Potential Risks Factors Research Articles

Vascular deficits contributing to skeletal fragility in type 1 diabetes.

Over 1 million Americans are currently living with T1D and improvements in diabetes management have increased the number of adults with T1D living into later decades of life. This growing population of older adults with diabetes is more susceptible to aging comorbidities, including both vascular disease and osteoporosis. Indeed, adults with T1D have a 2- to 3- fold higher risk of any fracture and up to 7-fold higher risk of hip fracture compared to those without diabetes. Recently, diabetes-related vascular deficits have emerged as potential risks factors for impaired bone blood flow and poor bone health and it has been hypothesized that there is a direct pathophysiologic link between vascular disease and skeletal outcomes in T1D. Indeed, microvascular disease (MVD), one of the most serious consequences of diabetes, has been linked to worse bone microarchitecture in older adults with T1D compared to their counterparts without MVD. The association between the presence of microvascular complications and compromised bone microarchitecture indicates the potential direct deleterious effect of vascular compromise, leading to abnormal skeletal blood flow, altered bone remodeling, and deficits in bone structure. In addition, vascular diabetic complications are characterized by increased vascular calcification, decreased arterial distensibility, and vascular remodeling with increased arterial stiffness and thickness of the vessel walls. These extensive alterations in vascular structure lead to impaired myogenic control and reduced nitric-oxide mediated vasodilation, compromising regulation of blood flow across almost all vascular beds and significantly restricting skeletal muscle blood flow seen in those with T1D. Vascular deficits in T1D may very well extend to bone, compromising skeletal blood flow control, and resulting in reduced blood flow to bone, thus negatively impacting bone health. Indeed, several animal and ex vivo human studies report that diabetes induces microvascular damage within bone are strongly correlated with diabetes disease severity and duration. In this review article, we will discuss the contribution of diabetes-induced vascular deficits to bone density, bone microarchitecture, and bone blood flow regulation, and review the potential contribution of vascular disease to skeletal fragility in T1D.

GIS BASED FREQUENCY DISTRIBUTION OF WINGLESS INSECTS INFESTING DOMESTIC POPULATION OF DOGS IN LAHORE, PUNJAB, PAKISTAN

The intent of the present study was conducted (January, 2020 to December, 2020) to estimate the prevalence of wingless insects in dog population and to identify the potential risks factors in selected areas of Lahore, Punjab, Pakistan. Results of the study revealed an overall prevalence of wingless insects 50.16% (1204/2400) in dogs of study area. Among various insects, fleas were found predominant (28.5%; 684/2400; P<0.05) as compared to lice (21.66%; 520/2400). Among the reported species 4 were wingless insects (Ctenocepahlides (Ct.) felis, Ct, canis, Linognathus setosus and Trichodectes canis). Breed, age and sex of host were not found to be related with risk factors (P>0.05) affecting incidence of wingless insects. These inscets effect different body parts differently as highest prvelance was noted at neck (15%) and back (11.5%) followed by abdomen (10%) and ear (7.4%).Prevelence of the ectoparasites was found to be 6.2% at forelegs and 4% in congenital area, 4% around the shoulder and 6% around the hind legs, however, tail area was minimally affected (1.2%). Prevelance of Ct. felis was noted to be 35.96, Ct. canis 68.43%, Linognathus setosus 21.1% and Trichodectes canis 78.8%. Town wise incidences were found to be highest in Shalimar Town (62.91%) followed by Wagha Town (59.58%), Aziz Bhatti(59.16%), Data Ganj Bakhsh (55.41%), Nishtar Town (46.66%), Samanabad (44.3%), Iqbal Town (43.6%), Ravi Town (42%), Lahore Cantonment (41.6%) and Gulberg (40.4%). Rate of ectoparasites infestation was observed higher (P<0.05) in stray dogs (80.36%) followed by guard dogs (63.7%), hunting dogs (37.5%) and pet dogs (35.66%). Amongst the different seasons, rainy season showed higher lice prevalence (26.1%; 157/600), fleas (37.8%; 227/600), as compared to summer season and spring. Though, summer season was found to be unfavourable for the increase of almost all these insects. Comparative results of blood profile revealed significant difference (P<0.05) between non-infested and infested dogs, in the sort of lower value of infested/infected animals. To control the prevelance and ultimate effect of wingless insects on dog population applicable a well planned and control startegies as well as extension facilities should be arranged. Pet owners should be provided awareness about the significance of controlling the wingless insects to keep the pets and owner healthy.

