Hackensack University Medical Center at Pascack Valley

OBJECTIVE: Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy. PURPOSE: The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

BACKGROUND: The Q-switched ruby laser is a 694 nanometer (red light) pulsed (20-40 nsecond) laser that has been shown to be effective in the treatment of cutaneous pigmented lesions. OBJECTIVE: This article will review my experience in the use of the Q-switched ruby laser to treat a wide gamut of epidermal and dermal pigmented lesions. RESULTS: The Q-switched ruby laser is highly effective in treating epidermal pigmented lesions and can be efficacious in the treatment of some dermal pigmented lesions. CONCLUSION: The Q-switched ruby laser is an effective addition to the cutaneous laser armamentarium.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Conventional chemotherapy for unresectable or metastatic adenocarcinoma of the pancreas has had little effect on palliation or survival. Almost all studies of systemic therapy have involved empiric use of a variety of Phase II or conventional agents alone or in combination. On the basis of recent studies using a human tumor pancreatic cancer (PC) xenograft in nude mice, a Phase I clinical trial of cisplatin, high-dose cytosine arabinoside (Ara-C), and caffeine (CAC) was performed in patients with advanced incurable PC. A tolerable dose and schedule of the three agents were developed. Seven of 18 patients with measurable disease in this Phase I trial had partial responses to CAC. A Phase III comparison of CAC versus standard treatment using streptozotocin, mitomycin, and 5-fluorouracil (SMF) was performed. Eighty-two patients with advanced PC were entered into this random assignment trial. The two treatment arms were well balanced for the usual prognostic factors. Although the acute (e.g., nausea and vomiting) toxicities of CAC were greater than those of SMF, both groups of patients tolerated treatment resonably well. Ninety percent of patients were evaluable for response. Two patients (5.5%) on the CAC treatment arm (95% confidence interval [CI], 0% to 15%) and four patients (10.2%) on the SMF treatment arm (95% CI, 1% to 22%) had objective responses (partial response in measurable disease or improvement in evaluable disease). No complete remissions were observed. The 95% confidence limits of response for CAC and SMF overlapped. The median duration of survival for all patients on the SMF treatment arm was 10 months, although it was 5 months on the CAC treatment arm (P = 0.008). In this Phase III comparison, CAC was not superior to conventional therapy with SMF in terms of response and was inferior for survival. Neither regimen is effective treatment for advanced PC.

Background Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. Methods Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). Results Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. Conclusions NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

Occult shoulder instability is recognized as a significant contributor to shoulder dysfunction in throwing athletes. Diagnosis of occult instability by physical examination remains challenging. The anterior release test is a test for physical examination of the shoulder. It was developed to facilitate detection of occult anterior instability. One hundred shoulders were examined preoperatively by the same examiner. Based on surgical findings, the shoulders were classified as anterior instability or other. The results of examination were compared with the operative findings. Sensitivity was calculated as 91.9%, specificity 88.9%, positive predictive value 87.1%, negative predictive value 93.0%, and accuracy 90.2%. The anterior release test is a reliable and reproducible test for the detection of the unstable shoulder.

