Electromyography in the prognostication of recovery in patients with acute peripheral facial nerve palsy: A systematic review.

OBJECTIVES: Needle electromyography (EMG) may be used to characterise the severity of the injury in acute peripheral facial nerve palsy (FNP) to predict recovery and guide management, but its prognostic value and clinical utility remain controversial. The aim of this systematic review was to evaluate the role of EMG to prognosticate the recovery of facial motor function in patients with acute peripheral FNP. DESIGN: A comprehensive search strategy was applied in PubMed, Embase, and Web of Science based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main outcome measure was the accuracy of EMG in predicting long-term facial function at least 6 months following symptom onset. RESULTS: Eleven studies were included comprising 3837 participants, with 91.6% of these diagnosed with Bell's palsy (BP). In BP patients, the positive predictive value and negative predictive value for a good outcome based on EMG findings ranged from 82.1% to 100% and 66.7% to 80.5%, respectively, with two out of three studies finding that EMG remained a significant predictor of the outcome on multivariate analysis. Three studies addressed the role of EMG in non-idiopathic FNP with two of these studies supporting EMG to predict prognosis. CONCLUSIONS: EMG is a useful tool to gain insight into the likely outcome to guide management decisions and counsel patients on their expectations, particularly in BP. However, given inconsistencies in its application and lack of evidence around non-idiopathic FNP, it should not currently be relied on to predict recovery. Ultimately, its prognostic value and widespread adoption are dependent on the implementation of a clear and standardised protocol in future high-quality studies and routine clinical settings.

Outcomes of immediate facial nerve reanimation with nerve transfer for facial nerve neoplasm-induced paralysis: a retrospective review.

BACKGROUND: The purpose of this study was to evaluate the outcomes of our polyneural, zone-based reanimation approach for patients with neoplasm-induced facial paralysis. METHODS: A retrospective review of consecutive patients who underwent facial reanimation surgery using multiple donor nerve transfers was undertaken. In each case, the selection of donor nerves was based on the availability of donor nerve and the viability of the motor endplate on the affected side. Sources of the neural inputs utilized included the remnant facial nerve stump, masseteric nerve, partial hypoglossal nerve, and branches of the contralateral facial nerve. Clinical outcomes were scored by expert raters. Ratings were undertaken using the modified House-Brackmann, eFACE and MEEI FACEgram scoring systems. RESULTS: Between 2017 and 2020, 12 patients were included in the study (mean age 60 years; range 26-81 years). Eight patients (67%) achieved a grade III outcome on the modified House-Brackmann grading scale. Mean eFACE static and dynamic scores were 76 and 57 respectively, reflecting a high degree of symmetry at rest and moderate restoration of dynamic movement. Mean time to movement was 5.4 months (SD 1.9). Objective FACE-gram measurements confirmed restoration of midface movement with an average improvement in smile excursion and mouth angle excursion of 3.19 mm (SD 3.18) and 4.81° (SD 2.90) respectively. CONCLUSION: Facial reanimation using multiple nerve transfers is effective in achieving improvements in facial function and symmetry.

Radiotherapy-induced glioblastoma: distinct differences in overall survival, tumor location, pMGMT methylation and primary tumor epidemiology in Hong Kong chinese patients.

