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Τρίτη, 11 Οκτωβρίου 2016

Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk



Plastic and Reconstructive Surgery - Global Open:
doi: 10.1097/GOX.0000000000000849
Original Article

Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk

Burusapat, Chairat FRCST; Nanasilp, Tirapat MD; Kunaphensaeng, Paiboon MD; Ruamthanthong, Anuchit MD

Open Access
Thailand
Article Outline
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Author Information

*Division of Plastic and Reconstructive Surgery, Department of Surgery, and Department of Radiology, Phramongkutklao Hospital, Bangkok, Thailand.
Received for publication April 8, 2016; accepted June 17, 2016.
Trial database registered: Thai Clinical Trials Registry (member of WHO registry network): registration number: TCTR20150728001
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
Chairat Burusapat, FRCST, Division of Plastic and Reconstructive Surgery, Department of Surgery, Phramongkutklao Hospital, 315 Ratchawithi Road, Thung Phayathai, Ratchathewi, Bangkok, 10400, Thailand, E-mail: pataranat@hotmail.com
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
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Abstract

Background: The anterolateral thigh (ALT) flap has been widely used for reconstructions. Nevertheless, the atherosclerotic risk factors that affect the lateral circumflex femoral artery (LCFA) are still inconclusive. The aim was to study the effect of atherosclerosis on the LCFA and descending branch (dLCFA) visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.
Methods: Retrospective studies of CTA of lower extremity were reviewed. The patients were divided into 2 groups: nonatherosclerotic and atherosclerotic risk factors. The angiographic study of LCFA and dLCFA was analyzed, and atherosclerotic and nonatherosclerotic risk factors were compared.
Results: Ninety-seven patients with 194 lower extremities were enrolled. Atherosclerotic risks comprised 76 patients. A total of 14, 16, and 46 patients had 1, 2, and 3 risk factors, respectively. Musculocutaneous perforator was 79.38%. The LCFA originated from deep femoral, common femoral, and superficial femoral artery was 97.42%, 2.06%, and 0.52%, respectively. The dLCFA was classified into 5 types depending on its origin. Diameters of LCFA in nonatherosclerotic and atherosclerotic patients were 4.03 ± 0.71 and 4.07 ± 0.97 mm, respectively. No statistical significance was found between both groups in diameters of LCFA. Diameters of dLCFA in nonatherosclerotic patients were 2.28 ± 0.28 mm and in atherosclerotic patients were 2.11 ± 0.28 mm. Statistical significance of diameters of dLCFA was found in patients having 3 risk factors and smoker groups (p < 0.05).
Conclusions: LCFA is not atherosclerosis resistant. Stenosis of the LCFA and dLCFA occurred in varying degrees in atherosclerosis-risk patients. Preoperative CTA should be considered to evaluate the patency in multiple risk factors patients.
The anterolateral thigh (ALT) flap was first described by Song et al1 in 1984. The advantages of this flap are pliable, long pedicle, good esthetic result, and low donor-site morbidity. The ALT flap has been used widely for both microsurgery and pedicle flap reconstructions. Moreover, ALT can be employed for myocutaneous,2 adipofascial,3,4and suprafascial flaps.5 The first described vascular supply of the ALT was the descending branch of the lateral circumflex femoral artery (dLCFA), which passed between the vastus lateralis and rectus femoris muscle and was classified as a septocutaneous perforator. Recent studies have reported that the septocutaneous perforator constitutes only 6.97% to 28.6%.6–8 However, most reports focused on the anatomic variation of the vascular pedicle and modification of this flap in both western and Asian populations.6–14
Nevertheless, among elderly patients with multiple underlying diseases, the safety of using this flap for microsurgery reconstruction is unclear and still debated. Only a few studies in the English literature have investigated the patency of the LCFA in atherosclerosis,15–17and the effects of atherosclerotic risk factors on LCFA are inconclusive.
The aim was to study the effect of atherosclerosis on the LCFA and dLCFA visualized by computer tomographic angiography (CTA) between nonatherosclerosis and atherosclerosis.
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MATERIALS AND METHODS