Hypersensitivity reactions to iodinate contrast media in Italy: a retrospective study. Characteristics of patients and risk factors.

Objective. The purpose of the study was to describe the characteristics of patients experiencing hypersensitivity reactions (HRs) to iodinated contrast media (ICM) in a large Italian population and to investigate potential risks factors in order to obtain a risk stratification, helpful in the management of these patients. Methods. Data of 407 patients investigated in 9 Italian Allergy Centers for suspected HRs to ICM were analyzed and compared with a control group of 152 subjects that tolerated one or more ICM-enhanced examinations. The univariate and multivariate logistic regression model was used to evaluate associated factors. Results. The mean age of reactive patients was 61 years and 60% were female; 67% of patients reported immediate reactions and 35% experienced the reaction, more frequently with immediate onset, at the first examination in life. Iomeprol, iopromide and iodixanol were the most frequent culprit agents and 20% of patients showed a positive skin test result. Previous adverse reactions to ICM were reported by 15.6% of patients, whereas 35% of subjects experienced the reaction, more frequently immediate, after the first ICM-enhanced examination in their life. The multivariate analysis showed that male gender and age > 65 were associated with ICM reactions as protective factors [ORadja = 0.51; 95% CI: 0.33-0.77 and ORadja = 0.60; 95% CI: 0.39-0.92 respectively]. Cardio-vascular disease [ORadja = 2.06; 95% CI: 1.22-3.50)], respiratory allergy [ORadja = 2.30; 95% CI: 1.09-4.83)] and adverse drug reactions [ORadja = 1.99; 95% CI: 1.05-3.77)] were identified as risk factors for ICM reactions. Food allergy was not significantly associated with reactions [ORadja = 1.51; 5% CI: 0.41-5.56]. Conclusions. This is the largest study on Italian patients experiencing hypersensitivity reactions to ICM. Most results are in line with other studies, showing some association with factors that could influence the incidence of hypersensitivity reactions but not allowing an easy risk stratification.

Prognosis and Risk Factors of Stroke After Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection.

Background: Stroke is a severe complication of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). Our aim is to identify predictors of stroke after TEVAR.Methods: From February 2016 to February 2019, 445 patients with TBAD who underwent TEVAR were retrospectively analyzed. Univariate and multivariate analyses were performed to identify predictors of stroke after TEVAR.Results: The total incidence of stroke was 11.5%, with transient neurological dysfunction (TND) of 10.6% and permanent neurological dysfunction (PND) of 0.9%. The average age of the patients was 53.0 ± 3.2 years, and the male/female ratio was 1.17. Univariate analysis suggested that age, body mass index (BMI), diabetes mellitus, chronic obstructive pulmonary disease (COPD), the urgency of repair, type of anesthesia, and left subclavian artery (LSCA) processing were potential risks factors of stroke after TEVAR. Multiple logistic regression identified that LSCA coverage (OR = 5.920, 95% CI: 2.077–16.878), diabetes mellitus (OR = 3.036, 95% CI: 1.025–8.995), and general anesthesia (OR = 2.498, 95% CI: 1.002–6.229) were independent predictors of stroke after TEVAR.Conclusions: Left subclavian artery (LSCA) coverage, diabetes mellitus, and general anesthesia were independent risk factors of stroke after TEVAR for TBAD.

Can We Predict the Progression of Vertebral Collapse in Conservative Treatment of Osteoporotic Vertebral Fractures? A 3-Year Retrospective Study of 180 Patients From the Emergency Department.

