Metastatic cutaneous malignancies of the head and neck, including cutaneous squamous cell carcinoma (cSCC) and malignant melanoma (MM), are aggressive cancers frequently involving the parotid-area ...lymph nodes (LNs). In such cases, controversy exists about the extent of surgical resection, with many centers choosing not to remove the parotid deep lobe LNs.
To determine patterns of intraparotid and neck metastasis, to identify risk factors, and to report outcomes in patients with parotid superficial lobe LN metastasis from cSCC and MM.
We retrospectively reviewed 65 adults from Mayo Clinic in Minnesota who underwent total parotidectomy and neck dissection for metastatic cSCC (n = 42) or MM (n = 23) involving the parotid superficial lobe.
Total parotidectomy and neck dissection.
The presence and number of parotid deep lobe and neck LNs involved with metastatic disease were assessed. Risk factors associated with metastatic spread to the parotid deep lobe were identified, and patient outcomes are reported.
Eleven of 42 patients with cSCC (26%) and 3 of 23 patients with MM (13%) metastatic to the parotid superficial lobe also had parotid deep lobe metastasis. Thirteen of 42 patients with cSCC (31%) and 6 of 23 patients with MM (26%) had positive cervical LN metastasis. Among all patients, 22% (14 of 65) had metastasis to the parotid deep lobe, and 29% (19 of 65) had metastasis to cervical LNs. By univariate analysis, neck metastasis and N2 neck disease were risk factors for metastatic cSCC spread to the parotid deep lobe. Parotid-area local control was excellent in patients with metastatic cSCC (93% 39 of 42) and MM (100% 23 of 23). Long-term survival remains poor because distant metastases are common.
Metastatic cSCC and MM to the parotid superficial lobe also involve LNs in the parotid deep lobe and neck in a significant and almost equal number of patients. Parotid deep lobe metastasis from cutaneous malignancies portends a poor prognosis. Therefore, patients with superficial parotid gland metastasis should be considered for management with not only neck dissection and adjuvant therapy but also deep lobe parotidectomy.
Purpose Radiotherapy induced urethral strictures are often difficult to manage due to proximal location, compromised vascular supply and poor wound healing. To determine the success of urethroplasty ...for radiation induced strictures we performed a multi-institutional review of men who underwent urethroplasty for urethral obstruction. Materials and Methods A total of 30 men (mean age 67 years) underwent urethroplasty at 3 separate institutions. Excision with primary anastomosis was used in 24 of 30 patients (80%), with 4 of 30 requiring a genital fasciocutaneous skin flap and 2 a buccal graft. Hospitalization was less than 23 hours for 70% of the patients. Recurrence was defined as cystoscopic identification of urethral narrowing to less than 16Fr in diameter. Results All strictures were located in the bulbomembranous region. Mean stricture length was 2.9 cm (range 1.5 to 7). External beam radiotherapy for prostate cancer was the etiology of stricture disease in 15 men (50%), with brachytherapy in 7 (24%) and a combination of the 2 modalities in 8 (26%). Successful urethral reconstruction was achieved in 22 men (73%) at a mean of 21 months. Mean time to stricture recurrence was 5.1 months (range 2 to 8). Two men required balloon dilation after stricture recurrence and none required urinary diversion. Incontinence was transient in 10% and persistent in 40%, with 13% requiring an artificial urinary sphincter. The rate of erectile dysfunction was unchanged following urethroplasty (47% preoperative, 50% postoperative). Conclusions Urethroplasty for radiation induced strictures has an acceptable rate of success and can be performed without tissue transfer techniques in most cases. Almost half of men will experience some degree of incontinence as a result of surgery but erectile function appears to be preserved.
Objectives/Hypothesis:
To describe the prevalence, clinical course, and outcomes of facial nerve paresis following cochlear implantation and to identify variables associated with poor definitive ...facial nerve function.
Study Design:
Retrospective cohort study with systematic literature review.
Methods:
All patients who underwent cochlear implantation between January 1990 and December 2010 at a single tertiary academic referral center were reviewed. Data including clinical presentation, intraoperative findings, onset, severity, management, and outcomes of all patients who experienced facial nerve paresis following cochlear implantation were recorded.
Results:
Eight hundred eighty‐eight cochlear implants (282 pediatric, 606 adult) were performed in 768 patients. Eleven patients with postoperative facial nerve paresis were identified. Ten patients (1.1%) developed delayed‐onset paresis and had complete recovery within 6 months of surgery, whereas a single patient (0.1%) demonstrated immediate onset paresis and experienced incomplete return of facial nerve function. Seventeen additional cases were identified in the literature and were summarized.
