Head Version Research Articles

Morphologic features of humeral head and glenoid version in the normal glenohumeral joint

The morphologic features and clinical significance of version of the humeral head and glenoid remain unclear. The purpose of this study was to evaluate the normal values of humeral head version and glenoid version on computed tomography scans and to clarify their features in the normal glenohumeral joint. Images for analysis were computed tomography scans of 410 normal shoulders from healthy volunteers. Values of humeral head and glenoid version were measured. In glenoid version measurement, 3-dimensionally corrected slices were reconstructed to eliminate scapular inclination. Differences in humeral head version and glenoid version were assessed between dominant and nondominant shoulders and between men and women. Correlation analyses were also performed in the values of version between dominant and nondominant shoulders and between humeral head version and glenoid version. The values of humeral head retroversion were widely distributed from -2° to 60°, with an average of 26° ± 11°. Average glenoid retroversion was 1° ± 3°, ranging from -9° to 13°. Both humeral head retroversion and glenoid retroversion were significantly higher on the dominant side than on the nondominant side and significantly higher in men than in women. Humeral head version and glenoid version values were well correlated with those of the contralateral shoulder. No correlation was found between humeral head version and glenoid version. This study found differences in humeral head version and glenoid version by sex and shoulder dominance in a large sample. Both the humeral head and glenoid are thought to be more retroverted in high-demand shoulders.

Resective surgery in the treatment of super-refractory partial status epilepticus secondary to NMDAR antibody encephalitis

BackgroundAnti-NMDAR encephalitis is an increasingly described clinical entity in children, comprising 40% of all cases. We present a case of super-refractory status epilepticus secondary to anti-NMDAR encephalitis treated with emergent resective surgery. Case studyA 7 years-old boy presented with progressive abnormal irritability. On the day after admission he had multiple seizures, characterized by head and eye version to the right. EEG revealed left parietal-occipital continuous paroxysmal activity. Anti-NMDAR antibodies were positive in CSF and serum. After almost 3 months in the Intensive Care Unit, in barbituric coma, and given the failure of all treatment regimens, a preoperative evaluation was conducted. Ictal SPECT showed significant hiperperfusion and brain FDG-PET a cortical hypometabolism in the left occipital lobe; a left occipital lobectomy was performed. In the next days it was possible to progressively suspend Thiopental. Currently, patient presents right homonymous hemianopsia, eats by his own hand but needs help in almost all other activities. DiscussionStatus epilepticus (SE) in the setting of anti-NMDAR encephalitis is unusual but described. Whilst the role of surgery in the management of refractory focal epilepsy is established, it is seldom used in the treatment of SE. In the patient with refractory SE (RSE), awareness of surgery as a potentially life saving treatment is an important issue. To our knowledge, this is the first report of a partial RSE secondary to anti-NMDAR encephalitis treated with resective surgery and illustrates the need to consider anti-NMDAR encephalitis as a cause of super-refractory SE.

Associations of oral health items of the Vanderbilt Head and Neck Symptom Survey with a dental health assessment

The Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0 oral symptom subscale addresses underreported oral health issues. We report the associations of xerostomia, dental health, dentures and trismus questions with oral examination findings. Between May 2011 and April 2012, fifty head and neck cancer (HNC) patients treated with chemoradiotherapy completed the 50-item VHNSS survey, an oral health assessment by a dentist, salivary flow, and inter-incisal opening (IIO) measurements. Patient reported "problems with dry mouth" correlated with unstimulated salivary flow (-0.43, p=0.002). "Cracked teeth" (0.55, p=<0.001) or "difficulty chewing due to teeth" (0.43, p=0.004) correlated with urgent/emergent dental issues identified on clinical exam. Scores of >4 on any dental question identified 83% of patients with urgent or emergent needs. The ROC curve separated routine from urgent/emergent dental issues (0.89, p<0.001). IIO correlated with reported jaw movement "limitations" (-0.43, p=0.002). Small numbers of patients with dentures precluded meaningful analysis of this subsample. Clinically significant oral health issues pertaining to xerostomia, dental health and trismus may be identified using the oral health subscale of the VHNSS version 2.0. MASCC guidelines should be followed by patients with xerostomia. The observation that a score of >4 is highly predictive of dental issues is important and needs further validation. If confirmed, this would be a useful screening tool for identifying and referring HNC patients for dental care. Patients with trismus should receive physical therapy.