BACKGROUND: Previous studies have reported volatile organic compounds (VOCs) in breath as biomarkers of breast cancer and abnormal mammograms, apparently resulting from increased oxidative stress and cytochrome p450 induction. We evaluated a six-minute point-of-care breath test for VOC biomarkers in women screened for breast cancer at centers in the USA and the Netherlands. METHODS: 244 women had a screening mammogram (93/37 normal/abnormal) or a breast biopsy (cancer/no cancer 35/79). A mobile point-of-care system collected and concentrated breath and air VOCs for analysis with gas chromatography and surface acoustic wave detection. Chromatograms were segmented into a time series of alveolar gradients (breath minus room air). Segmental alveolar gradients were ranked as candidate biomarkers by C-statistic value (area under curve [AUC] of receiver operating characteristic [ROC] curve). Multivariate predictive algorithms were constructed employing significant biomarkers identified with multiple Monte Carlo simulations and cross validated with a leave-one-out (LOO) procedure. RESULTS: Performance of breath biomarker algorithms was determined in three groups: breast cancer on biopsy versus normal screening mammograms (81.8% sensitivity, 70.0% specificity, accuracy 79% (73% on LOO) [C-statistic value], negative predictive value 99.9%); normal versus abnormal screening mammograms (86.5% sensitivity, 66.7% specificity, accuracy 83%, 62% on LOO); and cancer versus no cancer on breast biopsy (75.8% sensitivity, 74.0% specificity, accuracy 78%, 67% on LOO). CONCLUSIONS: A pilot study of a six-minute point-of-care breath test for volatile biomarkers accurately identified women with breast cancer and with abnormal mammograms. Breath testing could potentially reduce the number of needless mammograms without loss of diagnostic sensitivity.

BACKGROUND: Hydroxychloroquine has not been associated with improved survival among hospitalized COVID-19 patients in the majority of observational studies and similarly was not identified as an effective prophylaxis following exposure in a prospective randomized trial. We aimed to explore the role of hydroxychloroquine therapy in mildly symptomatic patients diagnosed in the outpatient setting. METHODS: We examined the association between outpatient hydroxychloroquine exposure and the subsequent progression of disease among mildly symptomatic non-hospitalized patients with documented SARS-CoV-2 infection. The primary outcome assessed was requirement of hospitalization. Data was obtained from a retrospective review of electronic health records within a New Jersey USA multi-hospital network. We compared outcomes in patients who received hydroxychloroquine with those who did not applying a multivariable logistic model with propensity matching. RESULTS: Among 1274 outpatients with documented SARS-CoV-2 infection 7.6% were prescribed hydroxychloroquine. In a 1067 patient propensity matched cohort, 21.6% with outpatient exposure to hydroxychloroquine were hospitalized, and 31.4% without exposure were hospitalized. In the primary multivariable logistic regression analysis with propensity matching there was an association between exposure to hydroxychloroquine and a decreased rate of hospitalization from COVID-19 (OR 0.53; 95% CI, 0.29, 0.95). Sensitivity analyses revealed similar associations. QTc prolongation events occurred in 2% of patients prescribed hydroxychloroquine with no reported arrhythmia events among those with data available. CONCLUSIONS: In this retrospective observational study of SARS-CoV-2 infected non-hospitalized patients hydroxychloroquine exposure was associated with a decreased rate of subsequent hospitalization. Additional exploration of hydroxychloroquine in this mildly symptomatic outpatient population is warranted.

Abstract This article describes the experiences of seventh‐grade students living in high poverty areas of New York City who participated in the Choice, Control and Change ( C3 ) science curriculum. Data were collected from eight case study students in the form of individual interviews, classroom observations, and student artifacts. Analysis of these data revealed that students were able to extend their C3 science understandings beyond the classroom door by developing and expressing science agency in the following ways: (1) critically analyze the conditions of their food environment, (2) purposefully make healthier choices, and (3) expand the food and activity options available to themselves and others. Through participation in the C3 curriculum, and the science content and practices addressed therein, students began to view their worlds with a more critical mindset and to devise ways to transform themselves and the conditions of their own and others' lives. Based on the findings, we propose taking a closer look at how we might create meaningful and relevant learning opportunities for students through connecting school science with issues of personal and social significance in students' lives outside of school. © 2011 Wiley Periodicals, Inc. J Res Sci Teach 49: 244–269, 2012

Pyogenic granuloma, a rapidly developing, benign vascular nodule often arising in children at sites of trauma in the skin or mucous membrane, was treated successfully with flashlamp-pumped pulsed dye laser in three pediatric patients. Excellent cosmetic results were obtained. The authors suggest that the flashlamp-pumped pulsed dye laser be considered as yet another effective modality in the treatment of pyogenic granuloma.

