Iris Publishers- Open access Journal of Current Trends in Clinical & Medical Sciences | Medical Use of Povidone Iodine Against Covid-19. Why Not?

 

Authored by Luis Mendoza*

Opinion

Povidone-iodine (PVP-I) is an old antiseptic used in practice of medicine as a surgical scrub; for pre- and post-operative skin cleansing; for the treatment and prevention of infections in wounds, decubitus ulcers, cuts, and burns; in gynecology for vaginitis associated with candidal, trichomonal or mixed infections. For these purposes, PVP-I has been formulated at concentrations of 7.5- 10.0% in solution, nasal and throat spray, surgical scrub, ointment, swab dosage forms, eye drop, and vaginal suppositories. The safety profile of PVP-I at such concentrations is well established and many available products in the market are over the counter. The most well-known brand for PVP-I is BETADINE.

PVP-I has been reported as a broad‐spectrum microbicide with potency to inactivate bacteria, fungi, protozoans, and several viruses. After searching the medical database “PubMed” and entering the keywords: povidone-iodine and virus, I have found that there 101 scientific publications connect with PVP-I against viruses. The first publication about the efficacy of PVP-I was reported in 1975 where the PVP-I can reduce the titers of herpesvirus type 2 by 92% [1].

Recent in vitro studies have demonstrated virucidal activity of PVP-I against a wide range of enveloped and non-enveloped viruses and rapid virucidal activity against the Ebola virus, MERS-CoV, and European reference enveloped virus [modified vaccinia virus Ankara (MVA)} [2,3]. The first evidence of the virucidal activity of PVP-I against SARS coronavirus was published in 2006 [4]. German researchers demonstrated the virucidal activity of PVP-I as skin cleanser against the Ebola virus and as gargle/mouthwash against MERS-CoV and MVA. [2]. Thanks to the funding from Mundipharma Research GmbH & Co, German researchers published the rapid inactivation of SARS-CoV, MERS-CoV, influenza virus A (H1N1), and rotavirus after 15 seconds of exposure [5]. Mundipharma Research have developed several PVP-I based products and a gargle/ mouthwash.

In contrast to other antiseptic agents, PVP-I oral care products do not lead to any irritation or damage to the oral mucosa, even with prolonged use [5]. Respiratory Syndrome (MERS) coronavirus or endemic human coronaviruses, which is killing thousands of human beings currently, can persist on inanimate surfaces like metal, glass, or plastic for up to 9 days where the PVP-I (0.23-7.5%) readily inactivated coronavirus infectivity by approximately 4 log10 or more [6]. In a recent paper released on 27 March 2020 in the journal Lancet Infectious Disease, the French researchers confirmed the high viral loads in upper respiratory tract samples are suggestive of the potentially high risk of transmissibility during the very first days of symptoms [7]. This finding is in line with data reported by Zou and colleagues beginning of this year, who analyzed viral load in the upper respiratory tract in relation to day of onset of symptoms in 17 symptomatic patients in whom higher viral loads were detected soon after symptom onset [8].This observation suggests that the virus shedding pattern of patients infected with COVID-19 have a high viral load in the upper respiratory tract at the disease onset.

So far, here is no vaccination or any specific antiviral treatment available for COVID-19. The COVID-19 pandemic is controlled with can, however, be quickly and effectively controlled with preventive strategies based upon early accurate viral diagnosis and adequate hygiene practices to decrease the risk of transmission.

Considering the proven in vitro efficacy of PVP-I, I am convinced that it would be an effective method of preventing the growth and spread out of the viruses-containing airborne/droplet from the nose and mouth of an infected individual. It is also possible that a reduction of COVID-19 viral load at nose, nasopharynx and oropharynx may help to the individual to present less severe disease and reduce the number of deaths. The destruction of the COVID-19 viral load at the upper respiratory tract will reduce of infectivity of infected individual in the community and consequently help to eradicate the COVID-19 pandemic and all terrible consequences.

On the market, several PVP‐I formulations and presentations are available that differ in their composition and indications. Therefore, my suggestion for achieving an efficient anti-COVID-19 effect will be to recommend the frequent daily use of the PVP- based mouthwash for gargles and mouth rinse, combined with the PVP-I based nasal rinse or nasal spray or the application of the PVP-I based ointment to prevent the COVID-19 infection through nasal foramens. The use of the PVP-I products against COVID-19 is empiric and it may be used at least 4 times a day for health worker professionals or other professional exposure to large number of potential or COVID-19 positive individuals. For COVID-19 negative patients and for whose follow careful the recommendation of social isolation, the use of 1 or 2 times a day of PVP-I products for disinfection of nasopharynx and oropharynx might be enough. The length of PVP-I products as a prophylactic should till the risk of infectivity by COVID-19 is considered controlled by local authorities. Every country has different PVP-I products in the market, therefore the physician should look at of the available products a recommended the use for the viral cleaning and protection. The mouthwash shouldn’t be swollen. The PVP-I used in humans is innocuous, but the physician should be aware some allergic (hypersensitivity) cases have been reported. In case of allergic reactions, the PVP-I should be discontinued immediately. Several cases of thyroid dysfunction induced by transcutaneous absorption of povidoneiodine have been reported. Therefore, the monitoring of the thyroid function is recommended in patients with thyroid diseases. I must also highlight here that besides the use of the PVP-I products, it is imperative to continue following the recommendations about the necessary protective measures advised to the public by WHO.