A University Head and Neck Symptom Survey Version 2.0: Responsiveness to Change Over Time

A University Head and Neck Symptom Survey Version 2.0: Responsiveness to Change Over Time

Pediatric Seizures

On the basis of strong evidence, treatment is highly dependent on the seizure semiology results, electroencephalography (EEG) findings, and origin. • On the basis of moderate evidence and consensus, vigorous use of video EEG recordings and home video cameras should be used to delineate the epileptic syndromes. • On the basis of strong evidence, pediatric epilepsy syndromes have common comorbidities. As a consensus, some pediatric epilepsy centers consider referral to a neuropsychologist to be first-line care in these patients. • On the basis of strong evidence and consensus, antiepileptic drug therapy has its own complications and should be discontinued after an appropriate treatment course. • On the basis of moderate evidence and consensus, uncontrolled seizures put patients at risk for significant morbidity and mortality.

Validation of the Vanderbilt Head and Neck Symptom Survey Version 2.0.

6049 Background: We previously reported the development and preliminary testing of the Vanderbilt Head and Neck Symptoms Survey version 2.0 (VHNSS 2.0 ) for assessment of symptom burden in head and neck cancer (HNC) patients who are undergoing or completed primary or adjuvant radiation based therapy (Cooperstein et al., Head and Neck, 2012, 24(6): 797-804). In addition to expanding items on existing domains, version 2.0 includes new domains such as dental health, mucosal sensitivity, and joint range of motion. Herein we report the results of initial validation of the instrument. Methods: 159 unique patients with HNC completed the 50 item VHNSS 2.0 as a part of one of three supportive care studies. Since each of these studies was prospective and longitudinal with repeated application of the VHNSS 2.0, we chose to utilize the first complete questionnaire for each patient for this analysis. Results: Patient characteristics: median age 57 (range 28-81 years), male 74.8%, Caucasian 91.8%, T3 or T4 46.5%, N2 or N3 66%, Site: pharynx 57.9%, oral cavity 15.1%, larynx 11.3%, 15.7%. Analysis identified 10 distinct clusters with 3 single items. The internal consistency of the clusters was good to excellent. Cronbach’s alpha coefficient, a statistical measure of reliability is shown in the Table. Conclusions: The VHNSS 2.0 is a robust, reliable measure of acute and late toxicities in patients undergoing radiation for HNC. These results provide a platform for administering appropriate interventions, which would ultimately provide for effective management of adverse oral health outcomes. [Table: see text]

Long-term symptom burden and orodental health of oropharyngeal cancer (OPC) survivors following treatment with chemoradiotherapy (CRT) or sequential therapy (ST).

9530 Background: OPC treatment is associated with significant long-term toxicity. Very little is known about the long-term symptom burden and orodental health in OPC survivors &gt;2 yrs from treatment. Methods: Survivors treated for OPC with CRT/ST (involving definitive RT) at Dana Farber Cancer Institute between 2002-2011 and &gt;2 yrs from treatment completion, were identified by chart review and asked to complete the Vanderbilt Head and Neck Symptom Survey version 2 (VHNSS v2), National Health And Nutrition Examination Survey for Oral Health Questionnaire, health care availability survey. Results: 200 survivors were contacted, 127 responded (RR: 64%). Median age at diagnosis was 54 yrs; 85% males; 85% stage IVA/B, 13% stage III; 56% CRT, 43% ST. HPV status: 47% (+), 10% (-), 43% unknown. Median time from treatment completion: 50 mths (24-135 mths). Residual moderate to severe toxicities reported in VHNSS v2: 71% dry mouth; 59% difficulty chewing/swallowing food; 53% feeling of food becoming stuck in the throat; 53% prolonged time to eat; 31% thick mucus, 6% had difficulty sleeping secondary to this; 16% trouble speaking, 27% trouble hearing;30% limitation of neck/shoulder movement; altered taste/smell - 45%/23%; sensitivity to spicy food and dryness-57%/62%; 30% decreased desire to eat, 11% had moderate weight loss. Orodental health assessment: 13% thermal sensitivity, 21% teeth cracking and chipping, 20% loose teeth, 33% had treatment for gum disease, 42% had lost bone around teeth. 98% survivors had health insurance; only 66% had dental insurance. No statistically significant difference was noted with respect to symptoms between CRT or ST. ST did not affect long-term toxicity compared to CRT alone. Conclusions: OPC is known to correlate with HPV positivity, early age at diagnosis and high rates of long-term survival after appropriate therapy. Our study documents that the OPC survivors have substantial residual long-term head and neck and orodental symptoms directly related to the treatment that significantly impacts their quality of life. A substantial number of patients lack dental health coverage, which likely further impacts symptom burden and QOL.