Approval of this study was obtained from the ethics committee of Phramongkutklao Hospital and College of Medicine. A 3-year retrospective review of patients who underwent CTA of the lower extremities from January 2013 to December 2015 was conducted. The patients were divided in 2 groups. Group 1 comprised patients with nonatherosclerotic risk factors, and indications for CTA included preoperative vascular assessment for the ALT or fibular free flap for head and neck tumors. The patients in group 2 had atherosclerotic risk factors and indications for CTA, including peripheral vascular disease (PVD) with symptoms or chronic ulcer of the legs or feet. The atherosclerotic risk factors, based on Framingham risk score,11included total and high-density lipoprotein cholesterol, hypertension, smoking, and diabetes mellitus (DM). Exclusion criteria included previous fracture or vascular injury or surgery of the lower extremities and vessel pathology, such as connective tissue disease (vasculitis).
Data were recorded including age, sex, underlying disease, atherosclerotic risk factor, and indication for CTA. The CT scanner used was a Siemens Somatom Sensation 64 multidetector row CT scanner (Siemens Medical Solutions, Malvern, Pa.). A standard bolus of 100 mL of intravenous ultravist 370 (Berlex Laboratories, Montville, N.J.) or Omnipaque 350 (GE Healthcare, Inc, Princeton, N.J.) was used for contrast. The LCFA and dLCFA were evaluated by a single radiologist. The volumetric data acquired were then used to reconstruct images with a slice width of 1.3 mm and reconstruction interval of 0.6 mm. The angiographic study of the deep femoral artery (DFA), LCFA, and dLCFA were analyzed, including the diameter of vessels, origin of LCFA, type of perforator, length of LCFA, length of anterior superior iliac spine (ASIS) to origin of LCFA, and length of ASIS to the largest perforator of dLCFA. Diameters of each vessel were measured at the origin of its branching off. Atherosclerotic and nonatherosclerotic risk factors were compared. The degree of stenosis was evaluated by 2 radiologists, and scores were defined as 0 for less than 20% greatest stenosis, 1 for 20% to 49% greatest stenosis, 2 for 50% to 99% greatest stenosis, and 3 for totally occluded.18
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Statistical Analyses
For comparative study statistics, the chi-square or Mann-Whitney Utest for categorical data and Student t test for continuous data were used. A P value <0.05 was considered to indicate statistical significance.
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RESULTS