BACKGROUND: The Erbium (Er):YAG laser represents a new laser approach for the treatment of rhytids and photodamaged skin. Because the Er:YAG laser's 2940-nm wavelength is at the peak of water absorption, this laser produces minimal thermal damage. OBJECTIVE: To document the Er:YAG laser's efficacy in the treatment of neck rhytids. METHODS: Ten patients with neck rhytids were treated with the Er:YAG laser. All individuals were evaluated for clinical improvement, scarring, and pigmentary changes. RESULTS: All patients showed fair to excellent results with no scarring or pigmentary changes at 6 months. CONCLUSION: The Er:YAG laser may be used to improve nonfacial photodamaged skin.

ObjectiveThere are no randomized data to support the use of postoperative radiation for salivary gland malignancies. This study uses the National Cancer Database (NCDB) to describe the epidemiology of salivary gland cancer patients and to investigate whether treatment with adjuvant radiation improves overall survival.Methods and materialsA total of 8243 patients diagnosed with a major salivary gland cancer were identified from the NCDB. All patients received primary surgical resection of their malignancy. Patients were risk-stratified by adverse features, and overall survival rates were determined. Patients were considered high risk if they had extracapsular extension and/or positive margin after resection. Patients were considered intermediate risk if they did not meet the criteria for high risk but had pT3-T4 disease, pN+ disease, lymphovascular space invasion, adenoid cystic histology, or grade 2-3 disease. Patients who did not meet criteria for high or intermediate risk were considered low risk. Overall patient demographics, disease characteristics, treatment factors, and outcomes were summarized with descriptive statistics and analyzed with STATA.ResultsMedian follow-up in this cohort was 42.4 months, with the median age of 58 years. Patients in the high-risk group had greater survival (hazard ratio [HR], 0.76; P = .002; 95% confidence interval [CI], 0.64-0.91) if they received adjuvant radiation therapy. In contrast, patients in the intermediate- (HR, 1.01; P = .904; 95% CI, 0.85-1.20) and low-risk groups (HR, 0.85; P = .427; 95% CI, 0.57-1.26) did not experience a survival benefit with adjuvant radiation therapy.ConclusionsThis large analysis compared survival outcomes between observation and adjuvant radiation alone in risk-stratified patients after resection of major salivary glands using a national database. The use of adjuvant radiation for high-risk major salivary gland cancers appears to offer a survival benefit. Although an overall survival benefit was not seen in low- and intermediate-risk salivary gland cancers, this study could not address impact on local control because of the limitations of the NCDB.

INTRODUCTION: YouTube is the most used social media website, and there is a growing body of literature examining the reliability of healthcare information on this platform. Patients seeking men's health information may be more likely to use YouTube owing to the sensitivity of these issues. OBJECTIVES: The objective of this study is to review the literature for studies related to the reliability of YouTube videos about men's health topics. METHODS: A literature review was conducted using PubMed and Google Scholar for publications related to the reliability of YouTube videos about men's health as of July 1, 2020. RESULTS: There were 17 studies related to YouTube and Men's Health. Most videos were found to be unreliable, and videos uploaded by physicians or healthcare organizations were usually more reliable. However, there were no studies in which more reliable videos had higher metrics of user engagement (views, likes, comments) than unreliable videos and there were several studies where unreliable videos had higher metrics of user engagement. In addition, the methods used to evaluate YouTube videos are not uniform across studies including the way that terms are searched (filtering by relevance vs view count) and the way in which reliability is assessed. For example, some studies create custom evaluation forms based on clinical guidelines, whereas others use validated questionnaires. The only validated questionnaire used across multiple studies was the DISCERN score criterion. CONCLUSIONS: Most information on YouTube about men's health is unreliable. Videos created by physicians and healthcare organizations are more reliable, and videos that are advertisements are less reliable. Physicians and healthcare systems should continue to upload educational YouTube videos but work to increase their views and user engagement. It may benefit patients if physician organizations could work with YouTube to create verified videos disseminating healthcare information that are favored in the search algorithm. Warren CJ, Sawhney R, Shah T, et al. YouTube and Men's Health: A Review of the Current Literature. Sex Med Rev 2021;9:280-288.