Validation of late oral health outcomes, an oral health subscale of the Vanderbilt Head and Neck Symptom Survey in post-radiation therapy head and neck cancer patients.

6040 Background: The Vanderbilt Head and Neck Symptom Survey (VHNSS) version 2.0 oral symptom subscale was developed to address potentially overlooked and underreported oral health issues. We report the validation of questions pertaining to xerostomia (4 items), dental health (4 teeth), dentures (1 item) and trismus (1 item). Methods: Between May 2011 and April 2012, 50 patients treated with chemoradiotherapy for head and neck cancer completed the 50-item VHNSS survey, underwent an oral health assessment by a dentist, salivary flow and inter-incisal opening (IIO) measurements. Results: Patient reported “problems with dry mouth” correlated with unstimulated salivary flow rates (-0.43, p = 0.002). “Cracked teeth” (-0.55, p = &lt; 0.001) or “difficulty chewing due to teeth” (-0.43, p = 0.004) correlated with urgent or emergent dental care issues identified on exam. Using a cut off of &gt;4 on any of four the dental questions, we were able to identify 83% of patients with urgent or emergent dental issues. The ROC curve was useful (0.89, p&lt; 0.001) for separating patients with and without urgent/emergent dental issues. “Limitations” in jaw movement correlated with IIO (-0.43, p = 0.002). Small numbers of patients with dentures precluded meaningful analysis of this subsample. Conclusions: Clinically significant oral health issues pertaining to xerostomia, dental health and trismus may be identified using the oral health subscale of the VHNSS version 2.0. Patients who score &gt; 4 on any of the teeth related items should be referred for immediate dental evaluation; and for trismus should be referred for physical therapy.

Assessment of the quality of life in maxillectomy patients: A longitudinal study

PURPOSETo longitudinally assess the quality of life in maxillectomy patients rehabilitated with obturator prosthesis.MATERIALS AND METHODSThirty-six subjects were enrolled in the span of 16 months, out of which six were dropouts. Subjects (age group 20-60 years) with maxillary defects, irrespective of the cause, planned for definite obturator prosthesis, were recruited. The Hindi version of European Organization for Research and Treatment of Cancer, Head and Neck version 1 of Quality of Life Questionnaire was used before surgical intervention and one month after definitive obturator. Questionnaire includes 35 questions related to the patient's physical health, well being, psychological status, social relation and environmental conditions. The data were processed with statistical package for social science (SPSS). Probability level of P<.05 was considered statistically significant.RESULTSThe quality of life after rehabilitation with obturator prosthesis was 81.48% (±13.64) on average. On item-level, maximum mean scores were obtained for items problem with teeth (1.87 ± 0.94), pain in mouth (1.80 ± 0.92), trouble in eating (1.70 ± 0.88), trouble in talking to other people (1.60 ± 1.22), problems in swallowing solid food (1.57 ± 1.22) and bothering appearance (1.53 ± 1.04); while minimum scores were obtained for the items coughing (1.17 ± 0.38), hoarseness of voice (1.17 ± 0.53), painful throat (1.13 ± 0.43), trouble in having social contacts with friends (1.10 ± 0.40) and trouble having physical contacts with family or friends (1.10 ± 0.31).CONCLUSIONObturator prosthesis is a highly positive and non-invasive approach to improve the quality of life of patients with maxillectomy defects.

