analysis of honey bee (Apis mellifera) pesticide toxicity data.

Current USEPA ecological risk assessments for pesticide registration include a determination of potential risks to bees. Toxicity data are submitted to support these assessments and the USEPA maintains a large database containing acute and chronic toxicity data on adult and larval honey bees (Apis mellifera), which USEPA considers a surrogate for Apis and non-Apis bees. We compared these toxicity data to explore possible trends. This analysis indicated a significant correlation between acute contact and oral median lethal dose (LD50) values for adult honey bees (ρ = 0.74, p <0.0001). Using default EPA modeling assumptions, where exposure for an individual bee is roughly 12x lower through contact than through ingestion, the analysis indicates that the oral LD50 is similarly if not more protective of the contact LD50 for the majority of pesticides and modes of action evaluated. The analysis also provided evidence that compounds with a lower acute toxicity for adults through contact and oral exposure pathways may still be acutely toxic for larvae. The acute toxicity of herbicides and fungicides was higher for larvae relative to oral and contact toxicity for adult honey bees for the same compounds and the no observed adverse effect level (NOAEL) from chronic toxicity studies were lower for larvae relative to adults, indicating increased sensitivity of larvae. When comparing 8-day LD50 values between single dose larval acute studies to those derived from repeat dose 22-day larval chronic toxicity studies, the LD50 values derived from chronic studies were significantly lower than those from acute toxicity tests (Z = -37, p = 0.03).

Update on Major Neurocognitive Disorders.

Dementia is a syndrome characterized by a gradually progressive course that spans a continuum from preclinical symptoms to major impairment in two or more cognitive domains with functional decline. In this review, the author examines some of the more common dementia syndromes from among dozens of different diseases. Findings show that as the U.S. population continues to age, the number of Americans with dementia is expected to rise drastically over the next several decades. This upsurge will contribute to increased health care costs and will have a significant public health impact. Neurodegenerative disorders such as Alzheimer's disease, frontotemporal degeneration, and alpha-synucleinopathies (e.g., Lewy body disease and Parkinson's disease) are some of the more prevalent causes for dementia. In recent years, advancements in neuroimaging, understanding of genetic contributions and pathological changes, and the development of novel biomarkers have fueled clinical understanding of these disorders. However, substantial disease-modifying therapies are still lagging. The advent of future interventions hinges on the ability to discern the distinct clinico-pathologic profiles of the various dementia syndromes and to identify reliable biomarkers for utilization in clinical trials.

A Systematic Review of Barriers Faced by Older Adults in Seeking and Accessing Mental Health Care.

Older adults in the United States have lower rates of mental health care utilization than young adults. To understand these lower rates of mental health care, we performed a systematic review, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of barriers that prevent older adults from seeking and accessing treatment. We searched PubMed, PsycINFO, and Clinical Key to identify studies of barriers to mental health treatment in the older adult population (in individuals 50 y of age and older). Thirty-two articles met inclusion criteria (English language and focused on barriers to care in older adults) and exclusion criteria (focus on non-United States populations, focus on younger adults, or no focus on barriers to care). We identified 5 categories of barriers to mental health care in older adults: (1) attitudes and knowledge among older adults; (2) comorbid medical conditions; (3) provider-related factors; (4) other extrinsic barriers (eg, cost, transportation, reliance on caregivers); and (5) unique factors that affect older adults in minority populations. Large studies have primarily identified intrinsic barriers, including negative attitudes toward mental health care and lack of perceived need for treatment, as preventing older adults from seeking mental health care. Minority populations have also been found to face cultural barriers and increased levels of stigma compared with non-Hispanic whites, although several of the identified articles concerning barriers among minority older adults involved qualitative studies with small samples. Larger quantitative studies may help clarify the relative importance of barriers affecting this population. Interventions that have been shown to increase access to mental health services for older adults include community-based care and integrated primary and psychiatric care, but these strategies can be difficult to implement in low-resource settings. More research is needed to determine which interventions and policies are most effective in targeting particular barriers.

Lymphoma: Diagnosis and Treatment.