Finally, even though the chemical composition is known, the reliability of virucidal activity of the marketed product cannot be predicted. Therefore, it is essential to test the PVP-I products in clinical trials to confirm the efficacy of them against COVID-19 primary infestation at the upper respiratory tract. In that regard, there are 3 ongoing COVID-19 clinical trials to demonstrate the prophylactic and therapeutic benefit of PVP-I as nasal alone and combined with gargle applications in USA. Meanwhile, not having therapeutic alternative against COVID-19, to enhance the preventive strategies, avoid movement and self-isolation to avoid the contagious or infectivity of the virus at the upper respiratory tract, the advice of health care and system to use of low-cost PVP-I products would be key to minimize the tragedy of the current COVID-19 pandemic. Why not.

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Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | Sensory Diets

Authored by  Vidya Pingale*

Mini Review

Sensory diets, a sensory-based intervention, are used by occupational therapists to manage sensory processing disorder (SPD). SPD is prevalent in children with diagnoses, such as autism, attention deficit hyperactive disorder, learning disabilities, fragile X syndrome, and developmental delays [1,2]. Children with SPD show a decreased ability to respond and organize sensory stimuli. As a result, SPD affects their participation in daily activities of self-maintenance, learning, play, sleep, and social interaction [3]. Sensory diets consist of a group of multisensory activities, such as pushing a ball, jumping on a trampoline, pushups, stationary postures. These activities are customized for a child based on his/her sensory processing patterns to provide sensorimotor experiences to help stay alert and organized [4].

A review of the literature on sensory diets in the last 15 years found five studies that investigated the effectiveness of sensory diets or interventions with similar conceptualization. Fazlioğlu, et al. [5] investigated the effect of sensory activities similar to sensory diets on children (n = 30) between the ages of 7-11 years with a diagnosis of autism using a randomized control design. A twogroup analysis of variance after 12 weeks of intervention showed a significant main effect for groups on total scores of the sensory evaluation form (F1,28 = 5.84, p< .05), pretest-posttest test time (F1,28 = 98.38, p< .01), interaction of group and time (F1,28 = 119.38, p< .01), and posttest scores (F2,27 = 167.16, p< .01), suggesting sensory activities can be beneficial in reducing sensory processing related issues in children with autism.

A study by Lin, et al. [6] used a matched group pretest-posttest design to observe the effect of sensory strategies on children (n = 36) between the ages of 3-6 years with SPD. Improvements in activity level (t [17] = 2.09, p=0.03) and feet-swinging (t [17] = 2.26, p=0.02) were noted after 8 weeks of intervention, suggesting sensory strategies can be effective in managing activity level and sensory seeking behavior.

Another study investigated the effect of sensory diets on sensory processing, psychosocial skills, and classroom engagement of children (n = 3) between the ages of 5-8 years with SPD using customized sensory diets. The binomial test results indicate that with sensory diets, all participants showed a significant decline in sensory seeking behaviors during individual (p<.05) and group activities (p<.10). Changes in interruptive or disruptive behaviors were significant for one participant for group activities, and all participants for individual activities (p < .05). Similarly, changes in classroom engagement were significant for all participants for group activities and one participant for individual activities (p < .05). These results favor the use of sensory diets for managing SPD [7].

A study that investigated the effect of a group proprioceptive program on nine-year-old children with SPD (n = 3) using a singlesubject ABA design and found a decline in the duration of aggressive behaviors of two participants and frequency of aggressive behaviors in one participant with nine days of intervention. Binomial test results suggest that the decline was (p< .05) statistically significant [8]. On the contrary, a single-subject alternating treatments design study that researched the effectiveness of sensory diets on children (n = 4) of ages 6-11 years with a diagnosis of autism did not find any improvements in self-injurious behaviors with 10 days of intervention [9]. Results of these studies cast doubt on the effect of sensory diets or similar interventions.

This review suggests that continued research is needed to investigate the effectiveness of sensory diets. Three studies in this review show promising results. However, intervention strategies, protocols, dosages, and dependent variables used in these studies show significant variations. These variations may have led to differences seen in the results of the studies. As it appears now, sensory diets can have a role in managing SPD; however, they should be used judiciously and in alignment with therapeutic goals.

