Pain behavior and the systems that mediate opioid analgesia and opioid reward processing display circadian rhythms. Moreover, the pain system and opioid processing systems, including the mesolimbic reward circuitry, reciprocally interact with the circadian system. Recent work has demonstrated the disruptive relationship among these three systems. Disruption of circadian rhythms can exacerbate pain behavior and modulate opioid processing, and pain and opioids can influence circadian rhythms. This review highlights evidence demonstrating the relationship among the circadian, pain, and opioid systems. Evidence of how disruption of one of these systems can lead to reciprocal disruptions of the other is then reviewed. Finally, we discuss the interconnected nature of these systems to emphasize the importance of their interactions in therapeutic contexts. Pain, opioid analgesia, and opioid reward processing all are regulated by circadian clocks . In turnVirtually all biological systems and processes display circadian rhythms. These rhythms are endogenous and cycle over a period of about 24 h in synchronization with the light-dark cycles of the environment . In mammIn mammals, circadian rhythms throughout the body are primarily synchronized by the suprachiasmatic nuclei (SCN) of the hypothalamus, commonly called the central pacemaker. To synchronize internal rhythms amongst one another and to the environment, the SCN integrates environmental photic signaling cues from the retina and relays this information in the form of neuronal and humoral signaling factors .At the cellular level, 24-h rhythms are generated by a set of core clock genes that form an autoregulatory transcription-translation feedback loop. The intricate details of this loop have been described extensively elsewhere and extend beyond the scope of this review . ImportaThe regulatory dominance of the circadian system indicates the importance of its integrity for health. In the remainder of this review, we will examine how pain and opioid analgesia are regulated by circadian rhythms. We will then highlight how the disruption of the pain and mesolimbic reward systems can negatively impact the circadian system. We will conclude by highlighting the need to consider the relationship among these systems in clinical and therapeutic contexts.The function of the pain system is regulated by circadian clocks . The preMesocricetus auratus) (Mus)  , and thes) (Mus) .Additional research during this period highlighted the complicated and inconsistent nature of the shape of these rhythms . Of thesA major study was recently published to demonstrate the circadian nature of pain behavior in humans , althougRhythms of pain sensitivity are present in various states of disease and pain syndromes. However, pain rhythms are inconsistently altered in these states . For exaTrpa1 in the trigeminal ganglia  and fibromyalgia are associated with altered activity and circadian rhythms . HoweverTaken together, it is apparent that disrupted circadian rhythms negatively affect pain, and additional correlative indicates that pain might also alter circadian rhythms. Continued research is needed to understand the mechanisms that drive this relationship. This approach could improve future therapeutic approaches by identifying novel therapeutic targets or could drive non-pharmacological and non-invasive treatment strategies for pain management, such as wearing blue light-filtering glasses during the night.Opioids can disrupt the integrity and timing of the circadian system . This isPer2 on morphine analgesic tolerance in the context of noxious heat stimulation by studying Per2Brdm1 mutant mice (Per2Brdm1 mice carry a mutation in the PAS domain of the mPer2 gene; mice with this mutation exhibit diminished rhythmic expression of mPer2 as well as mPer1 (Per2 mutant mice, but Per2 mutations led to reduced morphine tolerance over several days of injections, thereby increasing the analgesic efficacy of the drug relative to the wild types as the injections progressed. Further, Per2 mutant mice in this study exhibited reduced global withdrawal scores following naloxone-precipitated withdrawal at the end of the injection series (Per1 on morphine-conditioned place preference was assessed by administering a DNAzyme that cleaves the mPer1 transcript (Per1 transcript knockdown altered the acquisition phase of the conditioned place preference test, but it did not alter the expression phase of the test in mice (Much of the evidence exploring the mechanisms behind these effects comes from studies examining animals with genetic manipulations to the circadian clock, as this approach can provide strong insight into the role of these genes on behavior . For exaant mice . Per2Brdas mPer1 . Morphinn series . Anothern series . Disruptn series . Lastly,anscript . Per1 tr in mice . TogethePer1 