Lymphoma is a group of malignant neoplasms of lymphocytes with more than 90 subtypes. It is traditionally classified broadly as non-Hodgkin or Hodgkin lymphoma. Approximately 82,000 new U.S. patients are diagnosed with lymphoma annually. Any tobacco use and obesity are major modifiable risk factors, with genetic, infectious, and inflammatory etiologies also contributing. Lymphoma typically presents as painless adenopathy, with systemic symptoms of fever, unexplained weight loss, and night sweats occurring in more advanced stages of the disease. An open lymph node biopsy is preferred for diagnosis. The Lugano classification system incorporates symptoms and the extent of the disease as shown on positron emission tomography/computed tomography to stage lymphoma, which is then used to determine treatment. Chemotherapy treatment plans differ between the main subtypes of lymphoma. Non-Hodgkin lymphoma is treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) with or without rituximab (R-CHOP), bendamustine, and lenalidomide. Hodgkin lymphoma is treated with combined chemotherapy with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), Stanford V (a chemotherapy regimen consisting of mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, and prednisone), or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) with radiotherapy. Subsequent chemotherapy toxicities include neuropathy, cardiotoxicity, and secondary cancers such as lung and breast, and should be considered in the shared decision-making process to select a treatment regimen. Once remission is achieved, patients need routine surveillance to monitor for complications and relapse, in addition to age-appropriate screenings recommended by the U.S. Preventive Services Task Force. Patients should receive a 13-valent pneumococcal conjugate vaccine followed by a 23-valent pneumococcal polysaccharide vaccine at least eight weeks later with additional age-appropriate vaccinations because lymphoma is an immunosuppressive condition. Household contacts should also be current with their immunizations.

An Overview of Reviews on the Safety of Electroconvulsive Therapy Administered During Pregnancy.

OBJECTIVE: To inform obstetricians and psychiatrists about the safety of electroconvulsive therapy (ECT) administration during pregnancy and to reconcile conflicting recommendations concerning this treatment. METHODS: A systematically conducted overview was undertaken on the safety of ECT during pregnancy. The Cochrane Library, MEDLINE/PubMed, PsycINFO, and Ovid were independently searched by 2 of the authors from January 2015 to March 2017 using the following search terms: electroconvulsive therapy, ECT, and electroshock combined with pregnancy and reviews. Articles were reviewed and critically appraised using components of the PRISMA and AMSTAR systematic review assessment tools. RESULTS: Of the 9 articles that were identified, 5 publications of varying methodological quality met inclusion criteria and involved a range of 32 to 339 patients. The most common problems that occurred in association with ECT were fetal arrhythmia, fetal bradycardia, premature birth, developmental delay, abdominal pain, uterine contraction, vaginal bleeding, placental abruption, and threatened abortion. The number of fetal deaths in each of the reviews ranged from 2 to 12. The authors of 1 of the 5 reviews recommended that ECT only be used as a last resort, whereas the authors of the other reviews took the stance that the administration of ECT during pregnancy was relatively safe. Differences in recommendations among reviews were in part due to inclusion criteria and how adverse events were attributed to ECT. CONCLUSIONS: Our overview supports the conclusion, which has also been endorsed by the American College of Obstetricians and Gynecologists and the American Psychiatric Association, that administration of ECT during pregnancy is relatively safe. Conclusions about safety, however, will become better established with the availability of more data.

Racial/Ethnic Disparities in Receipt of Electroconvulsive Therapy for Elderly Patients With a Principal Diagnosis of Depression in Inpatient Settings.