Conclusions:
Facial nerve paresis following cochlear implantation is rare. Most cases demonstrate a delayed onset and have complete recovery within months of surgery. Delayed onset facial nerve paresis following cochlear implantation heralds an excellent prognosis, whereas immediate onset facial paresis prognosticates a poorer outcome. In the absence of medical contraindications, corticosteroid therapy should be considered in facial paresis following cochlear implant surgery.
To report the clinical presentation, management strategies, and outcomes of 14 endolymphatic sac tumors (EST).
Retrospective case series.
Collective experience accrued from 2 tertiary referral ...centers.
All patients with ESTs.
Microsurgery, stereotactic radiosurgery (SRS).
Treatment-related morbidity, recurrence.
Fourteen ESTs (13 patients) met inclusion criteria. Eight tumors were sporadic, and 6 were associated with von Hippel-Lindau disease (VHL). Twelve lesions were managed primarily, whereas 2 were referred for treatment of sizable recurrences after subtotal resection. Including all patients, the median age at diagnosis was 36 years, and the median duration of posttreatment follow-up was 78 months. Among primary tumors, the median delay between symptom onset and diagnosis was 36 months, and the median tumor diameter at presentation was 23 mm with most lesions demonstrating intracranial involvement. Subjects with VHL frequently presented with smaller, less extensive tumors and were more commonly female compared with patients with sporadic disease. Of the 9 ESTs presenting with normal facial nerve function, 8 maintained good (HB 1-2) posttreatment capacity. Two of 5 ears with useful preoperative hearing maintained pretreatment hearing levels after surgery. One of 12 tumors managed primarily recurred after microsurgical resection. Primary SRS was used in 1 medically infirm patient providing durable tumor control (94 mo) at last follow-up. Among recurrent tumors, 2 were managed successfully with reexcision, whereas 1 underwent salvage surgery followed by 2 sequential treatments of SRS for 2 separate intracranial recurrences; no in-field recurrence has been detected to date.
ESTs are rare primary neoplasms of the temporal bone that may occur sporadically or in association with VHL. Outcomes after treatment of small less-extensive tumors are favorable compared with patients with advanced primary or recurrent disease. Furthermore, subtotal resection carries a high risk of bulky or multifocal recurrence. As such, early gross total resection remains the management strategy of choice for primary and recurrent ESTs; however, SRS should be considered in poor surgical candidates or in cases of focal intracranial recurrence when the morbidity of salvage surgery is high.
Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are ...strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017.
The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure.
Three consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60–70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration.
There is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60–70 mm Hg are harmful during non-cardiac surgery.
Why the international community should have intervened in RwandaKassner contends that the violation of the basic human rights of the Rwandan Tutsis morally obliged the international community to ...intervene militarily to stop the genocide. This compelling argument, grounded in basic rights, runs counter to the accepted view on the moral nature of humanitarian intervention. It has profound implications for our understanding of the moral nature of humanitarian military intervention, global justice and the role moral principles should play in the practical deliberations of states.>A new approach to the intersection of human and sovereign rights that is of tremendous moral, political and legal importance to theorists working in international relations todayChallenges the immutability of the right of non-intervention held by sovereign states, assessing when it becomes right for the international community to intervene militarily in order to avoid another Rwanda
Criterion A of the AMPD in HiTOP Widiger, Thomas A.; Bach, Bo; Chmielewski, Michael ...
Journal of personality assessment,
07/2019, Letnik:
101, Številka:
4
Journal Article
Recenzirano
Odprti dostop
The categorical model of personality disorder classification in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th ed. DSM-5; American Psychiatric ...Association,
2013
) is highly and fundamentally problematic. Proposed for DSM-5 and provided within Section III (for Emerging Measures and Models) was the Alternative Model of Personality Disorder (AMPD) classification, consisting of Criterion A (self-interpersonal deficits) and Criterion B (maladaptive personality traits). A proposed alternative to the DSM-5 more generally is an empirically based dimensional organization of psychopathology identified as the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov et al.,
2017
). HiTOP currently includes, at the highest level, a general factor of psychopathology. Further down are the five domains of detachment, antagonistic externalizing, disinhibited externalizing, thought disorder, and internalizing (along with a provisional sixth somatoform dimension) that align with Criterion B. The purpose of this article is to discuss the potential inclusion and placement of the self-interpersonal deficits of the DSM-5 Section III Criterion A within HiTOP.
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