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Iris Publishers- Open access Journal of Pediatrics & Neonatal Care (GJPNC) | Unique Bronchoscopy Findings in a Child with Severe Bronchiolitis Obliterans Following Overlapping Triggers

 

Authored by Dima R Ezmigna*

Abstract

Acute pulmonary complications following Steven Johnson syndrome (SJS) are well recognized, in contrast, few cases have been reported describing chronic pulmonary complications [1]. We present a case of severe bronchiolitis obliterans (BO) with unique bronchoscopic findings following SJS overlapping with other triggers. Verbal consent was obtained from the caregiver prior to writing this case report.

Keywords: Bronchiolitis obliterans; Steven’s Johnson syndrome; Mycoplasma pneumoniae

Abbreviations: (SJS): Steven Johnson syndrome; (BO): Bronchiolitis obliterans; (PE): Physical examination; (LUL): Left upper lobe; (FEV1): Forced expiratory volume at the first second; (FVC): Forced vital capacity; (CT): Computed tomography; (MP): Mycoplasma Pneumoniae

Case Report

An 11-year-old boy presented to the pediatric emergency department with cough, fever, shortness of breath and skin rash for several days duration. His physical examination (PE) showed an ill-appearing child with: Temperature: 39.3C, Heart Rate: 140 per minute, Respiratory Rate: 32 per minute, Blood Pressure: 130/80 and oxygen saturation of 93% on room air. Skin exam showed multiple erythematous and targetoid papules with central dusky necrosis involving the upper trunk and both extremities. Mucositis involving the upper and lower lips and buccal mucosa was noted. Eye exam with evidence of bilateral purulent conjunctivitis. Chest auscultation was positive for bilateral fine crackles. The rest of PE was unremarkable. His chest x-ray showed Peribronchial cuffing and thickening with mild left upper lobe (LUL) atelectasis. Due to the described skin involvement, SJS was considered and skin biopsy result was consistent with histopathologic changes of SJS. Mycoplasma Pneumonia was suspected, and serology was positive for IgA -specific antibodies. Respiratory viral panel and HSV PCR were negative. He was treated with five-day course of azithromycin, hydration, oxygen supplement and pain management. The patient was discharged home following stabilization. 4 weeks following discharge, he developed exertional dyspnea and was referred to pediatric pulmonology for consultation. His PE revealed diffuse bilateral expiratory wheezes with no signs of respiratory distress and his oxygen saturation was 98% on room air. Skin exam showed post inflammatory hyperpigmented lesions involving the trunk and extremities. The rest of the PE was unremarkable. He was treated with inhaled bronchodilator (albuterol) and systemic steroids for 5 days and upon follow up he reported partial response with continued wheezing and dyspnea. Follow up CXR showed worsening LUL atelectasis with left-sided mediastinal shift. Spirometry showed moderately-severe airway obstruction that is not reversible following bronchodilator therapy with forced expiratory volume at the first second (FEV1) at 46 % predicted and forced vital capacity (FVC)of 78% predicted and a ratio of FEV1/FVC of 52. This prompted obtaining urgent computed tomography (CT) of chest (Figure 1) which showed mosaic attenuation of the right lung, LUL atelectasis and a small left lung with vascular attenuation and a mediastinal shift to the left side; findings suggestive of BO. Flexible bronchoscopy revealed inflamed mucosa, increased mucous plugs in the LUL with difficulty to pass the scope through the LUL bronchus due to scarring and complete obliteration (Figure 2). Bronchoalveolar lavage analysis with dominant neutrophils (71%) and bacterial culture was positive for Haemophilus Influenza. Transbronchial biopsy showed nonspecific mild chronic inflammation. Despite insufficient transbronchial biopsy results, the patient was diagnosed with BO based on the clinical picture and radiology findings. He was treated with Methylprednisolone pulse therapy (10 mg/kg/dose) daily for 3 days repeated monthly for 3 courses with minimal improvement on spirometry. Ventilation/ perfusion scan was obtained and showed ventilation of 91% on the right lung and 9% on the left with matched perfusion of 87% on the right lung and 13% on the left lung. Upon follow up 3 months later, chest CT revealed worsening of the above findings with complete collapse of the left lung and herniation of the hyperexpanded right lung to the left hemi-mediastinum. Spirometry findings became consistent with a restrictive rather than an obstructive pathology. Despite radiologic worsening, the patient remained stable on room air. FEV1 remained at 46%.

Discussion

BO or constrictive bronchiolitis is a chronic obstructive pulmonary disease caused by immune and nonimmune - mediated triggers resulting in airway inflammation and epithelial cell injury leading to increased fibroblast and myofibroblast activity during the healing process [1]. The latter results in the formation of scar tissue obliterating the small airways - the bronchioles. Diagnosis of BO in children can be made with confidence based on the clinical picture and associated radiological findings in addition to fixed pulmonary obstructive disease [2]. Large airways are usually spared, making this case unique in describing proximal involvement of the bronchial tree with fibrosis and scarring captured on flexible bronchoscopy images, in this case involving the LUL bronchus.