OBJECTIVE: Electroconvulsive therapy (ECT) is underused despite being among the most effective treatments for older adults with severe, pharmacotherapy-resistant mood disorders. Furthermore, those in minority groups are even less likely to receive ECT. The objective of this study was to examine racial and ethnic disparities in the receipt of ECT in older adults. METHODS: We used survey-weighted log-binomial regression to generate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) that represented the associations between race/ethnicity and receipt of ECT during hospitalization at an ECT-available hospital. We used data from the 2002-2015 National Inpatient Sample, the largest all-payer inpatient database in the United States. The analysis was restricted to hospitalizations of adults aged 65-95 with depression as a principal diagnostic code. The primary exposure was patient race/ethnicity, and the primary outcome was receipt of ECT during hospitalization, restricted to ECT-available hospitals. RESULTS: Among the 685,939 patients included in the analysis, 45% received care at an ECT-available hospital, and among those, 17% received ECT. Non-Hispanic (NH) blacks were nearly half as likely to receive ECT as NH whites (aPR: 0.56 [0.47-0.81]; t: -6.42; df: 1,327; p < 0.001). Hispanics were nearly half as likely to receive ECT as NH whites (aPR: 0.57 [0.44-0.72]; t: -4.59; df: 1,327; p < 0.001). CONCLUSION: This national cross-sectional study of racial/ethnic disparities in receipt of ECT among depressed elderly patients confirms prior literature and reveals the potential worsening of disparities for racial/ethnic minorities blacks.

Multi-center clinical evaluation of the Access AMH assay to determine AMH levels in reproductive age women during normal menstrual cycles.

BACKGROUND: AMH is widely used for assessing ovarian reserve, and it is particularly convenient, because it is thought to have minimal variability throughout the menstrual cycle. However, studies assessing the stability of AMH over the menstrual cycle have been conflicting. PURPOSE: The purpose of this study is to determine whether AMH levels vary across the normal menstrual cycle. DESIGN: A multi-center, prospective cohort study conducted at three US centers. METHODS: Fifty females with regular menstrual cycles aged 18-45 underwent serial venipuncture every 3-5 days starting in the early follicular phase and lasting up to 10 collections. AMH was tested using the Access 2 immunoassay system. RESULTS: Age-adjusted mixed-effect models utilizing data from 384 samples from 50 subjects demonstrated a within subject standard deviation of 0.81 (95% CI 0.75-0.88) with a coefficient of variation of 23.8% across the menstrual cycle and between subject standard deviation of 2.56 (95% CI 2.13-3.21) with a coefficient of variation of 75.1%. Intra-class correlation (ICC) of AMH across the menstrual cycle was 0.91. CONCLUSION: Overall, AMH levels, using the automated Access AMH assay, appear to be relatively stable across the menstrual cycle. Fluctuations, if any, appear to be small, and therefore, clinicians may advise patients to have AMH levels drawn at any time in the cycle.

Biopharmaceutics data management system for anonymised data sharing and curation: First application with orbito IMI project.

The OrBiTo IMI project was designed to improve the understanding and modelling of how drugs are absorbed. To achieve this 13 pharmaceutical companies agreed to share biopharmaceutics drug properties and performance data, as long as they were able to hide certain aspects of their dataset if required. This data was then used in simulations to test how three in silico Physiological Based Pharmacokinetic (PBPK) tools performed. A unique database system was designed and implemented to store the drug data. The database system was unique, in that it had the ability to make different sections of a dataset visible or hidden depending on the stage of the project. Users were also given the option to hide identifying API attributes, to help prevent identification of project members from previously published data. This was achieved by applying blinding strategies to data parameters and the adoption of a unique numbering system. An anonymous communication tool was proposed to exchange comments about data, which enabled its curation and evolution. This paper describes the strategy adopted for numbering and blinding of the data, the tools developed to gather and search data as well as the tools used for communicating around the data with the aim of publicising the approach for other pre-competitive research between organisations.

Reproductive modification in forest plantations: impacts on biodiversity and society.

1000 I. 1000 II. 1001 III. 1014 IV. 1015 V. 1016 1016 References 1016 SUMMARY: Genetic engineering (GE) can be used to improve forest plantation productivity and tolerance of biotic and abiotic stresses. However, gene flow from GE forest plantations is a large source of ecological, social and legal controversy. The use of genetic technologies to mitigate or prevent gene flow has been discussed widely and should be technically feasible in a variety of plantation taxa. However, potential ecological effects of such modifications, and their social acceptability, are not well understood. Focusing on Eucalyptus, Pinus, Populus and Pseudotsuga - genera that represent diverse modes of pollination and seed dispersal - we conducted in-depth reviews of ecological processes associated with reproductive tissues. We also explored potential impacts of various forms of reproductive modification at stand and landscape levels, and means for mitigating impacts. We found little research on potential reactions by the public and other stakeholders to reproductive modification in forest plantations. However, there is considerable research on related areas that suggest key dimensions of concern and support. We provide detailed suggestions for research to understand the biological and social dimensions of containment technologies, and consider the role of regulatory and market restrictions that obstruct necessary ecological and genetic research.