INTRODUCTION: Radiotherapy-induced glioblastomas (RIGB) are a well-known late and rare complication of brain irradiation. Yet the clinical, radiological and molecular characteristics of these tumors are not well characterized. METHODS: This was a retrospective multicentre study that analysed adult patients with newly diagnosed glioblastoma over a 10-year period. Patients with RIGB were identified according to Cahan's criteria for radiation-induced tumors. A case-control analysis was performed to compare known prognostic factors for overall survival (OS) with an independent cohort of IDH-1 wildtype de novo glioblastomas treated with standard temozolomide chemoradiotherapy. Survival analysis was performed by Cox proportional hazards regression. RESULTS: A total of 590 adult patients were diagnosed with glioblastoma. 19 patients (3%) had RIGB. The mean age of patients upon diagnosis was 48 years ± 15. The mean latency duration from radiotherapy to RIGB was 14 years ± 8. The mean total dose was 58Gy ± 10. One-third of patients (37%, 7/19) had nasopharyngeal cancer and a fifth (21%, 4/19) had primary intracranial germinoma. Compared to a cohort of 146 de novo glioblastoma patients, RIGB patients had a shorter median OS of 4.8 months versus 19.2 months (p-value: <.001). Over a third of RIGBs involved the cerebellum (37%, 7/19) and was higher than the control group (4%, 6/146; p-value: <.001). A fifth of RIGBs (21%, 3/19) were pMGMT methylated which was significantly fewer than the control group (49%, 71/146; p-value: .01). For RIGB patients (32%, 6/19) treated with re-irradiation, the one-year survival rate was 67% and only 8% for those without such treatment (p-value: .007). CONCLUSION: The propensity for RIGBs to develop in the cerebellum and to be pMGMT unmethylated may contribute to their poorer prognosis. When possible re-irradiation may offer a survival benefit. Nasopharyngeal cancer and germinomas accounted for the majority of original malignancies reflecting their prevalence among Southern Chinese.

Performing MRI Scans on Cochlear Implant and Auditory Brainstem Implant Recipients: Review of 14.5 Years Experience.

OBJECTIVE: To assess the complication rate of magnetic resonance imaging (MRI) using 1.5 T scanners on cochlear implant (CI) and auditory brainstem implant (ABI) recipients over 14.5 years. METHODS: Prospective study conducted in a tertiary referral center for cochlear and auditory brainstem implantation, including patients with neurofibromatosis 2. The primary outcome was complications related to MRI scanning in implant recipients, including failure to complete MRI sessions. The secondary outcome was magnet void size due to MRI scanning with magnet in situ. RESULTS: Ninety-seven patients (21 ABI recipients, 76 CI recipients of whom 23 were bilateral) underwent a total of 428 MRI sessions consisting of 680 MRI procedures, which generated 2,601 MRI sequences (excluding localizers). Of these, 28/428 (6.5%) MRI sessions were performed with magnet removed, and the remaining 400/428 (93.4%) with the magnet in situ. The overall complication rate per session was 15/428 (3.5%). The majority of complications were accounted for by patient discomfort, in some cases requiring abandoning the scan session, but 5 magnet dislocations were also recorded. There were no cases of implant device failure or excessive demagnetization of the receiver stimulator magnet.For CI and ABI recipients, the implant caused large voids of around 110 mm × 60 mm with the magnet in situ which reduced to 60 mm × 30 mm when the magnet was removed. However, it was usually possible to visualize the internal acoustic meatus and cerebellopontine angle by positioning the implant package higher and further forward compared with conventional positioning. CONCLUSION: MRI scanning in ABI and CI recipients is generally safe and well tolerated without magnet removal, and carries a low rate of complications. However, patients should be fully informed of the possibility of discomfort, and precautions such as local anesthetic injection and head bandaging may reduce the likelihood of adverse events.

Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation.

We sought to establish the effect of introducing a multidisciplinary tracheotomy management team (MDT). Tracheotomies are high-cost interventions with potentially devastating complications. Multidisciplinary teams have been introduced in many hospitals with the aim of reducing complications, however, data supporting them are lacking. There is currently insufficient evidence to conclude MDTs reduce length of hospital or intensive care unit (ICU) stay, and there is little information on cost analysis. A chart review identified patients who had a tracheotomy inserted at a major metropolitan teaching hospital with an acute spinal medicine service 2 years before and after the MDT was implemented. The primary outcome was time to decannulation. Other outcomes included tracheotomy complications, the proportion of patients decannulated, length of ICU and hospital stay, and admission cost. Our search identified 174 (78 prior and 96 post-MDT) patients. Baseline demographics were similar between groups. There was no difference in time to decannulation, the decannulation rate, or the length of hospital or ICU stay. Complication rates were low in both groups. There was an increase in the proportion of patients who received speaking valves and a reduction in cost of admission in a subgroup of patients who did not undergo head and neck surgery. There is insufficient evidence to support the widespread introduction of tracheotomy MDTs. Institutions considering introducing a tracheotomy team should carefully consider their case-mix, volume, and available resources as well as the structure and responsibilities of the team, and the timing of its activities within the working week. The potential benefits of MDTs including teaching of staff, and collaboration of teams should be acknowledged. Given the potentially significant implications for cost to the health system, a randomized trial is needed to guide policy in this area.