In this report of severe BO, another distinctive finding is the overlap of 2 pathologic triggers, both of which have been separately reported to cause BO; Stevens Johnson Syndrome (SJS) and Mycoplasma Pneumoniae (MP) infection. MP is currently a wellrecognized cause of post-infectious BO in the pediatric and adult population. Our patient was diagnosed with MP 4-6 weeks prior to the development of chronic wheezing and dyspnea, however, this coincided with the occurrence of SJS; an immunologic trigger that is believed to have simultaneously contributed to the pathogenesis of BO and abnormal pulmonary function subsequently. SJS is a severe mucocutaneous reaction that is commonly triggered by medications including sulfonamides, anticonvulsants, and nonsteroidal anti-inflammatory drugs, as well as infectious etiologies especially in the pediatric population. In severe cases of SJS, multisystemic involvement is a sequela, including the pulmonary system. In the acute phase, pulmonary involvement following SJS is commonly reported and can affect up to 40% of patients3 with pneumonitis, acute respiratory distress, and respiratory failure requiring mechanical ventilation. In contrast, chronic pulmonary complications are less common, and are being recognized over time through case reports and case series [1,3,4] including BO and abnormal lung function [5]. The severity of this case and the progressive findings on chest CT suggest continued active airway inflammation for several weeks despite immune suppression by Methylprednisolone pulse therapy. This led to the development of profound scarring involving the left lower lobe leading to the complete collapse of the left lung, which contributed to the restrictive pattern demonstrated on spirometry on a later follow up. Long term Azithromycin therapy, another agent described in the management of BO due to its immune-modulatory effect (although with variable outcomes [6]), was avoided in this case given the possibility that it may have contributed to the development/worsening of SJS.

Summary

This is a unique case of BO with severe large airway involvement secondary to overlapping triggers; MP and SJS. The development of respiratory symptoms following SJS should prompt early evaluation and management by a pediatric pulmonologist to prevent serious irreversible lung damage. Response to current available therapies is not promising, and lung transplant is the ultimate treatment in severe cases [2].

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ModIris Publishers- Open access Journal of ern Concepts in Material Science | Mechanomagnetic Spectroscopy: A Review

 

Authored by ML Corró*

Abstract

In the last years the Mechanomagnetic Spectroscopy technique has been developed from the PUCOT, improved and successfully used to study magnetic materials. In such technique, based in the reversible Villari effect, we study the magnetostriction at ultrasonic frequencies and different experimental conditions of temperature, polarizing field and stress. We will review the history, the set-up of the technique and some results obtained in different materials as rare earth Dy and ferromagnetic shape memory alloy Ni-Fe-Ga-Co.

Keywords: Magnetism; Magnetostriction; Ferromagnetic shape memory alloy; Dy

Abbreviations: MMS: Mechanomagnetic Spectroscopy; PUCOT: Piezoelectric Ultrasonic Composite Oscillator Technique; RVE: Reversible Villari Effect; FSMA: Ferromagnetic Shape Memory Alloy

Introduction: The History

The Piezoelectric Ultrasonic Composite Oscillator Technique (PUCOT) [1-3] is used to study the internal friction in materials. In such technique, quartz transducers are used to induce resonant oscillations at ultrasonic frequencies in bar-shaped samples. In our laboratory, the basic experimental PUCOT system was improved with several additions. We designed a cryostat to change the temperature during the experiments. Besides, a coil to apply polarizing fields was introduced in order to measure magnetic effects in the internal friction, as the magneto mechanical damping. Lately it was thought that, due to the reversible Villari Effect (RVE), the use of PUCOT under polarizing applied fields should produce measurable stress-induced induction in materials. To measure it, the experimental set-up of PUCOT was modified by the addition of a pick-up coil around the samples. Such experiments were successful, and the new developed technique was called Mechanomagnetic Spectroscopy (MMS) [4]. First measurements of stress-induced induction showed only positive values and some unexpected zero values. It was thought that we recorded the magnitude (modulus, absolute value) of the signal and some of such zeros could correspond to the transition between positive and negative values. To check this hypothesis a lock-in amplifier was introduced to measure the phase of the signal with reference to the oscillatory applied stress. Successfully, 180° shifts in the phase were measured. Such result implicated a change of the sign at zero points, as it was expected [5]. The last step in the development of the MMS was to relate the measured stress-induced induction to the reversible inverse and direct magnetostriction [6]. Nowadays we can consider the MMS as a fully developed technique.