Symptom burden in head and neck cancer: impact upon oral energy and protein intake

This study explored relationships between oral symptom burden (xerostomia, thick secretions, and mucosal sensitivity), energy and protein intake, and weight change over time among head and neck cancer (HNC) patients who have completed concurrent chemoradiation (CCR). Symptom burden was assessed utilizing the Vanderbilt Head and Neck Symptom Survey version 2.0. Weight change was measured from diagnosis to treatment completion, and to the early, mid, and late recovery stage. Energy and protein intake were determined utilizing 24-h diet recalls. Forty-three adult patients treated for HNC enrolled in the study. Mean percentage weight loss from diagnosis to treatment completion was 7.91 ± 4.06 %. Within the mid-recovery stage significant inverse relationships were found between oral protein intake and xerostomia and mucosal sensitivity (r = -0.818, p = 0.012; r = -0.726, p = 0.032, respectively). After controlling for weight change, significant inverse relationships were found within the mid-recovery stage between oral energy intake and xerostomia and mucosal sensitivity (r = -0.740, p = 0.046; r = -0.751, p = 0.043, respectively). Significant, inverse relationships were also found between oral protein intake and xerostomia and mucosal sensitivity (r = -0.835, p = 0.019; r = -0.726, p = 0.033, respectively). Xerostomia and mucosal sensitivity were significantly related to oral energy and protein intake post-CCR in mid-recovery. Weight loss was greatest from diagnosis to treatment completion and continued through the mid-recovery stage. Assessment of oral symptom burden (xerostomia and mucosal sensitivity) and its impact on oral intake and weight post-CCR should be conducted routinely in good patient care.

Reply to Letter to the Editor: Increased Anteversion of Press-Fit Femoral Stems Compared with Anatomic Femur

Drs Wettstein and Mouhsine are correct to point out the benefits of advanced axial imaging for total hip replacement planning. It is especially helpful in assessing the rotational anatomy of the femur and acetabulum which may help individualize the best component alignment. They also are correct to point out that determination of the actual rotational version of the femur requires scanning the distal femur. The purpose of my study [1] was not to determine anteversion of the arthritic hip or postoperative version of the surgically treated hip since such studies have been reported. Rather, the purpose of my study was to compare preoperative version with the final postoperative version in the same patient. The methodology used was a fluoroscopic technique at the time of surgery, the interpretations of which are subjective and therefore the data were checked with a different methodology. Given similar findings, I presumed the study methods were valid. Two MRI series were used, one with a group of patients with no arthritis (scanned for other medical reasons) and another with patients who underwent MRI as part of the planning for hip replacement, which did include the knee, as Wettstein and Mouhsine suggested. Unfortunately, they missed the main point of the study which showed that version of the anatomic femoral head did not predict version of the prosthetic femoral head using a canal filling broach-only bone ingrowth stem. In fact, on average, the total hip femoral head is more anteverted than the native femoral head, 18.9° (femoral head) versus 27.0° (prosthesis). The range of postoperative version was wide, 0° to 42°, so there were outliers with extremes of retroversion and anteversion. This has implications for polyethylene wear and joint stability. Briefly, as the technique is presented in detail in the paper, a neutral femoral position is determined and marked, and the preoperative proximal femur version is compared with the postreplacement proximal femur. The end points for both of these determinations are subjective, based on change in shape of the image, leaving the conclusions open to criticism regarding the validity of the observation. As the shape of the femoral canal determines the position of a canal-filling stem, a comparison of the canal shape (and therefore version) of the neck can be compared with the head, using axial imaging, either CT or MRI, and the neck version should differ from the head version in the same direction if the study methods are valid. Both scan series showed the same findings, namely that the neck version was more than the head version, which would lead to the canal-filling stem having more anteversion on average compared with the femoral head. The magnitude of the differences was interesting: the average difference for the fluoro-surgical series between preoperative and postoperative images was 6.1°, whereas the MRI series differences of 15.4° for the nonarthritic group and 11.2° for the arthritic group were in the same ballpark as that of the surgical group. Therefore, the conclusions of my study were valid, namely that the postoperative femoral stem is, on average, more anteverted than the preoperative femoral head when using a canal-filling broach-only stem, and the surgeon needs to be aware of this fact to keep the appropriate relationship between the acetabulum and femur to avoid impingement and excessive polyethylene wear. The increased use of axial imaging for total hip planning is a good idea because it would indicate when a specialized implant is needed or when a change from routine component placement is warranted.