A Systematic Review of the Safety of Electroconvulsive Therapy Use During the First Trimester of Pregnancy.

OBJECTIVES: Because of the lack of focus on the safety of electroconvulsive therapy (ECT) during the first trimester of pregnancy in current literature, we set out to assess the safety of ECT use during this vital period of fetal development. METHODS: A systematic review was conducted, and a case where ECT was employed during the first trimester was presented. Cochrane Library, Ovid MEDLINE, PsycINFO, and PubMed were independently searched by 2 authors using the following search terms: "ECT," "electroconvulsive therapy," "electroshock" combined with "pregnancy," "first trimester of pregnancy," and "teratogenicity." RESULTS: Of the 97 articles reviewed, 13 met inclusion criteria. We identified 32 first-trimester patients as cases or case series. Adverse outcomes, including miscarriage with previous vaginal bleeding, vaginal bleeding, self-limited abdominal pain, and self-limited fetal spasms, were observed. We added 1 case of a pregnant patient at approximately 9 weeks gestation who experienced a threatened abortion after the administration of ECT. CONCLUSIONS: Although the data are limited, they suggest that ECT is relatively safe when administered during the first trimester of pregnancy. The possible adverse consequences of ECT during the first trimester of pregnancy should be carefully weighed against the potential benefits of ECT on untreated mental illness.

A Case of Anti-NMDA Receptor Encephalitis Treated with ECT.

We describe the case of a 17-year-old male who presented with acute onset of seizures and malignant catatonia with psychosis, agitation, and hypermetabolism, who responded to electroconvulsive therapy (ECT). Soon after he began to respond, he was diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and then given immunosuppressive therapy. Anti-NMDA receptor encephalitis is an increasingly recognized autoimmune disorder that often presents with neuropsychiatric symptoms. The mainstays for treatment have been early diagnosis, tumor work-up and removal if found, and initiation of immunosuppressive therapy. Treatment response is often slow and residual symptoms common. In this case, ECT produced clinical stabilization before the underlying diagnosis of anti-NMDA receptor encephalitis was made and standard treatment initiated. We suggest that ECT may be highly beneficial for stabilizing life-threatening neuropsychiatric symptoms in this syndrome and should be considered as a potentially additive treatment to immunotherapy when rapid relief is sought.

Intravenous Anesthesia With Bispectral Index Monitoring vs Inhalational Anesthesia for Rhytidoplasty: A Randomized Clinical Trial.