Set-Up

As it was stated, we apply an oscillatory stress (in the order of 90 kHz) to bar-shaped samples (typical size of 1x1x15 mm3) by means of quartz transducers. The length of the sample depends on the Young Modulus in the following way:

Equation (1)

E=4ρl2f2,

where ρ is the density, l the length, and f the fundamental resonant frequency of the sample, respectively. The oscillatory strain in the sample produces a stress-induced induction in magnetic samples Citation: ML Corró. Mechanomagnetic Spectroscopy: A Review. Mod Concept Material Sci. 3(3): 2020. MCMS. MS.ID.000561. DOI: 10.33552/MCMS.2020.03.000561 Page 2 of 4 due to the RVE. To measure it, it was conceived to place a pickup coil around the maximum strain section of the sample since a voltage would be generated due to the Faraday’s law. Such voltage can be estimated in the following way.

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Iris Publishers- Open access Journal of Dentistry & Oral Health | Oral Pigmentation as a Sign of Addison’s disease

 

Authored by Adel Bouguezzi*

Abstract

Addisonian skin hyperpigmentation, an important element of the pathology, is relatively rare, mucosal involvement is even less frequent. Likewise, there is little iconographic documentation of these pathologies. Addison’s disease is a primary adrenal failure caused by infiltrative or autoimmune processes. One of the most important signs of Addison’s disease is cutaneous and mucosal hyperpigmentation’s related to ACTH melanogenesis action. Pigmentation can be homogeneous or blotchy, it does not depend on gender or race. It may involve skin, oral cavity, conjunctiva and genitalia. It is more evident in areas exposed to the sun and under mechanical stimulations. Here, we describe a patient who was affected by brown maculae involving the oral cavity. Treatment with hydrocortisone allowed biological normalization and improvement of the general condition. Currently, the patient no longer has a systemic disorder, however the mucous hyperpigmentation persists.

Keywords: Addison’s disease; Oral pigmentation; Cortisol

Introduction

Careful examination of the mouth may reveal findings indicative of an underlying systemic condition and permit for early diagnosis and treatment. Etiology of acquired hyper pigmentation are many. In some patients it gives a clue to the diagnosis of systemic disorders. Addison’s disease could be a rare endocrine disease during which there’s destruction of the endocrine gland with resultant inadequate secretion of the adrenal cortical hormonescortisol, aldosterone and androgens. Cortisol, the most hormone affected is very important within the body’s ability to deal with stressful situation like infection, hypotension, and surgical procedures [1]. Primary adrenal insufficiency is a life-threatening disorder particularly in stressful situation, since cortisol secretion cannot be increased on demand at all. The prevalence of primary adrenal insufficiency (Addison’s disease) has been reported to be 39 to 60 per million population [2].

A 53-year-old female patient presented with anorexia, weight loss, hypotension, weakness, abdominal pain and black patches on the face and oral mucosa. During anamnesis, the patient reported that these patches had grown in recent months, the patches had persisted despite treatment with oral fluconazole, which had been prescribed empirically for presumed oral candidiasis. Results of a physical examination revealed scattered, asymptomatic, bluishblack macules these lesions were asymptomatic, had varying sizes with irregular and imprecise limits, and were located on the skin face and buccal mucosa (Figure 1, 2). No cervical lymphadenopathy was noted.

Our major diagnostic doubt was between diagnosing diffuse oral maculae because of melanosis or more serious systemic diseases associated to oral diffuse pigmentation like Peutz-Jeghers syndrome or Addison’s disease. Colonoscopy didn’t reveal intestinal polyps. Additionally, to low pressure level (110/60 mmHg), blood chemistry tests revealed low plasma cortisol associated to hyponatremia (120 mEq/l) and hyperkaliemia (6 mEq/l). Furthermore, a brief synacthen test (short corticotrophin test) was requested to verify adrenal insufficiency, during which impaired response to adrenocorticotropin hormone was found (240 pg/ ml; normal values = 6-60 pg/ml). Ultrasonography and MRI of the adrenal glands showed absence of any masses or swellings that would mimic a neoplasm producing ACTH or hemorrhages.

As a result of the above findings, a diagnosis of Addison’s disease was made. The patient was then addressed to the endocrinology division where she was managed for an accurate therapy of the disease. Treatment with hydrocortisone allowed biological normalization and improvement of the general condition. Currently, the patient no longer has a systemic disorder (clinical or biological), however the mucous hyperpigmentation persists.

Discussion

Hyperpigmentation of the oral mucosa (i.e., Addison disease) is the primary manifestation of primary adrenal insufficiency. However, diffuse melanin pigmentation of the oral mucosa could be a nonspecific finding, and diverse other conditions are also considered within the medical diagnosis (e.g., ethnic pigmentation, tobacco-related pigmentation, medication-related pigmentation, neurofibromatosis [3], McCune-Albright syndrome, Peutz-Jeghers syndrome). Primary adrenal insufficiency may occur in association with the autoimmune poly endocrino pathy candidiasisectodermal dystrophy syndrome, during this condition, chronic mucocutaneous candidiasis develops in childhood in conjunction with hypoparathyroidism and other findings ,within the mouth, candidiasis can present as pseudomembranous (white plaques that may be wiped away), hyperplastic (white plaques that can’t be wiped away), or erythematous. Skin and tissue layer hyperpigmentation is present in 95% of patients with primary adrenal insufficiency [4].