Long‐term follow‐up of febrile infection–related epilepsy syndrome

Febrile infection-related epilepsy syndrome (FIRES) is an increasingly recognized epileptic syndrome that presents with multifocal refractory status epilepticus in previously normal children and evolves into a chronic, refractory, focal epilepsy with associated cognitive and behavioral difficulties. Herein we describe the features of the chronic epilepsy and critically review evidence for the etiology of this syndrome. Seven patients with FIRES were studied. The duration of follow-up in six survivors was 5-17 years. Clinical, electroencephalography (EEG), neuroimaging, and other investigative findings during the acute and chronic phases were reviewed. These previously normal children presented with a febrile illness and status epilepticus that was refractory to antiepileptic medications in all children, to immunotherapies (including immunoglobulin, corticosteroids, plasma exchange, and rituximab) in four, and to acute vagus nerve stimulation in one. Markers of cerebral inflammation were few and response to antiepileptic and immunomodulatory therapies was poor. Evolution to chronic epilepsy occurred without a silent period. Seizure characteristics in the chronic phase were strikingly stereotyped and similar to the acute phase, with head and eye version, unilateral facial jerking, asymmetric tonic posturing, and unilateral limb jerking in all patients. Electrographic ictal onset was lateralized in all recorded seizures, unilateral in one patient, and independent bilateral in three. Seizures were refractory to multiple antiepileptic medications in all patients and partly responsive to chronic vagus nerve stimulation in two patients. Moderate to severe intellectual impairment was noted in four patients, and borderline intellectual abilities were noted in two. Magnetic resonance imaging (MRI) in the chronic phase was normal in three patients and showed mild diffuse cortical atrophy and/or mild hippocampal atrophy or sclerosis in three. The similar perirolandic and perisylvian features of acute and chronic seizures, the lack of a silent period, the absence of evidence of cerebral inflammation, and the poor response to immunotherapies suggest FIRES is best conceptualized as a chronic epilepsy with explosive onset, not a remote-symptomatic epilepsy with an acute inflammatory antecedent.

The correlation between ictal semiology and magnetoencephalographic localization in frontal lobe epilepsy

ObjectiveThe aim of this study was to investigate the correlation of ictal semiology with localization and/or lateralization by magnetoencephalography (MEG). MethodsSeven patients from the Neurology Department of the University Hospital Erlangen who underwent resective surgery for frontal lobe epilepsy (FLE) with an Engel 1a outcome were investigated retrospectively. MEG localizations were classified according to five compartments (separate or combined) of the frontal lobe: frontal basal (FB), frontal lateral (FL), frontal polar (FP), frontal mesial (FM), and frontal precentral (FPr). On the basis of previous studies that investigated the value of ictal semiology in localization and lateralization, we compared the experiential localization and/or lateralization of the epileptogenic region deduced from ictal semiology, that is, both seizure history and ictal video/EEG monitoring, with MEG localization. ResultsIt is easier to determine lateralization than localization from ictal semiology because of the variety of signs and fast propagation in FLE. All of the patients had specific MEG localizations according to favorable postoperative outcome. Three patients had MEG foci associated with ictal semiology; in another four, the MEG localization was adjacent to the estimated area suggested by ictal semiology. Head version signs could be observed in all compartments of the frontal lobe: clonic in FB and FP areas; postural in FPr, FL, and FM areas; hypermotor in FB, FP, FPr, and FM areas; sensation aura in FB, FL, and FM areas; and automatisms in FP, FPr, and FL areas. All patients had concordant lateralizing and limited valuable locating information from ictal semiology, but no complete correlation with MEG foci. ConclusionIctal semiology may indicate the involvement of a symptomatogenic brain region during a seizure, but extent of seizure onset in central motor or sensorimotor area is not reliable enough to indicate the seizure onset zone and favorable postoperative outcome in FLE. MEG provided specific localization of epileptic activity in a FLE compartment, and indicated the relationship between epileptogenic region and lesion. MEG can complement ictal semiology in establishing a noninvasive focal localization hypothesis.

Vanderbilt head and neck symptom survey version 2.0: Report of the development and initial testing of a subscale for assessment of oral health

The prevalence, severity, and functional implications of adverse oral health outcomes attributed to head and neck cancer therapy are largely undefined. We report development of an oral health outcome subscale for the Vanderbilt Head and Neck Symptom Survey (VHNSS). Oral health outcome questions were formulated through literature review and consultation with an expert panel. Questions were incorporated into the VHNSS resulting in a 50-item survey, scored 0 (none) to 10 (severe). The tool was administered to 70 subjects who completed radiation to assess for feasibility. Patient acceptance was high with a completion time <10 minutes. A full range of scores was noted for 46 of 50 questions. Oral health symptom burden was high early and late posttreatment. The VHNSS version 2.0 was feasible and could be completed in a timely manner. Validation studies are ongoing. The high prevalence of adverse oral health outcomes warrants further study.