IMPORTANCE: Minor adverse effects related to anesthesia are common and worrisome to patients, including perioperative vomiting, gagging on the endotracheal tube, incisional pain, and nausea. A previously published intravenous anesthesia protocol reports extremely low rates of postoperative nausea and vomiting (<1%) and decreases in postoperative pain perception compared with rates reported following administration of inhalational anesthetics. OBJECTIVE: To evaluate and compare postoperative outcomes in patients after administration of combined propofol and ketamine hydrochloride anesthesia with bispectral index monitoring (PKA-BIS protocol) vs inhalational anesthesia (IA) during lower rhytidoplasty. DESIGN, SETTING, AND PARTICIPANTS: We performed a prospective, double-blind, randomized comparison trial of the PKA-BIS protocol and IA in 30 consecutive female patients undergoing rhytidoplasty by a single surgeon at a single outpatient surgery center from October 2013 to June 2014. MAIN OUTCOMES AND MEASURES: Outcome measures included nausea, vomiting, pain, overall feeling of well-being, time to awaken, time to discharge, and cost. Patient measures were recorded using a combination of a 40-item validated postoperative quality of recovery questionnaire (QOR-40) and visual analog scales (VASs). Results were recorded immediately after surgery and on postoperative days 1 and 7. RESULTS: A statistically significant reduction in emergence time (mean [SD], 29.8 [10.6] vs 46.0 [10.2] minutes; P < .001) and time to meet discharge criteria (51.4 [19.3] vs 66.1 [12.9] minutes; P = .02) was seen in patients in the PKA-BIS group. Patient-reported (subjective) postoperative nausea (3 of 15 [20%] vs 7 of 15 patients [47%]; P = .12; χ2 = 2.40), vomiting (0 vs 2 of 15 patients [13%]; P = .14; χ2 = 2.14), and confusion on the day of surgery (3 of 15 [20%] vs 6 of 14 patients [43%]; P = .18; χ2 = 1.77) were also decreased in the PKA-BIS group, but these differences did not reach significance. Differences in global recovery scores (QOR-40 scores in the postanesthesia care unit, 158.13 [22.68] vs 155.33 [18.09]; P = .71; at day 1, 166.47 [26.39] vs 166.00 [16.00]; P = .96), postoperative overall feeling of well-being (VAS scores at day 1, 6.10 vs 6.26; at day 7, 7.49 vs 8.00), and postoperative pain perception (VAS scores at day 1, 3.40 vs 3.65; at day 7, 2.26 vs 1.81) between the PKA-BIS and IA groups, respectively, did not reach significance. The costs of anesthesia administration were similar between the PKA-BIS ($10.37/h) and IA ($8.47/h to $9.87/h) groups. CONCLUSIONS AND RELEVANCE: The PKA-BIS protocol for anesthesia appears to be a comparable alternative to traditional IA in patients undergoing elective rhytidoplasty. A larger patient sample size is needed to determine whether trends toward decreased nausea, vomiting, and postoperative confusion and differences in postoperative pain perception are significant. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02410460. LEVEL OF EVIDENCE: 1.

Outcomes of early versus late tracheostomy: 2008-2010.

OBJECTIVES/HYPOTHESIS: The ideal timing of tracheostomy varies. This study sought to determine demographic, management, and outcome differences in patients undergoing early tracheostomy (ET) versus late tracheostomy (LT) (<10 days vs. >10 days postintubation, respectively). STUDY DESIGN: Retrospective review of the 2008 to 2010 Nationwide Inpatient Sample for patients with extreme severity of illness who underwent tracheostomy. METHODS: Patients were subdivided based on the timing of tracheostomy placement (days 1-5, 6-10, 11-15, 16-20, 21-25). ET and LT were defined using a 10-day cutoff. Descriptive statistics were obtained for hospital and patient demographics. Multivariate models analyzed the effect of tracheostomy timing on primary outcomes of in-hospital morbidity/mortality, length of stay (LOS), and charges. RESULTS: A total of 124,990 tracheostomy cases met inclusion criteria. Of the total cases, 53,749 underwent ET, and 71,244 underwent LT. Significant predictors (P < .01) of ET included patient age <65 years (odds ratio [OR]: 1.136), admission to a Midwest hospital (OR: 1.430), neurologic disorder (OR: 1.196), paralysis (OR: 1.264), and admission to a government, nonfederal hospital (OR: 1.434). Significant predictors of LT included admission to a small hospital (OR: 1.150), acute respiratory failure (OR: 1.601), and acute chronic respiratory failure (OR: 1.349). The economic outcomes of hospital costs and LOS increased linearly and significantly with time to tracheostomy, as did mortality (P < .001). ET was associated with a significantly increased rate of discharge to home (P < .001) and decreased rate of sepsis (P < .001) and ventilator-associated pneumonia (P < .001). CONCLUSIONS: Efficient and effective healthcare delivery is paramount in today's economic climate. Identification of patients likely to need prolonged ventilator support and ET may prove to be a cost- and morbidity-saving measure and deserves further prospective examination.

Spontaneous carotid-cavernous fistula: challenges in clinical and radiologic diagnosis.