Osteoporotic vertebral fractures (OVFs) have a high incidence in the elderly population and are usually treated conservatively with good outcomes. Nevertheless, failure of the conservative treatment may lead to serious complications. The aim of the study is to identify clinical, radiographic, and magnetic resonance imaging findings potentially related to the failure of the conservative treatment of OVFs. Data from 620 patients treated in the emergency department for vertebral fracture from 2014 to 2016 were analyzed; after patient identification and inclusion criteria, only fresh OVFs of patients older than 65 years have been included. Main outcome measurements were vertebral collapse, fracture shape types, and progression of vertebral collapse. A progression of vertebral collapse >100% was taken as an independent variable to underline the statistically significant difference among the risk factors. A total of 180 patients (138 women; 42 men) and 200 OVFs were analyzed (mean age = 77 years, range = 65-94 years). Potential risks factors for the progression of vertebral collapse >100% were found when fractures occurred in the thoraco-lumbar junction. The swelling type and the bow-shaped type showed higher risk of vertebral collapse, while the concave was the most stable type of fracture with good prognosis. Traumatic fractures had lower risks of fracture progression compared to nontraumatic fractures (eg, fractures after an effort). A linear black signal pattern on short inversion time inversion recovery findings of magnetic resonance imaging corresponded to a risk of progression of the vertebral collapse. Thoraco-lumbar fractures, swelling and bow-shaped fractures, and a linear black area at MR are negative prognostic factors for the failure of conservative treatment. 4. The identification of negative prognostic factors may lead to different strategies of treatment to prevent vertebral collapse or failure of conservative treatment.

Frequency And Potential Risks Factors For Systemic Reactions (SRs) During Subcutaneous Immunotherapy (SCIT) In A Puerto Rican Cohort.

Frequency And Potential Risks Factors For Systemic Reactions (SRs) During Subcutaneous Immunotherapy (SCIT) In A Puerto Rican Cohort.

Resident Attrition in Plastic Surgery: A National Survey of Plastic Surgery Program Directors.

Attrition in plastic surgery is poorly characterized in the literature with previous data indicating that independent residents may have a higher rate of voluntary attrition with integrated residents having a higher rate of involuntary attrition. The aim of this study is to identify risk factors, note differences between pathways, and provide insight into resident attrition from plastic surgery residencies. An institutional review board-approved anonymous, multiple-choice and short answer, online survey regarding resident attrition was sent to all plastic surgery program directors (PDs) in the United States focusing from 2003 to 2013. Outcomes measured included demographics of the program and attritional resident, timing and reasons for attrition, and possibility of preventing attrition. Thirty-three (35%) of 95 PDs responded. Average attrition rates were calculated at 2.15% for independent and 0.85% for integrated programs. Risk factors for attrition included being single, divorced, male, and having no dependents. One hundred percent of independent residents left by year 2, and 86% of integrated residents left by year 4. Lifestyle and loss of interest were most sited reasons for attrition. Most independent residents returned to their original field of training, whereas integrated residents were more likely to transfer to another integrated program. Only 17% of PDs believed attrition could have been prevented. Approximately 3.0% of all plastic surgery residents underwent attrition. Being single, male, divorced, or having no dependents increases the risk of attrition in plastic surgery residencies. This is the first study to demonstrate potential risks factors for plastic surgery residents undergoing attrition.

Exercise and Cancer Survivors: Lessons Learned from a Multi-Faceted Model for Exercise Prescription.