Il trattamento degli esiti delle fratture dell’omero prossimale in viziosa consolidazione o in non unione

Prospective follow-up data after non-surgical treatment for proximal humerus fractures are scarce. Operative treatment of displaced and pluri-fragmentary proximal humeral fractures can lead to malunion or non-union. Even two-part fractures can lead to a varus malunion that frequently causes pain and functional limitation. Surgical treatment of malunions and non-unions is technically challenging for the orthopedic surgeon and frequently results in a relatively high rate of complications. From 1996 to 2009, 30 patients with proximal humeral fracture sequelae underwent surgical osteotomy to restore humeral head version and the position of tuberosities. In seven patients we performed arthroplasty (4 standard and 3 reverse). In other cases, we used arthroscopy to treat greater tuberosity malunion, secondary impingement, and associated cuff tear.

Risk Factors for Failure After Open Reduction for DDH

No controlled data exists regarding the risk factors for redislocation after a technically proficient open reduction for developmental dysplasia of the hip (DDH). The purposes of this study were to examine predictors of redislocation and to evaluate the long-term outcomes after revision surgery. We performed a retrospective match-controlled study comparing 22 patients who had successful open reduction for DDH with 22 who required revision open reduction. Radiographs were compared in terms of acetabular index, pelvic width, triradiate cartilage width, height of dislocation, size of ossific nucleus, abduction angle in the spica cast, Tönnis grade, and Severin grade. At final follow-up, Sharp's angle, center-edge angle, migration index, and continuity of Shenton's line were compared between the 2 cohorts. Hips were reclassified according to the Tönnis and Severin criteria, and graded for avascular necrosis. Univariate t tests, multivariate logistic regression, and Fisher exact tests were used to compare the statistical data. Twenty-five of 421 patients (5.9%) developed a redislocation at a mean of 124 days after the initial open reduction. Patients with right or bilateral DDH were significantly more likely to fail (P=0.01). Compared with matched controls, the 22 study patients had significantly larger pelvic width and lower abduction angle (mean 39 degrees vs. 51 degrees) in the postoperative spica cast (P=0.003 and 0.037). According to the surgeon's findings at revision surgery, the most common reasons for failure were a dysmorphic femoral head and abnormal femoral version. At final follow-up, subluxation rate and Severin grade were significantly higher in the revision group versus controls but the incidence of avascular necrosis was comparable (revision group=55% and control group=41%; P=0.55). On the basis of this study, right-sided (or bilateral) involvement, greater pelvic width, and decreased abduction in the spica cast were risk factors for redislocation after open reduction. We believe that abnormal femoral version and femoral head dysplasia are also important factors although they were not addressed in this study. Level III (case-controlled study).

Brain activation patterns of versive, hypermotor, and bilateral asymmetric tonic seizures

Patients who have seizure onset from different brain regions can produce seizures that appear clinically indistinguishable from one another. These clinically stereotypic manifestations reflect epileptic activation of specific networks. Several studies have shown that ictal perfusion single photon emission computed tomography (SPECT) can reveal propagated ictal activity. We hypothesize that the pattern of hyperperfusion may reflect neuronal networks that generated specific ictal symptomatology. All patients were identified who were injected with (99m)Tc-hexamethyl-propylene-amine-oxime (HMPAO) during versive seizures (n = 5), bilateral asymmetric tonic seizures (BATS; n = 5), and hypermotor seizures (n = 7) in the presurgical epilepsy evaluation between 2001 and 2005. The SPECT ictal–interictal difference image pairs of each subgroup were compared with image pairs of 14 controls using statistical parametric mapping (SPM 2) to identify regions of significant hyperperfusion. Hyperperfused regions with corrected cluster-level significance p < 0.05 were considered significant. We have identified a distinct ictal perfusion pattern in each subgroup. In versive seizure subgroup, prominent hyperperfusion was present in the frontal eye field opposite to the direction of head version. In addition, there was associated caudate and crossed cerebellar hyperperfusion. The BATS subgroup showed pronounced hyperperfusion supplementary sensorimotor area ipsilateral to the epileptogenic region, bilateral basal ganglia, and contralateral cerebellar hemisphere. The hypermotor seizure subgroup demonstrated two clusters of significant hyperperfusion: one involving bilateral frontomesial regions, cingulate gyri, and caudate nuclei, and another involving ipsilateral anteromesial temporal structures, frontoorbital region, insula, and basal ganglia. We have identified distinct hyperperfusion patterns for specific ictal symptomatology. Our findings provide further insight into understanding the anatomic basis of seizure semiology.