It’s considered a tell-tale sign of Addison’s disease, thus differentiating it from secondary and tertiary hypoadrenalism. This often precedes other manifestations by months to years, and therefore the patient can present with the sole complaint of getting darker. Moreover, with other systemic manifestations, it’s a high predictive value for Addison’s disease. It results from the stimulatory effect of ACTH on melanocytes. Other commonly involved areas are nail bed, palmar creases, buccal tissue layer, perianal and vaginal mucosa [5].

Diagnoses which will mimic the oral pigmentation of Addison disease include oral “black tongue” candidiasis, ethnic pigmentation, and reactions to certain drugs. Black furry tongue and hairy tongue candidiasis are disorders believed to be caused by candida and infrequently Aspergillus species. These conditions are related to long run use of antibiotics. Characterized by dense, black, bluish-black, or brown “matted” areas of the dorsal surface of the tongue, hairy tongue candidiasis is successfully eliminated by discontinuation or minimization of antibiotics, gentle brushing of the tongue surface, and use of an oral antifungal agent [6] the foremost common pattern of ethnic or racial pigmentation could be a band of pigment at the junction of attached and alveolar mucosa. In contrast to Addison disease, pigmentation on the tongue of these with skin of color is often localized to isolated groups of filiform papillae [7]. Such pigmentation, usually found only in persons with dark skin, can also be found as isolated pigmented patches in 5% of Caucasians. Drug-induced pigmentation can range from brown (seen with oral contraceptives, cytotoxic agents, and a few anticonvulsants) to yellow or blue-black (as seen with the antimalarial drugs quinacrine, chloroquine, and hydroxychloroquine) [8]. Long-term use of minocycline has been related to a blue-gray staining of the tongue, gingival margins, palate, and pretibial surfaces [9].

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Iris Publishers- Open access Journal of Otolaryngology and Rhinology | Intraoperative Finding of Cholesteatoma in Central Tympanic Perforation

 

Authored by  María Luisa Navarrete Álvaro*

Introduction

Clinically, the chronic otitis media is defined as the recurrent or chronic infection of the middle ear of a patient with an eardrum perforation, and it can be classified as:

1) Benign (or inactive), which is characterized by a dry tympanic perforation, which is not related to an active infection.

2) The chronic effusive otitis media (also known as serous chronic otitis media), which presents a continuous serous drainage, without pathogen grown.

3) The chronic suppurative otitis media, which is diagnosed when there is persistent purulent drainage through the tympanic perforation.

On the other hand, when we talk about the chronic cholesteatomatous otitis media, we refer to the accumulation of desquamative keratinized epithelium, either in the tympanic cavity or in the mastoid bone, which may be secondary to an eardrum perforation but may also occur as a primary lesion [1]. Marginal perforations are considered to be more dangerous because they are usually associated with the development of a cholesteatoma [2]. In this type of perforations, the stratified squamous epithelium of the external auditory canal can grow into the middle ear and form a cholesteatoma [3].

On the contrary, central perforations have been considered as innocuous since cholesteatoma is not usually associated with them. These may be anterior, posterior, inferior or subtotal; dry or active, which can cause recurrent otorrhoea. When inflammatory pathology associated with central perforations is found, it implies the formation of granulation tissue and polyps in addition to the fixation or destruction of the ossicular chain. Despite the fact that this type of perforations is not usually related to the formation of cholesteatoma, cases have been reported in the literature, although the prevalence is very low [4]. In this review we want to explain three cases in which cholesteatoma was found as a casual discovery, in patients with central perforation, as opposed to what is commonly described in the bibliography.

Clinical Cases

Case 1

26-years-old male patient with no medical history of interest, who suffered burns due to fulguration from a lightning stroke, with an estimated total extension of 2,5% of the total body surface with burns and polytrauma associated with loss of consciousness. During the hospital admission he did not show signs of neurologic focality but he did mention bilateral hearing loss with left side predominance, denying vertiginous syndrome or another otorhinolaryngologic symptoms. The cranial CT informed us about a left parietal subarachnoid haemorrhage, a comminute fracture of the right zygomatic arch with no occupation of tympanic cavity nor the mastoid bone (Figure 1,2).