Objective This study evaluated the effects of obesity on health-related quality of life (HRQOL) measures in juvenile-onset systemic lupus erythematosus (jSLE). Methods Obesity was defined as a body mass index (BMI) ≥95th percentile according to the Sex-specific Center for Disease Control BMI-For-Age Charts and determined in a multicenter cohort of jSLE patients. In this secondary analysis, the domain and summary scores of the Pediatric Quality of Life (PedsQL) Inventory and the Child Health Questionnaire (CHQ) of obese jSLE patients were compared to those of non-obese jSLE patients as well as historical obese and non-obese healthy controls. Mixed-effects modeling was performed to evaluate the relationship between obesity and HRQOL measures. Results Among the 202 jSLE patients, 25% ( n = 51) were obese. Obesity had a significant negative impact on HRQOL in jSLE, even after adjusting for differences in current corticosteroid use, disease activity, disease damage, gender and race between groups. Obese jSLE patients had lower physical functioning compared to non-obese jSLE patients, and to non-obese and obese healthy controls. Compared to their non-obese counterparts, obese jSLE patients also had worse school functioning, more pain, worse social functioning and emotional functioning. Parents of obese jSLE patients worry more. The CHQ scores for obese jSLE patients were also worse compared to non-obese jSLE patients in several other domains. Conclusion Our study demonstrates the detrimental effects of obesity on patient-reported outcomes in jSLE. This supports the importance of weight management for the therapeutic plan of jSLE.

Nursing home patients who sustain hip fractures have a much higher than average complication rate after surgical repair, and few ever walk again. Operation is not necessary to ensure the patient's survival in the postfracture period. The majority of these patients are better off managed without surgery. For patients with little or no chance to walk again, a nonsurgical treatment regimen in the nursing home is safer, more humane, and far less expensive than hospitalization.

A sample of 61 volunteer older adults, age 64 to 88, living independently in a suburban, residential senior citizen setting, participated in this dual-pronged investigation. It was the first study of its kind to analyze the current and previous learning styles of a sample of older adults. Current learning-style preferences were assessed through the Productivity Environmental Preference Survey (PEPS) and recalled learning-style preferences identified through the Previous Learning Experiences Questionnaire. Each older adult participant was administered the Short Portable Mental Status Questionnaire to assess their cognitive functioning. Two directional research hypotheses were tested. Single-sample t tests confirmed that these older adults scored significantly different on learning-style elements as measured by the PEPS from the original normed group. Single-sample t tests also revealed that older adult men were significantly different from older adult women on certain learning-style preferences. Research conducted with the Dunn and Dunn Learning-Style Model during the past 30 years has yielded valuable insights into how learning-style preferences evolve over time. This model's research continuum, until recently, extended from early childhood through the midlife years of between 40 and 50. This investigation currently has expanded the learning-style continuum to incorporate octogenarians. The element of perception has provided additional information that is important and useful for educators when preparing instructional sessions that include diverse older adult participants.