Hearing loss.

Hearing loss affects one in six people in the UK and is a significant disease burden. In addition to communication problems, there is also an association with depression and dementia. Clinical assessment with targeted history and examination can identify the characteristics and cause of hearing loss, and complementary audiological testing can confirm its type and severity. Retrocochlear screening is recommended for sudden, rapidly progressive or asymmetric sensorineural hearing loss. Medical or surgical therapies may be indicated in cases of conductive hearing loss, while hearing assistive devices and hearing aids are the mainstay of rehabilitation for sensorineural hearing loss.

Utility of salivary enzyme immunoassays for measuring estradiol and testosterone in adolescents: a pilot study.

AIM: We investigated the utility of enzyme immunoassay kits for measuring low levels of salivary estradiol and testosterone in adolescents and objectively assessed prevalence of blood contamination. METHODS: Endocrine patients provided plasma and saliva for estradiol (females) or testosterone (males) assay. Saliva samples were also tested with a blood contamination kit. RESULTS: Picomolar levels of salivary estradiol in females failed to show any significant correlation with plasma values (r=0.20, p=0.37). The nanomolar levels of salivary testosterone in males showed a strong correlation (r=0.78, p<0.001). A significant number of saliva samples had blood contamination. After exclusion, correlations remained non-significant for estradiol, but strengthened for testosterone (r=0.88, p<0.001). CONCLUSION: The salivary estradiol enzyme immunoassay is not clinically informative at low levels. Users should interpret clinical saliva with caution due to potential blood contamination. Our data supports the utility of the salivary testosterone enzyme immunoassay for monitoring adolescent boys on hormone developmental therapy.

Prethreshold retinopathy in premature infants with intrauterine growth restriction.

AIM: To determine, among very preterm newborns, whether those who are growth-restricted are at increased risk of retinopathy of prematurity (ROP), and to explore whether the mixed findings of prior studies are the consequence of sampling based upon birthweight instead of gestational age. METHODS: Using data from the ELGAN Study, we created logistic regression models of prethreshold ROP risk to adjust for confounders and calculate odds ratios and 99% confidence intervals. We created scatter plots to display the gestational age/birthweight relationship in infants enrolled in studies with different selection criteria. RESULTS: Low gestational age [23-24 weeks, OR 11.6 (2.9, 47); 25-26 weeks, 8.1 (2.1, 32)] and severe growth restriction [birthweight Z-score <-2, OR 9.1 (1.1, 76)] were associated with increased risk of prethreshold ROP. We documented in scatter plots that a sample defined by birthweight has an excess of gestationally older, severely growth-restricted newborns. CONCLUSION: In this sample, low gestational age and severe growth restriction were associated with increased risk of prethreshold ROP.

Pregnancy disorders appear to modify the risk for retinopathy of prematurity associated with neonatal hyperoxemia and bacteremia.

OBJECTIVE: To explore (1) whether extremely low gestational age newborns exposed to inflammation-associated pregnancy disorders differ in retinopathy of prematurity (ROP) risk from infants exposed to placenta dysfunction-associated disorders, and (2) whether ROP risk associated with postnatal hyperoxemia and bacteremia differs among infants exposed to these disorders. METHODS: Pregnancy disorders resulting in preterm birth include inflammation-associated: preterm labor, prelabor premature rupture of membranes (pPROM), cervical insufficiency, and abruption and placenta dysfunction-associated: preeclampsia and fetal indication. The risk of severe ROP associated with pregnancy disorders was evaluated by multivariable analyses in strata defined by potential effect modifiers, postnatal hyperoxemia and bacteremia. RESULTS: Compared to preterm labor, infants delivered after pPROM were at reduced risk of plus disease (Odds ratio = 0.4, 95% confidence interval: 0.2-0.8) and prethreshold/threshold ROP (0.5, 0.3-0.8). Infants delivered after abruption had reduced risk of zone I ROP (0.2, 0.1-0.8) and prethreshold/threshold ROP (0.3, 0.1-0.7). In stratified analyses, infants born after placenta dysfunction had higher risks of severe ROP associated with subsequent postnatal hyperoxemia and bacteremia than infants born after inflammation-associated pregnancy disorders. CONCLUSION: Infants exposed to placenta dysfunction have an increased risk of severe ROP following postnatal hyperoxemia and bacteremia compared to infants exposed to inflammation-associated pregnancy disorders.