Metaversion can reliably predict humeral head version: A computed tomography-based validation study

Circumstances occur when the determination of anatomic humeral head version is difficult. In the setting of irreparable proximal humeral fracture, there are few reliable intraoperative landmarks to determine anatomic humeral head version. This study tested our hypothesis that the metaphyseal version (metaversion) is a landmark that can assist with correct head version and used computed tomography (CT) to evaluate its reliability as a predictor of anatomic version. CT scans from 50 consecutive patients (20 women, 30 men) were examined using commercial software. Patients were a mean age of 46 years (range, 17-85 years). Exclusion criteria included previous fracture, arthritis, or humeral deformity. The metaversion and humeral head version were measured. Measurements were conducted independently by 2 surgeons blinded to the results of the other. Interobserver and intraobserver reliability was calculated using intraclass correlation. The mean difference between the metaversion and the humeral head version was 2.5° (95% confidence interval [CI], 0.9°-3.9°). The mean difference between metaversion and humeral head version was 1.8° (95% CI, 0.0°-3.6°) in women, 2.9° (95% CI, 0.6°-5.1°) in men, 2.4° (95% CI: 0.6°-4.1°) in right shoulders, and 2.5° (95% CI, -0.1° to 5.1°) in left shoulders. Interrater and intrarater reliability was excellent, 0.97 and 0.98, respectively. Proximal humeral metaphyseal version (metaversion) is an accurate predictor of ipsilateral humeral head version.

Clinical Reasoning: A 9-year-old girl with seizures and encephalopathy

A 9-year-old girl presented to the emergency department with seizures and altered mental status. Her seizures were characterized by left eye deviation and head version followed by generalized tonic-clonic movements. She received 20 mg of phenytoin equivalents per kilogram of IV fosphenytoin and 4 mg of IV lorazepam. She was febrile (102°F), but otherwise had normal vital signs. On examination, she was lethargic without focal cranial nerve findings or weakness. She experienced mood lability and visual hallucinations, but had no further seizures. She previously had normal development with no decline in cognition or school performance. She was on levothyroxine for hypothyroidism resulting from prior thyroiditis with a goiter. There were no recent medication changes or infections. Family history included hypothyroidism and lupus; there was no family history of epilepsy or neuropsychiatric disorders. ### Questions for consideration: 1. What is the differential diagnosis for seizures and encephalopathy in a pediatric patient? 2. How do the patients' history and physical examination narrow or broaden the differential diagnosis? 3. What diagnostic tests would you order? The differential diagnosis for seizures with persistent altered mental status includes nonconvulsive status epilepticus, CNS infections, metabolic encephalopathies, structural lesions, toxins, acute disseminated encephalomyelitis, and inflammatory encephalopathies. In this patient, pertinent data included pyrexia, seizures, and thyroiditis. Meningitic doses of antibiotics and acyclovir were initiated on presentation. …

Vanderbilt Head and Neck Symptom Survey Version 2.0 (VHNSS 2.0): A tool for the study of long-term oral health consequences of therapy for head and neck cancer (HNC).

9055 Background: HNC therapy causes adverse late oral health outcomes (LOHO), the prevalence, severity, and functional implications of which are largely unknown. VHNSS 1.0 was developed to measure treatment-related symptom burden, but common LOHO were not included. We report the development of a LOHO subscale. Methods: Questions were developed by an expert panel and review of oral health measures for the general population. Final tool included 50 items which scored symptoms or functional manifestations from 0 (none) to 10 (severe). It was administered to 70 subjects who completed radiation ± chemotherapy. Results: Completion time <10 minutes. To focus on late effects, we report on 48 participants ≥ 6 months post-treatment. 60% reported moderate/severe (M/S) xerostomia which impacted chewing/swallowing (54%), speaking (39%), and sleeping (30%). 44% reported M/S thick mucous resulting in choking/gagging (22%), difficulty swallowing (22%), and altered sleep (15%). 28% reported M/S voice changes with hoarsene...