A total of 115 patients who underwent CTA of the lower extremities were recorded. Eighteen patients were excluded because of previous hip or knee arthroplasty and vascular injury at the thigh. The remaining 97 patients with 194 lower extremities were enrolled. All patients were Asian with 61 men (62.89%) and 36 women (37.11%). A total of 76 (78.35%) patients had atherosclerotic risks and 21 (21.65%) patients had nonatherosclerotic risk. The mean ages in nonatherosclerotic and atherosclerotic groups were 41.86 and 69.12 years, respectively. The mean age was statistically significant between groups (Table 1). Among the atherosclerotic risk patients, 14 patients (18.42%) had 1 risk factor (hypertension, DM, or dyslipidemia), 16 patients (21.05%) had 2 risk factors (hypertension and DM, hypertension, and dyslipidemia or DM and dyslipidemia), and 46 patients (60.53%) had 3 risk factors (combined hypertension, DM, and dyslipidemia). Seventy-three patients (96.05 %) had hypertension, 58 patients (76.32%) had dyslipidemia, and 53 patients (69.74 %) had DM.
Table 1
Table 1
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According to the type of perforator, 154 extremities (79.38%) were musculocutaneous type and 40 extremities (20.62%) were septocutaneous type. No statistical significance was found between nonatherosclerotic and atherosclerotic patients regarding the type of perforator (Table 2).
Table 2
Table 2
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According to origin of LCFA, 189 extremities (97.42%) found that the LCFA originated from the DFA, 4 extremities (2.06 %) originated from the common femoral artery, and 1 extremity (0.52 %) had a takeoff from the superficial femoral artery. No statistical significance was found between nonatherosclerotic and atherosclerotic patients in the origin of LCFA. The dLCFA was classified into 5 types depending on its origin (Fig. 1). A total of 153 extremities (78.87 %) had descending branch takeoff from LCFA that originated from the DFA, 34 extremities (17.53%) had descending branch direct take off from the DFA, 4 extremities (2.06 %) had the LCFA take off from the common femoral artery, 2 extremities (1.03 %) had the LCFA take off from the DFA at bifurcation (Fig. 2), and 1 extremity (0.52 %) had descending branch takeoff from the LCFA that originated from the superficial femoral artery (Fig. 3). No statistical significance was found between nonatherosclerotic and atherosclerotic patients regarding the origin of the dLCFA (Table 2). The average thigh length was 45.09 ± 3.26 cm. The average length from ASIS to perforator was 23.61 ± 2.85 cm. The average length from ASIS to LCFA was 12.36 ± 1.56 cm, and the average pedicle length was 13.62 ± 1.99 cm (Table 3).
Table 3
Table 3
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Fig. 1
Fig. 1
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Fig. 2
Fig. 2
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Fig. 3
Fig. 3
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Diameters of the DFA in nonatherosclerotic patients were 5.84 ± 0.99 and 5.93 ± 1.11 mm in atherosclerotic patients. Diameters of DFA in atherosclerotic patients were classified in each risk factor as demonstrated in Table 4. No statistical significance was found between nonatherosclerotic and atherosclerotic patients in diameters of DFA. Diameters of the LCFA in nonatherosclerotic patients were 4.03 ± 0.71 and 4.07 ± 0.97 mm in atherosclerotic patients. Diameters of LCFA in atherosclerotic patients were classified in each risk factor as demonstrated in Table 5. No statistical significance was found between nonatherosclerotic and atherosclerotic patients in diameter of LCFA.
Table 4
Table 4
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Table 5
Table 5
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Diameters of dLCFA in nonatherosclerotic patients were 2.28 ± 0.28 and 2.11 ± 0.28 mm in atherosclerotic patients. Statistical significance was found between nonatherosclerotic and atherosclerotic patients in diameters of dLCFA. After subgroup analysis of the diameters of dLCFA in each risk factors, significance was found between nonatherosclerotic and patients having 3 risk factors (P < 0.05). All patients in the nonatherosclerotic risk factor group were nonsmokers. In the atherosclerotic risk factor group, patients were classified as nonsmoking, former smoking, smoking less than 1 pack per day, and smoking equal to or more than 1 pack per day.
The mean diameter of DFA for nonsmokers without risk factor was 5.84 mm, for nonsmokers with risk factor was 5.93 mm, for former smokers with risk factor was 5.98 mm, for smokers of less than 1 pack per day with risk factor was 5.94 mm, and for smokers of more than 1 pack per day with risk factor was 5.77 mm. No statistical significance was found between nonsmoker and smoker groups.
The mean diameter of LCFA in nonsmokers without risk factor was 4.03 mm, in nonsmokers with risk factor was 4.15 mm, in former smokers with risk factor was 4.01 mm, in smokers of less than 1 pack per day with risk factor was 4.05 mm, and in smokers of more than 1 pack per day with risk factor was 4.09 mm. No statistical significance was found between nonsmoker and smoker groups.
The mean diameter of dLCFA in nonsmokers without risk factor was 2.28 mm, in nonsmokers with risk factor was 2.22 mm, in former smokers with risk factor was 2.05 mm, in smokers of less than 1 pack per day with risk factor was 2.09 mm, and in smokers of more than 1 pack per day with risk factor was 1.98 mm. Statistical significance was found between nonsmokers and smokers in the diameters of dLCFA.
According to the sclerosis change of DFA, score 0 was found for 26 extremities (92.86%) in 1 risk factor patient, 28 extremities (87.50%) in 2 risk factors patients, and 76 extremities (82.61%) in 3 risk factors patients (Table 6) (Figs. 4 and 5). According to the sclerosis change of LCFA, score 0 was found for 24 extremities (85.71%) in 1 risk factor patient, 26 extremities (81.25%) in 2 risk factors patients, and 72 extremities (78.26%) in 3 risk factors patients. According to the sclerosis change of dLCFA, score 0 was found for 24 extremities (85.71%) in 1 risk factor patient, 26 extremities (81.25%) in 2 risk factors patients, and 72 extremities (78.26%) in 3 risk factors patients. The occlusion of LCFA more than 50% was found in 4 extremities and only in 2 or more risk factors. No totally occluded (score 3) case was found in all patients.
Table 6
Table 6
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Fig. 4
Fig. 4
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Fig. 5
Fig. 5
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DISCUSSION