Cancer is the second leading cause of death, and the most common diagnosis among the general population is breast and colon cancer. Recently, an increasing number of new cases of invasive breast and colon cancer have been estimated, and more people die from these diseases. In addition to the genetic pattern, diet and lifestyle including smoking, alcohol consumption, and sedentary behaviour have also been identified as potential risks factors. Recent studies of cancer survivors have shown the beneficial effects of regular physical activity to reduce the prevalence of comorbidity, muscle atrophy, weight changes, reduced aerobic capacity, fatigue, depression, and reduced quality of life. Dedicated and individual programs are crucial for achieving the goals of improving quality of life and reducing comorbidities. A multidisciplinary approach is fundamental: lifestyle assessment, including estimating the level of physical activity, as well as nutritional habits, may be the first step. A periodic cardiovascular examination is crucial for detecting asymptomatic early myocardial failure. According to current ACSM guidelines, different levels of exercise (low-moderate 40% and moderate up to 60% of the maximal HR) may be prescribed, and patients enrolled may follow the exercise program if in the absence of contraindications. The current paper reports observations from our clinical practice and provides practical strategies that bridge contemporary, published guidelines into practice within a multi-disciplinary team working with cancer survivors in Italy.

A proposed Mining System for Recognition of the Peripheral Arterial Disease and Analyzing Risk Factors

Association rule techniques is considered as one of the most well-known techniques which has been employed to find the most dominant associations and correlations of the items within large data set. Thus, it can be used as useful method to analyze and fix many data mining issues. In this research, the association rule has been adopted as a proposal method for the cases that are related to peripheral arterial disease (PAD) risk factor.
 PAD is one of the most common problem with high morbidity and mortality, which has many potential risks factors that might affect its severity. Such factors can be modified, and beneficial to good assessment and diseases’ progress control and the effect of those treatments and its modalities, by the understanding of some relations between those factors. The gender factor among other factors was not discussed because the ratio of male to female is almost the same. Our data collected out from 250 patient persons with PAD which was analyzed and recognized. By the use of the proposed method that implemented within two stages: firstly we implemented stage a back propagation-NN was trained on records of patients with PAD, and secondly the association rules encoding was performed, here the relations between pre-disposing factors was extracted.
 Our proposed miming system offers a faster and better data analysis and recognition; also it reduces time, efforts, and also explores the relations between factors. Therefore, we got the relations those been mentioned above, in which they are important in the process of PAD management in the future.
 There was a strong relations among alcoholism, smoking ,diabetes and

Volatile Organohalogen Compounds Determination with Dispersive Liquid-Liquid Microextraction Applying Solvent Lighter than Water

Background: Volatile organohalogen compounds (VOX) are a group of environmental pollutants that risk the quality of drinking water. These compounds are characterized by certain acute and chronic toxicities, possessing mutagenic properties. Because of these potential risks factors that these compounds cause, the maximum allowable concentrations (MACs) have been established by respective organizations. The abundance of VOX, their potential hazards and legislation are driving factors to develop analytical procedures for their determination in water samples. Objective: The aim of the study is to develop greener DLLME technique for VOX determination in water samples, incorporating extraction solvent lighter than water. To achieve this goal the design of new extraction device is required. Methods: The DLLME-GC-ECD procedure was developed to perform an analysis of water samples in order to determine VOX. The sample preparation step was performed by applying the solvent lighter than water (pentane). Results: The best results regarding sample preparation are obtained when 70 µ L of pentane is used as extractant solvent, 0.5 mL acetone is used as dispersive solvent. The analytical procedure is characterized by good analytical performance with limit of detection within 0.0010 - 0.30 µ g L-1 and precision within 2.4 - 6.6% range. Conclusion: Dispersive liquid-liquid microextraction is a suitable technique for determination of VOX. The newly designed extraction device is suitable for extraction of organic compounds as the area of polymeric parts is greatly reduced in comparison to similar home-made extraction devices. It allows for application of pentane - solvent lighter than water and safer in use than carbon disulfide.