Retinopathy of prematurity in the Dominican Republic: challenges to screening and prevention.

OBJECTIVE: To determine the incidence of retinopathy of prematurity (ROP) in an intensive care nursery in the Dominican Republic and to identify factors that impact ROP outcomes, screening, and treatment. STUDY DESIGN: A database analysis was performed. The database was prospectively created by the pediatric ophthalmologist in a public maternity hospital in Santo Domingo during 2009. From January to December, all infants (n = 234) who received at least one ophthalmologic examination for ROP were included. ROP screening criteria were based upon: (1) American Academy of Pediatrics guidelines and (2) the presence of critical illness in larger, more mature infants at the discretion of the neonatologist. RESULTS: Overall, 22% were diagnosed with ROP and 4.3% had severe disease. Infants with ROP had a mean birth weight of 1452 g and a mean gestational age of 31 weeks, with 35% having a gestational age >32 weeks. In multivariable regression, only gestational age remained significant (0.8, 0.68 to 0.95). Twenty-two percent diagnosed with ROP did not complete all screening procedures. CONCLUSION: There are many challenges to preventing and treating ROP in the Dominican Republic. Increased awareness of the detrimental effects of hyperoxia, broader screening criteria, and an improved screening program will help to reduce visual impairment from ROP.

Novel approach of medialization thyroplasty with arytenoid adduction performed under general anesthesia with a laryngeal mask.

OBJECTIVE: To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. STUDY DESIGN: Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. SETTING: Tertiary referral teaching hospital in Sydney, Australia. SUBJECTS: All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. METHODS: Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). RESULTS: Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. CONCLUSION: Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.

Future applications of antioxidants in premature infants.

PURPOSE OF REVIEW: This review will examine the unique susceptibility of premature infants to oxidative stress, the role of reactive oxygen species (ROS) in the pathogenesis of common disorders of the preterm infant, and potential for therapeutic interventions using enzymatic and/or nonenzymatic antioxidants. RECENT FINDINGS: Oxidative stress is caused by an imbalance between the production of ROS and the ability to detoxify them with the help of antioxidants. The premature infant is especially susceptible to ROS-induced damage because of inadequate antioxidant stores at birth, as well as impaired upregulation in response to oxidant stress. Thus, the premature infant is at increased risk for the development of ROS-induced diseases of the newborn, such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and periventricular leukomalacia. SUMMARY: Potential therapies for ROS-induced disease include both enzymatic and nonenzymatic antioxidant preparations. More research is required to determine the beneficial effects of supplemental antioxidant therapy.

IL-6, IL-8 and IL-10 levels in healthy weight and overweight children.

BACKGROUND/AIM: In adults, studies have shown that obesity is a chronic low-grade inflammatory state characterized by altered levels of cytokines. Studies in children have mainly focused on C-reactive protein and adiponectin, and there is limited data for other inflammatory markers in healthy weight and overweight children. The aim of this study was to measure IL-6, IL-8 and IL-10 levels in healthy normal weight and overweight children at 8 and 15 years. METHODS: 118 normal weight and overweight children (59 boys) from the Nepean longitudinal study were recruited at age 8 years and followed up at 15 years. Serum IL-6, IL-8 and IL-10 levels were measured at both time-points. RESULTS: At 8 years, we found no significant differences in cytokine levels between normal weight and overweight (owt)/obese (ob) groups. However, at 15 years, owt/ob girls (n = 23) had higher levels of IL-6 (p = 0.04), IL-8 (p = 0.04) and IL-10 (p = 0.03) compared to normal weight girls (n = 36), even after adjustment for puberty; no differences were seen in boys. CONCLUSION: The effects of obesity on IL-6, IL-8 and IL-10 levels vary with age and sex, with owt/ob girls at 15 years showing raised IL-6, IL-8 and IL-10 levels compared to healthy weight girls.