In the otorhinolaryngology evaluation seen under microotoscopic vision of both ears, we appreciated the external auditory canal with hematic rests, very erythematous and thickened eardrum with pulsatile otorrhoea of both ears; topical antibiotic treatment was indicated. In the audiometry we found a mild bilateral transmission hearing loss and the tympanography showed flat curves. In the follow up (15 days later) we find a dry central perforation in the right ear and dry subtotal perforation in the left ear; 6 months later we recommended bilateral myringoplasty, starting with the right ear which presented more hearing loss. When the edges of central perforation were revived, a pearl suggestive of cholesteatoma was observed and extracted, desisting from the tympanic plasty. Central perforation cholesteatoma was confirmed in the histopathologic study.

Case 2

38-years-old female patient with asthma and allergic rhinitis, was referred to our centre presenting a tympanic perforation of the right ear of long-data, not associated to episodes of otorrhoea. The otoendoscopic exploration showed a normal left ear and a dry central perforation of the right eardrum. Surgical treatment was indicated to accomplish the closure of the perforation. An attic occupied by cholesteatomatous-looking tissue, that was not present in the previous explorations nor radiologic studies (Figure 3), was evident during this surgical procedure and the histophatological study confirmed the diagnosis of cholesteatoma. After 18 months of clinical and radiological follow up, findings compatible with granulomatous tissue were shown in the middle ear and surgical treatment was decided. Right aticoantrostomy is performed and now the patient has been free of disease for two years.

Case 3

42-years-old male patient with no medical history, who comes to our center referring intermittent otorrhoea in the left ear and ipsilateral hearing loss. A dry central eardrum perforation was revealed in the micro-otoscopy and a myringoplasty is suggested. In this surgical act, epidermic tissue with inflammatory signs in the attic was observed and just like in the other cases, this findings were not shown in the previous follow ups not CT scan (Figure 4). The histopathological study resulted in cholesteatoma and currently the patient follows control without signs of recurrence.

Discussion

It has been widely described that central perforations tend to have fewer complications in comparison with the marginal ones. However, both sequelae and complications have been reported, albeit to a lesser extent [5]. It is accepted that histologically the inflammation of the middle ear affects the inner mucous layer of the tympanic membrane in some of these perforations, allowing the external keratinized epithelium to migrate to the inside of the tympanic cavity generating a cholesteatoma. Cholesteatoma has been defined as a mass of stratified squamous tissue found with the temporal bone and its epithelium is characterized by a dysregulation of the keratinocytes [6]. The microscopic study of the basement membrane shows a layer of extracellular matrix separating the epithelium from the connective tissue [7]. Although we have previously mentioned the low incidence of cholesteatomas in central perforations, authors as Matsui, K & Kubota [9] and collaborators published a review showing central perforations in 8 of 142 middle ears with acquired secondary cholesteatoma (5,6%) [8,9]. There were no signs of cholesteatomatous otitis media in clinical and complementary exploration in our three patients, but it was in the surgical act when the presence of cholesteatoma was observed.

Despite the etiologic difference between our patients, publications like the one of Ruedi et at, explain that the inflammation and the toxic effects of the exudate may cause injury to the mucous epithelium and affect its basement membrane. These changes added to poor ventilation of the middle ear could support the growth of papillary squamous epithelium there [10,11]. We want to add a study in which central eardrum perforation observed in 29 temporal bones of 25 patients of the same age were included. The authors Oktay [12] showed that central eardrum perforations whether caused by inflammatory pathology or by the placement of ventilation tubes, should not be considered as mere defects: 62% of the tympanic membrane with central perforations showed excessive eardrum thickening, 66% showed signs of sequelae or tympanosclerosis with papillary projections and epithelial infiltration towards the middle ear [12,13].

Conclusion

Cases of chronic otitis media associated to secondary cholesteatoma with central perforation are uncommon; however, it is a finding reported in the literature and should be taken into consideration. When doing a myringoplasty, it is imperative to start by examining the tympanic cavity thoroughly, taking samples of those tissues that may make us suspect of a cholesteatomatous lesion. Its diagnosis will be essential to properly guide the treatment. In addition, adequate follow-up of the patient for the assessment of possible recurrences should be carried out.

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Iris Publishers- Open access Journal of Cardiology Research & Reports | Mitral Valve Repair Operations - Aspects of Risk and Uncertainty

 

Authored by  John Mangan*

Introduction

About 18 months ago, I received a shock during a routine health examination. I had noises coming from my heart. It was subsequently diagnosed as a (mitral prolapse regurgitation at severity level 3 from 4). Yet, apart from some tiredness during the day, I was asymptomatic. As an economist, with some knowledge of risk and probabilities, I needed to make some decisions regarding timing of treatment, form of treatment, expectations of outcome and the possibility of ongoing treatment. Of course, it could not be purely an analytical exercise, health and possibly life itself, were on the line but the economics and statistics training took hold. Below I outline the decision process.

To treat or not?