BACKGROUND: Some leading anatomy texts state that all three heads of the triceps brachii are innervated by the radial nerve. The posterior cord of the brachial plexus bifurcates to terminate as the radial and axillary nerves. Studies have noted the presence of axillary innervation to the long head of the triceps brachii muscle, patterns different from the classic exclusive radial nerve supply. An understanding of these variations may assist the clinician in the assessment of shoulder weakness and in preoperative and operative planning of radial and axillary neuropathies. QUESTIONS/PURPOSE: We aimed to further investigate, in cadaver dissections, the prevalence of axillary nerve contribution to the innervation of the long head of the triceps brachii. METHODS: We performed bilateral brachial plexus dissections on 10 embalmed cadavers combining anterior axillary and posterior subscapular approaches. Two additional unilateral cadaveric brachial plexuses were dissected. The posterior cords were fully dissected from the roots distally. The radial and axillary nerves were followed to their muscle insertion points, the dissections were photographed, and the length of branching segments were measured. RESULTS: Of the 10 paired cadavers dissected (20 specimens), in only one of the 10 cadavers was the classic innervation pattern of radial nerve observed. The other nine cadavers had varying patterns of radial and axillary nerve innervation, The observed patterns were radial and axillary (dual) on one side with radial alone on the other, dual innervation bilaterally, or axillary with contralateral radial innervation. The two additional unilateral dissected specimens were innervated exclusively by the axillary nerve. CONCLUSIONS: Gross and surgical anatomy sources state that the radial nerve is the sole nerve supply to the long head of the triceps. In our study sample, pure radial innervation of the long head of the triceps brachii was not the predominant nerve pattern. We found four other studies that looked at axillary innervation of the long head of the triceps; of the 62 total cadaver shoulders examined in those studies, 71% were found to have nonclassic innervation patterns. Nonclassic patterns may include purely axillary, dual, or posterior cord innervation to the long head of the triceps, and may account for the majority of innervation to the long head of the triceps. These are similar to our findings. CLINICAL RELEVANCE: Understanding the innervation of the long head of the triceps and variations in axillary nerve course is critical to the clinical diagnosis of injury, surgical treatment options, and rehabilitation of axillary nerve injuries. With this information, the practitioner may have additional surgical options, clearer rationales for clinical situations, and explanations for patient outcomes.

The findings of the present study indicate that the application of the Impella device during ECMO support is effective in LV unloading and confers optimal hemodynamic support.

Recent literature in occupational therapy and nursing indicates that collaborative goal setting can lead to increased patient satisfaction, shorter inpatient stays, and better goal attainment (Neis-tadt, 1995). Therapist and patient collaboration on goal formulation, beliefs of their relevance, and how they are to be accomplished, are essential for better treatment outcomes. Questionnaires from a matched convenience sample of 10 registered occupational therapists and 10 occupational therapy patients were analyzed to determine if, and when, differences occurred in perceptions about the collaborative nature of the goal-setting process. The findings from this pilot study indicated that therapists were uniformly positive about the collaboration that occurred during goal setting, but their patients were more neutral. Patients were most positive about the process of collaboration, but less so about the substance of that collaboration. Perceptions about the collaborative nature of the goal-setting process were significantly discrepant for several topics including discussion of patient interests, purpose of activities chosen, and availability of assistance after discharge, with patients being significantly less positive about the collaboration.

The water industry and especially the wastewater treatment sector has come under steadily increasing pressure to optimize their existing and new facilities to meet their discharge limits and reduce overall cost. Gravity separation of solids, producing clarified overflow and thickened solids underflow has long been one of the principal separation processes used in treating secondary effluent. Final settling tanks (FSTs) are a central link in the treatment process and often times act as the limiting step to the maximum solids handling capacity when high throughput requirements need to be met. The Passaic Valley Sewerage Commission (PVSC) is interested in using a computational fluid dynamics (CFD) modeling approach to explore any further FST retrofit alternatives to sustain significantly higher plant influent flows, especially under wet weather conditions. In detail there is an interest in modifying and/or upgrading/optimizing the existing FSTs to handle flows in the range of 280-720 million gallons per day (MGD) (12.25-31.55 m(3)/s) in compliance with the plant's effluent discharge limits for total suspended solids (TSS). The CFD model development for this specific plant will be discussed, 2D and 3D simulation results will be presented and initial results of a sensitivity study between two FST effluent weir structure designs will be reviewed at a flow of 550 MGD (∼24 m(3)/s) and 1,800 mg/L MLSS (mixed liquor suspended solids). The latter will provide useful information in determining whether the existing retrofit of one of the FSTs would enable compliance under wet weather conditions and warrants further consideration for implementing it in the remaining FSTs.