Cortisol response to general anaesthesia for medical imaging in children.

OBJECTIVE: The cortisol response to surgical stress has been frequently studied, and recommendations developed for steroid replacement in adrenally insufficient patients. There are currently no guidelines, however, for adrenal hormone replacement during anaesthesia alone. The objective of this study was to characterize the normal cortisol response to general anaesthesia in the absence of a surgical procedure in children. DESIGN: Prospective observational study. PATIENTS: Thirty-seven children (aged 0.5-7 years) without known endocrine disease or cranial neoplasms undergoing outpatient magnetic resonance imaging, under general anaesthesia for investigation of nonacute problems in a tertiary referral paediatric hospital. MEASUREMENTS: Serum cortisol and salivary cortisol were measured before and after anaesthesia and during recovery. RESULTS: The mean cortisol level was 303 (± 117) nmol/l at induction, 396 (± 241) nmol/l at emergence from anaesthesia and 584 (± 218) nmol/l during recovery. A stress response (increase in serum cortisol >550 nmol/l) occurred in 23% of children at emergence and in 52% of children at recovery. Eight children (31%) actually demonstrated a decrease in cortisol levels during anaesthesia, without an increase in complications. Mean salivary cortisol levels were 6.5 ± 4.8 nmol/l before induction, 23.5 ± 13.8 nmol/l at emergence from anaesthesia and 26.9 ± 21.6 nmol/l during recovery. A stress response (an increase in salivary cortisol greater than seven-fold) occurred in 26% of children during the study. CONCLUSIONS: While some children demonstrated a rise in their cortisol levels in response to anaesthesia without surgery, the response was variable and often more pronounced during recovery. There was consistently no classic stress response.

Discordant trends in microvascular complications in adolescents with type 1 diabetes from 1990 to 2002.

OBJECTIVE: Since the Diabetes Control and Complications Trial, diabetes management goals have changed. The aims of the present study were to assess complication rates, including nerve abnormalities, in adolescents from 1990 to 2002 and to investigate associated risk factors. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of complications was assessed in three study periods (1990-1994 [T1], 1995-1998 [T2], and 1999-2002 [T3]) in adolescents matched for age and diabetes duration (n = 878, median age 14.6 years, median duration 7.5 years). Retinopathy was assessed by seven-field stereoscopic fundal photography, albumin excretion rate (AER) from three consecutive timed overnight urine collections, peripheral nerve function by thermal and vibration thresholds, and autonomic nerve function by cardiovascular reflexes. RESULTS: Retinopathy declined significantly (T1, 49%; T2, 31%; and T3, 24%; P < 0.0001), early elevation of AER (> or = 7.5 microg/min) declined (38, 30, and 25%, respectively, P = 0.022), and microalbuminuria (AER > or = 20 microg/min) declined (7, 3, and 3%, respectively; P = 0.017, T1 vs. T2 and T3). Autonomic nerve abnormalities were unchanged (18, 21, and 18%, respectively; P = 0.60), but peripheral nerve abnormalities increased (12, 19, and 24%, respectively; P = 0.0017). More patients were treated with three or more injections per day (12, 46, and 67%, respectively; P < 0.0001) and insulin dose increased (1.08, 1.17, and 1.22 units x kg(-1) x day(-1), respectively; P < 0.0001), but median HbA(1c) (A1C) was unchanged (8.5, 8.5, and 8.4%, respectively). BMI and height SD score increased: BMI 0.46, 0.67, and 0.79, respectively (P < 0.0001), and height -0.09, 0.05, and 0.27, respectively (P < 0.0001). CONCLUSIONS: Retinopathy and microalbuminuria declined over time in this cohort, but the increased rate of peripheral nerve abnormalities is of concern. Despite intensified management (higher insulin dose and more injections), A1C has not changed and remains well above the recommended targets for adolescents.