The application of improved modified early warning score combined with predictive symptomatic nursing to the tuberculosis hemoptysis patients

Objective To explore the application effect of modified early warning score combined with predictive symptomatic nursing system to patients with hemoptysis tuberculosis. Methods A total of 30 patients with hemoptysis tuberculosis treated in our hospital from November 2014 to May 2015 were chosen as the control group by the random sampling method.While another 30 patients with hemoptysis tuberculosis treated in our hospital from July 2015 to January 2016 were chosen as the observation group by the random sampling method.The observation group were treated by the modified early warning score system, while the control group adopted the routine nursing care.The occurance rate of complications, average times of hemoptysis, interval time of hemoptysis and average hospital stay of the two groups were compared. Results The average times of hemoptysis, interval time of hemoptysis, hospital stay and the occurance rate of the complications of the observation group was significantly lower than that of the control group(P<0.05). Conclusions The application of modified early warning score system to patients with hemoptysis tuberculosis can find out the potential risks factors as soon as possible, decrease the times of hemoptysis, reduce the occurance rate of complications and shorten the time of hemoptysis and hospital stay. Key words: Modified early warning score; Hemoptysis tuberculosis; Application value; Nursing care

High Body Mass Index (BMI) and Smoking as Potential Risk Factors Associated with Adenomatous Polyp Detection in Young Patients

Introduction: Adenomatous polyps (AP) are the most common precursor lesions for colon cancer. Colonoscopy can effectively detect and remove these lesions justifying it an irreplaceable cancer prevention method. The prevalence of AP is variable and an older age is a major risk factor. In fact, AP in young patients (under 40 years old) is quite rare, particularly in individuals without any known genetic syndromes associated with a possible risk of colon cancer. To study associated factors (comorbidities and risk behaviors) in such young patients may help to identify potential new risks factors for colon cancer development. Methods: Thirty-four patients were identified who were under 40 years old and had AP including sessile serrated polyp/adenoma (SSP/A) detected by colonoscopy during the years of 2013 to 2015. Patients age, sex, colonic pathology and location of polyp, and bmi were reviewed. To obtain this information, the review was done in the electronic medical record through review of epic patients' charts and endoscopy reports through Provation Results: Forty- seven percent (16/34) patients were female, sixty percent (18/34) were male. Thirty-two percent of patients (11/34) had polyp sizes less than 5 mm. Forty-seven percent of patients (16/34) had polyp sizes between 5 mm and 10 mm. Twenty-one percent of patients (7/34) had polyp sizes over 10 mm. Twelve percent of patients (4/34) had a BMI less than 24.9. Forty-one percent of patients (14/34) had a BMI between25 and 29.9 classified as overweight. Forty-seven percent of patients (16/34) had a BMI over 30 classified as obese. Fifty three percent of patients (18/34) reported a positive smoking history or were a current smoker. The majority of polyps (56%) (19/34) were detected in the sigmoid colon. Conclusion: Based on this retrospective chart review, in a young patient population (age range between 30-49), a BMI over 25 and a positive smoking history or being a current smoker was associated with a higher likelihood of detection of tubular adenoma on colonscopy. Follow-up surveillance colonscopy intervals were variable, with the most common follow-up interval being approximately 5 years.

Outbreak of diarrhoeal illness in participants in an obstacle adventure race, Alpes-Maritimes, France, June 2015.

An acute gastroenteritis (AG) outbreak occurred among participants in an obstacle race in France in the summer of 2015. An investigation in two phases was conducted to identify the source of infection and document the extent of the outbreak. First, a message on a social media website asked racers to report any symptoms by email to the Regional Health Agency of Provence-Alpes-Côte d'Azur. Second, a retrospective cross-sectional study was conducted through an interactive questionnaire for all participants, followed by an analytical study of potential risks factors. Of 8,229 persons registered, 1,264 adults reported AG resolved within 48 hours. Of adults who reported AG, 866 met the case definition. Age group, departure time and ingestion of mud were associated with AG. Twenty stool specimens tested negative for bacteria. All four stool samples tested for viruses were positive for norovirus genogroup I and genotype 2. No indicator bacteria for faecal contamination were found in drinking water but muddy water of ponds tested positive. The outbreak was possibly caused by human-to-human transmission of a norovirus introduced by one or more persons and transmitted through contaminated mud. Risks related to similar races should be assessed and recommendations be proposed to raise awareness among health authorities and organisers.