I was seemingly in good health, playing active sport and recorded a very low (zero) reading on a calcium test. Operations always bring risk and I was informed, that people with my degree of prolapse often continued-on without an operation. On the other hand, medical advice indicated that treatment sooner than later increased the chances of success, and that level 3 cases eventually needed to be treated sometime in the future. In essence, the probabilities were coming around towards intervention sooner than later. It was then my economics training took over and I remembered the classic Frank Knight paper on Risk and Uncertainty and Profit. Knight was among the first to set out the distinctions between risk and uncertainty. He distinguishes uncertainty from risk. Risk is technically defined as a situation where the possible consequences of the decision that is to be made are known. By contrast, true uncertainty may be defined as the possibility of alternative outcomes whose probabilities are not capable of measurement. I faced both risk and uncertainty. The risk (in aggregate), was fairly well known from recent aggregate studies of successful operations from the Mayo Clinic [1]. Then the uncertainties entered the equation. There was no guarantee that the leaky valve could be repaired. It may need to be replaced, but this decision would only come into play only after the operation had begun.

Almost all studies indicated that repair was better than replacement (Oliveria and Antunes, 2006 [2]). This is because under the repair scenario, there is less chance of the need for follow up surgery and a requirement of lifetime medication. Prior diagnosis will not reveal the need for repair and so my uncertainty about outcome soon became ambiguity as defined by Savage [3].

Savage assumed that it is possible to take convex combinations of decisions and that preferences would be preserved. So, if a person prefers x (= xi) to y (= yi) and s (= si) to t (= ti}) then that person will prefer

λ x + (1 − λ) s to λ y + (1 − λ) t for any 0 < λ < 1

In this case, I preferred repair (x) to replacement (y) and minimal invasive surgery (s) to open heart surgery (t).

My best-case scenario was x-s, the worst was y-t but I could end up with x-t or y-s. According to Savage, my uncertainty had passed to ambiguity and to advance. I could choose either adverse ambiguity, deciding if it was still desirable even under the worse scenario [4] or Savages “sure thing” principle, whereby I would take the optimistic view that the outcome will be the most desirable. Having opted for minimal invasive, the uncertainty revolves around the repairability of the leaky valve (x-s) or need to be replaced? As well, further study of the topic revealed that 30% of patients using this treatment suffered atrial fibrillation, which if uncontrolled could require a pacemaker to be fitted. Would I be one of those 30%?

Open heart or minimal invasive surgery?

Two alternative procedures were available [5]. The minimal invasive technique and the more traditional open-heart surgery. To most, the minimal invasive technique seems more appealing to the patient as it involves less physical disruption, can be robot assisted and has a lower hospital duration time. Offsetting this was the increased risk associated with relatively new techniques. I chose minimal invasive surgery acting upon advice from The Swiss Medical Weekly (2012) and PubMed (2011) [6].

“Modern repair techniques such as neo-chord implantation with the loop-technique combined with minimally invasive access routes result in low mortality and morbidity and short hospital stay as well as high patient approval” (Sunderman, Falk and Jacobs, 2012).

Risk profiles between the two techniques are similar, so we were back to uncertainty and in particular ambiguity about the benefits of the more proven method against the advantages of a less intrusive and quicker healing procedure. I went for “sure thing” or optimistic ambiguity, choosing what to me was the more palatable technique on the assumption that the risk factors were relatively equal between the two options.

Choice of surgeon?

In making such a choice, risk and uncertainty again were intermingled. In Australia, surgeons do not publish success rates. If we assume that, on average doctors, are relatively similarly skilled) then the success rate of the procedure overall should be a good proxy. Unfortunately, doctors are not equally skilled and in the absence of performance monitors, the next best means of rational selection is through word of mouth and the reputation of the facility. I did this by visiting two separate cardiologists and getting their recommendations. Fortunately, their advice steered me in the same direction.

Result

Medical procedures and their aftermath are classic mixtures of risk and uncertainty within which prospective patients need to navigate. Most medical procedures are repeated trials, with known success or failure probabilities. Therefore, in aggregate a patient has a good idea of the risk of a procedure. However, for each person, the procedure is individualized; uncertainty enters through choices around the timing of operation, choice of technique, choice of doctor and location and best means of recovery. Without reasonable approximations of outcome, this uncertainty leads to ambiguity and possibly non- optimal outcomes. In such cases, the best form of decision rule is to determine the worst, best and most likely outcomes and see which of these fit within your risk portfolio. In my case, I fitted the average patient stereotype; successful repair, suffered atrial fibrillation and discharged within 10 days. As an intending and then actual patient, I needed to make a number of decisions that had various and substantially different outcomes. Published data are aggregate in nature and do not address the many uncertainties facing individuals in ex-ante, pre-operation situations. In assessing the real risk, the economic and statistical principles can be adapted to transform uncertainty into acceptable risk.

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