We present a 47-year-old female patient with spontaneous carotid-cavernous fistula without comorbidities. The symptoms of a carotid-cavernous fistula may be confused with other pathology in the region of the orbit and cavernous sinus such as cavernous sinus thrombosis. Carotid-cavernous fistulas most commonly result from direct injury to the internal carotid artery, as with skull base or surgical trauma, but it can also result from weakness in the arterial wall, as with an aneurysm. Because of the high flow of the internal carotid artery, carotid-cavernous fistulas typically present with rapidly progressive symptoms. The case study presented demonstrates the usefulness of radiologic studies in distinguishing between these similarly presenting disease processes. Clinically, cavernous sinus thrombosis generally presents bilaterally and carotid-cavernous fistula presents unilaterally; however, there are a number of exceptions in the literature. The use of a variety of radiologic and angiographic studies will help differentiate between these pathologies. On magnetic resonance imaging, both pathologies can appear as an enlargement of cavernous sinus. Magnetic resonance angiography sequence can reveal aneurysms communicating with the cavernous sinus, and magnetic resonance venography will define thrombosis within the cavernous sinus. Differentiating between cavernous sinus thrombosis and carotid-cavernous fistula can be clinically difficult, and a team approach including emergency physicians, neurosurgeons, ophthalmologists, and otolaryngologists will be called upon to assist in diagnosis. Prompt diagnosis and management can allow for potentially vision and lifesaving interventions.

Recent trends in epistaxis management in the United States: 2008-2010.

IMPORTANCE: The treatment of epistaxis is variable. It is important to analyze the effect of the available interventions on patient outcomes. OBJECTIVE: To determine demographic, management, and outcome trends in patients admitted with a primary diagnosis of epistaxis and treated with conservative management, nasal packing, arterial ligation, or embolization. DESIGN, SETTING, AND PARTICIPANTS: A review of the data reported by hospitals to the 2008-2010 Nationwide Inpatient Sample for patients admitted with a primary diagnosis of epistaxis was conducted. INTERVENTIONS: Conservative management, nasal packing, arterial ligation, or embolization for epistaxis control. MAIN OUTCOMES AND MEASURES: Descriptive statistics for hospital and patient demographic data. Multivariate models were constructed to compare treatment modalities, controlling for patient- and hospital-level variation while reporting the treatment outcomes of mortality, stroke, blindness, length of stay, and total cost. Comparisons were made between patients undergoing embolization, surgical ligation, or nasal packing. Descriptive statistics for patients treated conservatively are reported. RESULTS: A total of 57, 039 cases of primary epistaxis were identified. Of these, 21, 872 patients (38.3%) were treated conservatively, 30, 389 (53.3%) received nasal packing or cauterization, 2706 (4.7%) underwent arterial ligation, and 1956 (3.4%) underwent embolization The odds of stroke in patients following embolization were significantly higher than in patients who underwent nasal packing (odds ratio, 4.660; P = .003), with no significant difference seen compared with surgical ligation (P = .70). There were no significant differences in the odds of mortality or blindness between any of the study groups. Patients undergoing embolization incurred the highest total hospital costs, nearly doubling the cost of ligation (P < .001), without a corresponding increase in the length of hospital stay (P = .20). CONCLUSIONS AND RELEVANCE: Treatment for epistaxis is highly variable. No significant differences in clinical outcomes were noted between arterial ligation and embolization in the population studied, although embolization resulted in significantly higher costs. Further prospective studies are needed to elucidate variables affecting outcomes of the various treatment options for epistaxis.

Delayed diagnosis of nasal natural killer/t-cell lymphoma.

Midline destructive lesions of the face have multiple possible etiologies. The majority of these cases are found to be due to an extranodal lymphoma of natural killer/T-cell-type non-Hodgkins lymphoma (NKTL). Unfortunately, diagnosis is often delayed. With variable presenting complaints, including nonspecific issues like chronic rhinosinusitis or nasal congestion, initial treatments are aimed at these presumed diagnoses. Only as the lesion progresses do overt signs of destruction occur. As with our patient, who was initially treated for presumed infection and abscess, final diagnosis often does not occur until several months, and several antibiotic courses, from initial presentation. As such, it is important for this rare entity to remain in the clinician's differential diagnosis for nasal lesion.