Neonatal Mortality, Vesicular Lesions and Lameness Associated with Senecavirus A in a U.S. Sow Farm.

SummaryA 300‐sow farrow‐to‐finish swine operation in the United States experienced a sudden and severe increase in mortality in neonatal piglets with high morbidity followed by vesicular lesions on the snout and feet of adult females and males. Affected live piglets were submitted for diagnostic investigation. Samples tested polymerase chain reaction (PCR) negative for foot‐and‐mouth disease virus, porcine delta coronavirus, porcine epidemic diarrhoea virus, porcine rotavirus types A, B and C, transmissible gastroenteritis virus, and porcine reproductive and respiratory syndrome virus. Senecavirus A (SV‐A) formerly known as Seneca Valley virus was detected by real‐time reverse‐transcription polymerase chain reaction (rRT‐PCR) from serum, skin and faeces of piglets and from serum and faeces of sows. SV‐A was isolated in cell culture from piglet samples. SV‐A VP1 gene region sequencing from piglet tissues was also successful. A biosecurity and disease entry evaluation was conducted and identified potential biosecurity risks factors for the entry of new pathogens into the operation. This is the first case report in the United States associating SV‐A with a clinical course of severe but transient neonatal morbidity and mortality followed by vesicular lesions in breeding stock animals. Veterinarians and animal caretakers must remain vigilant for vesicular foreign animal diseases and report suspicious clinical signs and lesions to state animal health authorities for diagnostic testing and further investigation.

Management of the temporomandibular joint after ablative surgery.

Management of the temporomandibular joint in ablative head and neck surgery is controversial with no standardized approach. The aim of the study was to establish risk-based guidelines for the management of the temporomandibular joint after ablative surgery. Analysis of all patients' records receiving ablative surgery involving the temporomandibular joint in the Department of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zürich, from 2001 to 2012, was performed, identifying 15 patients and 14 reconstructive procedures. A literature search was done identifying all relevant literature on current approaches. Applicable cohorts were constructed, and relevant risks were extrapolated. Evaluated studies are not uniform in their reporting with nonhomogeneous patient groups. A diverse approach is used in the management of these patients with complications such as infection, ankylosis, limited mouth opening, plate penetration in the skull base, and plate loosening. Risk factors for complications appear to be radiation, costochondral graft, disk loss, and plate use alone. Clinical data suggest use of a plate with metal condyle reconstructions and previous radiation therapy as potential risks factors. Employing literature evidence and cumulated clinical data, a risk-based flowchart was developed to assist surgical decision making. Risk factors such as radiation, disk preservation, and soft tissue conditions are important complication-associated factors when planning surgery. Free vascularized fibula grafts appear to have the least complications that must be weighed against donor site morbidity.

Cluster detection of diseases in heterogeneous populations: an alternative to scan methods.

Cluster detection has become an important part of the agenda of epidemiologists and public health authorities, the identification of high- and low-risk areas is fundamental in the definition of public health strategies and in the suggestion of potential risks factors. Currently, there are different cluster detection techniques available, the most popular being those using windows to scan the areas within the studied region. However, when these areas are heterogeneous in populations' sizes, scan window methods can lead to inaccurate conclusions. In order to perform cluster detection over heterogeneously populated areas, we developed a method not based on scanning windows but instead on standard mortality ratios (SMR) using irregular spatial aggregation (ISA). Its extension, i.e. irregular spatial aggregation with covariates (ISAC), includes covariates with residuals from Poisson regression. We compared the performance of the method with the flexible shaped spatial scan statistic (FlexScan) using mortality data for stomach and bladder cancer for 8,098 Spanish towns. The results show a collection of clusters for stomach and bladder cancer similar to that detected by ISA and FlexScan. However, in general, clusters detected by FlexScan were bigger and include towns with SMR, which were not statistically significant. For bladder cancer, clusters detected by ISAC differed from those detected by ISA and FlexScan in shape and location. The ISA and ISAC methods could be an alternative to the traditional scan window methods for cluster detection over aggregated data when the areas under study are heterogeneous in terms of population. The simplicity and flexibility of the methods make them more attractive than methods based on more complicated algorithms.