Although the ALT flap is widely used in reconstructive surgery, the anatomic variation has appeared increasingly. Most of patients with diagnosed head and neck tumors and undergoing ALT microvascular reconstruction are elderly and have multiple underlying diseases. Only a few studies in the English literature have investigated the patency of LCFA in atherosclerosis,15–17 and the effects of these risk factors on LCFA are still inconclusive.
Halvorson et al15 studied patients with vascular disease and concluded that the dLCFA and DFA seem to be relatively spared from atherosclerosis and be relatively atherosclerosis resistant. Ahn et al17showed that the dLCFA is not affected by patient comorbidity, including PVD when compared with medically fit controls. Even in individuals with severe disease of the superficial vascular system, sparing of the deep system was observed often.17
Kamdar et al19 argued that LCFA is not always atherosclerosis resistant and reported the reconstructed anterior scalp defect in a 75-year-old man with hypertension and coronary artery disease, undergoing a renal transplant 12 years ago. Preoperatively, no evidence was found for significant lower extremity vascular disease. Two lateral thigh perforating vessels were identified using Doppler ultrasonography, but the entirety of the LCFA was extensively and completely calcified, making microanastomosis of these vessels extremely difficult.19 Although the stenosis of the superficial femoral artery was 67.2%, the stenosis of the DFA was 12.5 %, the LCFA was 10.9%, and the dLCFA was 10% to 12.5 %, in this, 7% were severe atherosclerotic changes.15–17
Interestingly, Ahn et al17 reported that 24.0% of patients without PVD showed some degree of stenotic changes in the dLCFA. This unexpected finding could be a result of those patients in the no-symptom group having undiagnosed PVD.17 These data demonstrated that the dLCFA, LCFA, and DFA were not atherosclerosis resistant and experienced atherosclerotic change. The effect of atherosclerosis risk factor was supported in the study by Choi et al.16 They analyzed the degree of stenosis in the dLCFA in regard to each risk factor having shown that hypertension, impaired pulmonary function, history of lower limb amputation, and total score of 11 risk factors were statistically significant. In the same direction with our study, the size of internal diameters of DFA and LCFA was not significant between nonatherosclerosis and atherosclerosis groups. However, the size of the internal diameters of the dLCFA was statistically significant in the combined 3 risk factors and smoking group.
According to the anatomic variation of the LCFA, the dLCFA that originated from the common femoral artery or superficial femoral artery may have higher incidence of atherosclerosis. The subgroup analysis of the dLCFA and LCFA from the origin will be beneficial. When the dLCFA arises from the superficial femoral artery, it may in theory be more prone to atherosclerosis.15 However, some studies have revealed that the proximal tract of the superficial femoral artery is not narrowed by atherosclerosis to a significantly higher degree than that portion of the DFA situated 1 cm distal to the origin of the LCFA.20
Although, the free ALT in severe atherosclerosis is not contraindicated and the successful microsurgical ALT for limb salvage in diabetic foot ulcer was demonstrated,21–23 the failure rate increased in the smoking and multiple atherosclerotic risk factor groups.24 The clinical significance of the differences in arterial diameter between atherosclerosis and nonatherosclerosis is still inconclusive, but the effects of atherosclerotic risk factors caused stenosis of the dLCFA, LCFA, and DFA occurred in varying degrees. So, in the patients with multiple atherosclerotic risk factors, preoperative CTA should be considered to evaluate the patency of the dLCFA before reconstruction.