Hyoid-related internal carotid artery dissection

A 30-year-old man without cardiovascular risk factors presented, after 1 week of right-sided anterior neck pain, with acute left hemiplegia immediately after heavy weight lifting (i.e., removing large boxes filled with books with the head in mid-position without rotation). There was no recent history of head or cervical trauma. Brain MRI showed an acute infarction in the right middle cerebral artery territory. Carotid duplex examination revealed a high degree of stenosis of the right internal carotid artery, which was confirmed by CT angiography showing a segmental tapered narrowing of the right internal carotid artery located just lateral of the greater horn of hyoid bone, in the absence of atheromatous plaques (Fig. 1). Fat-saturated T1 MRI showed the presence of an intramural hematoma in the right internal carotid artery. A diagnosis of carotid dissection, in absence of clear head/ cervical trauma was made, and anticoagulation treatment was started. CT angiography also showed a 90-mm-long bilateral elongated styloid process (Fig. 1). However, the tip of the elongated styloid process was located at 9.1 mm of the right internal carotid artery, and the smallest distance between the body of the elongated styloid process and the right internal carotid artery was 3.5 mm, making impingement of the carotid artery by the styloid process, even with head rotation or flexion, unlikely. Another abnormality was noticed on CT angiography, consisting of an elongated hyoid bone resulting in a extremely reduced distance of 1.6 mm between the anterior tubercle of the transverse process of the third cervical vertebra and the greater horn of the hyoid bone (Figs. 1, 2). Three months later, CT angiography revealed complete recanalization of the right internal carotid artery (with a diameter of 4.5 mm at the level of the greater horn of the hyoid bone), now located medial of the greater horn of the hyoid bone (Fig. 2). Carotid duplex examination showed normal velocities, in the absence of changes in velocities after head rotation. We hypothesized that intermittent change in position of the internal carotid artery (diameter 4.5 mm) through the small space (1.6 mm) between the third cervical vertebra and the hyoid bone may have provoked the arterial dissection, although carotid injury due to the elongated styloid bone could not be excluded. In a vast portion of patients with carotid dissection, there is no clear history of head or cervical trauma. The exact cause of these, so-called spontaneous, dissections is unclear. Recently, certain anatomic characteristics of the styloid process (i.e., the length and the proximity to the carotid artery) have been reported as potential risks factors for carotid dissection [1]. The stylohyoid complex consists of the styloid process, the stylohyoid ligament, and hyoid bone. Pathological conditions (called the stylohyoid complex syndrome) associated with these structures, which can include an elongated styloid process, ossified stylohyoid ligament, elongated hyoid bone, or combinations of several of these conditions (like in our patient with both elongated styloid process and elongated hyoid bone) can cause cervical and pharyngeal symptoms, probably related to irritation of the structures around this complex (including the carotid arteries and the cranial nerves VII, IX, and X) [2]. D. Renard (&) Department of Neurology, CHU Nimes, Hopital Caremeau, Place du Pr Debre, 30029 Nimes Cedex 4, France e-mail: dimitrirenard@hotmail.com

Risk Factors and Clinical Outcomes of Ventilator-Associated Pneumonia in Patients on the Liver Transplant Waiting List

BackgroundProlonged intubation results in ventilator-associated pneumonia (VAP), which contributes to significant mortality among patients on the waiting list. The aim of this study was to determine the risk factors for and clinical outcomes of VAP among patients into the intensive care unit (ICU). MethodsWe enrolled 50 consecutive critically ill patients with end-stage liver disease admitted to the ICU from January 2005 through December 2010. All patients were intubated for more than 4 days; no definite infection was found initially. We evaluated potential risks factors for VAP and clinical outcomes. ResultsSmoking, underlying liver disease, and lobar focal consolidations were significant factors for patients with versus without VAP. Fourteen-day mortality rates were 61.5% for VAP versus 40.5% for patients without VAP. Twenty-eight-day mortality rates for both groups were 92.3% and 86.5%, respectively. Multivariate analysis failed to identify independent predictors of early 14-day mortality. ConclusionsUnderlying liver disease and lobar focal consolidations were risks factors for VAP in patients with prolonged intubation. Patients with prolonged intubation have a dismal prognosis even without VAP. The clinical outcomes of patients with versus without VAP were similar. However, early liver transplantation (<14 days of intubation) improves the chance to rescue patients before development of VAP.

Clinical evaluation of a temporary fecal containment device for non-surgical fecal diversion in perineal burns

The aim of this study was to evaluate the clinical results of a temporary fecal containment device (Flexi-Seal® FMS) in our burn center. All patients in whom temporary fecal containment devices were applied for perineal burns between August 2008 and August 2009 in our institution were reviewed. Demographics, etiology of burns, total body surface area (TBSA) burned, intensive care unit (ICU) need, early mortality, and post-application data were obtained from a prospectively designed database. In addition, some variables were investigated as potential risks factors for fecal leakage. The mean age of patients (n=15) was 43.1±22.1 years, and 66.7% of the patients were male. The mean %TBSA burned was 40.7±16.6. Fecal leakage was seen in 6 patients. Local infection in the perineum was observed in 6 patients, including 4 of the 6 patients with fecal leakage. The mortality rate was 33% (5 deaths). All exitus patients had 50% or more TBSA burned. Electrical burn injury was found as a significant risk factor for fecal leakage in surviving patients (p<0.05). Autologous split-thickness grafting was performed in 8 patients without complication. The mean duration of catheterization was 22.5±5.7 days. Except for superficial mucosal erosion in the distal rectum in 2 cases, no complication was observed. The mean hospitalization time was 46.7±12.7 days. If the safety of these devices is proven in further prospective, high-volume studies, they may reduce the necessity of diverting stoma operation in burn patients.

Comments on: Epidemiological study of urge urinary incontinence and risk factors in China

Dear Editor,Zhu and colleagues investigated urge urinary incontinence(UUI) and risk factors in China via a cross-sectional studyinvolving 20,000 adult Chinese women [1]. This cross-province survey is intriguing in that the authors provide uswith a general profile of UUI among the general populationin China. However, we are concerned about their interpre-tation of their findings.As many potential risks factors were not evaluated in thestudy, the conclusion that age is a major independent riskfactor of UUI as draw in the article would raise concerns.The diagnosis of UUI is mainly based on clinicalsymptoms. Thus UUI can be viewed as a clinical syndrome.A variety of diseases may present symptoms like UUI, andmany risk factors may contribute to the prevalence of UUI[2]. Limited by the methodological pitfall, this study failedto determine the causal relationships between UUI and riskfactors. We agree that UUI should not be accepted as anatural consequence of aging and being untreatable.Therefore, patients with UUI, especially those who haveatypical features or severe symptoms, should appeal tospecialist and undergo full assessment with cystoscopy andurodynamic study if necessary [2].In their study, severity assessment such as informationabout incontinence episode frequency was not reported.Although limited by the relatively sample size, it would beinteresting if there is a positive correlation between UUIseverity and age, which might support age as a major riskfactor indirectly.Besides the common risk factors of UUI like gyneco-logical diseases, urological disorders, as well as neurolog-ical disorders, such as cerebrovascular diseases mightaccount for the causes of UUI. In the light of thisconsideration, urological symptoms such as urodynia,hematuria, or neurological symptoms which may point toa neuropathic bladder as the cause of UUI (e.g., new onsetweakness, paraesthesia, back pain, visual disturbances) areof great value to clarify the etiology of UUI [3].In addition, since it is a cross-province survey, we wouldlike to know whether there is difference in the prevalence ofUUI among provinces, as well as between rural and urbanareas.