The pathologic variation may be occurred from atherosclerotic change. Some reports have shown the aneurysm of the LCFA in multiple atherosclerosis.25,26 Although, the ALT flap is commonly used and the perforator from the dLCFA is the vascular supply, the anatomic variation still occurred and appeared increasingly. Furthermore, the absent perforator was found overall at 1.8% to 4.8% (0.85% in Asian and 3.08% in western countries),8,27 and the knowledge of anatomical variation will help surgeons to plan their operations. Our study found the anatomic variation of the dLCFA and LCFA in 5 types. The LCFA takeoff from the DFA and dLCFA takeoff from the LCFA are classic in anatomy and found at 78.87%, and that correlated with another study that reported 75%.28
The dLCFA direct takeoff from the DFA was found at 17.53% in our study and 6% to 13% in other studies.12,29,30 The LCFA takeoff from common femoral artery was 2.06%, whereas other studies found 10% to 25%.7,28,31 Our study showed 0.52% LCFA takeoff from the superficial femoral artery that has never been reported and 1.03% LCFA takeoff from the DFA at bifurcation of the deep and superficial femoral arteries. Some anatomic variations were not found in our study, such as the dLCFA from the DFA at bifurcation of the LCFA 17.1%,12 the dLCFA from the common femoral artery 1% to 6%,12,30,32 and the LCFA from the external iliac artery 6%.13Moreover, the perforators arising from the transverse branch of the LCFA were found in 4% to 32.4%14,33,34 and from the oblique branch were found at 14%, which was first described by Wong et al.10
Preoperative planning and investigation are important. In nonatherosclerosis, Doppler ultrasonography is commonly used for preoperative planning, and the accuracy depends on the experience of the surgeon and type of Doppler ultrasonography. Color Doppler ultrasonography is significantly more accurate than acoustic Doppler ultrasonography.35 Furthermore, the accuracy of Doppler ultrasonography decreased when body mass index increased.12 One study using color Doppler ultrasonography showed 19.04% and did not find any perforator. Moreover, 11.76% that detected the perforator by Doppler ultrasonography did not find the perforator intraoperative.36
Preoperative investigations are controversial regarding atherosclerosis. Ahn et al17 reported that surgical reconstruction using the ALT flap was a safe procedure for patients even with multiple comorbidities, including significant PVD.17 Hage and Woerdeman37 reported a partial necrosis of the foot and calf caused by the interruption of the dLCFA, which acted as critical collateral for the obstructed superficial femoral artery. They recommended preoperative angiography of the donor leg in patients in whom palpable popliteal pulsations are lacking. In our study, we found the calcified plaque in LCFA and dLCFA and we suggest preoperative angiography in the multiple atherosclerosis and smoking group even Doppler ultrasonography is detectable.
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CONCLUSIONS

In summary, LCFA and its descending branch are not atherosclerosis resistant. Stenosis of the dLCFA, LCFA, and DFA occurred in varying degrees in atherosclerosis-risk patients. Statistical significance in the diameters of the dLCFA was found among multiple atherosclerotic patients. For patients with multiple atherosclerotic risk factors, preoperative CTA should be considered to evaluate the patency of the dLCFA before reconstruction.
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ACKNOWLEDGMENT

We thank Mrs. Supak Cae-ngow, statistician and the research assistant of the Office of Research Development, Phramongkutklao College of Medicine for her kind help in the statistical analysis of this article.
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REFERENCES

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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.



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1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

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5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

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7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

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12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

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Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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