and Per2 expression (Opioid administration can also directly influence the circadian system and behavioral rhythms, including sleep. Numerous clinical and preclinical studies support this claim. For example, fentanyl administration can phase-shift circadian rhythms in hamsters . This efpression . Acute (pression . Deficiepression .Morphine administration can also modulate circadian rhythms. For example, administration altered the peak of locomotor rhythms and the phase of activity in male rats . The dirAdditional evidence indicates that opioids can also modulate circadian rhythms in humans. One large-scale post-mortem study examined the effects of opioid use disorder on rhythmic transcriptomic profiles in humans . By usinTaken together, the evidence presented in this section highlights the disruptive interaction between the circadian system and opioids. Preclinical studies have provided mechanistic insight into these effects, with strong evidence pointing to the role of clock genes on both opioid-mediated disruption of the circadian system, as well as clock gene signaling integrity on opioid processing. The disruptive effects of opioids include altered synchronization and integrity of circadian rhythms in clock gene expression, neural activity, and behavior. In isolation, these effects may be considered manageable, but out of isolation, they can create a spiraling feedforward loop between the pain and circadian systems.via the effects of opioids on pain and pain hypersensitivity. In basal contexts, the relationship among circadian rhythms, pain, and opioid processing is likely not of significant importance, but the components of this relationship are particularly important to consider in the context of disease and disordered substance use.The circadian system, pain system, and opioid processing pathways form a spiraling and disruptive feedback loop. Opioids can disrupt circadian rhythms, circadian rhythms modulate opioid analgesia and opioid processing, and disrupted circadian rhythms can alter the efficacy of opioids. In turn, circadian rhythms regulate pain behavior and sensitivity across the day, and circadian rhythm disruption can exacerbate pain behavior. This loop is closed Given the dire state of the opioid epidemic in the United States, additional understanding and consideration of this loop will likely improve therapeutic interventions for pain. Moreover, the interaction among the circadian, pain, and opioid processing systems highlights the need for the development and implementation of non-pharmacological interventions. These interventions may seek to mitigate circadian rhythm disruption in pain patients, or they might target the circadian system to manage pain, such as recent and promising light therapies . Pain alJB and RN conceived the idea behind the manuscript. JB and EM conducted the research for the manuscript. All authors wrote and edited the manuscript and approved the submitted version.


Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis. It requires prompt and appropriate management to cure the patient.We report the case of a 52-year-old patient, initially admitted for an acute non-ST-segment elevation coronary syndrome at very high ischemic risk, in whom coronary exploration was negative, and whose echocardiography showed a mobile image on the aortic valve, suggesting infective endocarditis. The patient benefited from an aortic valve replacement because of the size and the embolic complications he presented, with a favorable evolution.Acute coronary syndrome during infective endocarditis is a rare complication with a high mortality rate. Several mechanisms are possible: the embolic mechanism, coronary extraluminal compression due to coronary mycotic aneurysm and obstruction of the coronary ostium by a large vegetation. The management remains multidisciplinary and personalized according to the phenotype of the patient, with the need to have the endocarditis team to be able to take the best therapeutic choice.Infective endocarditis must be evoked in any patient without usual cardiovascular risk factors who presents with an ACS that is accompanied by fever and elevated inflammatory markers, and a thorough clinical examination as well as the performance of additional tests. •Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis.•Our case presents a diagnostic challenge in the face of an initial misleading clinical presentation evoking ACS in a patient finally diagnosed with infective endocarditis.•The management of endocarditis remains multidisciplinary, between cardiologist, infectiologist, radiologist, resuscitator and heart surgeons. It requires prompt and appropriate management to cure the patient. The management of a patient with infective endocarditis (IE) presenting with ACS requires an endocarditis team, including the specialties of interventional and non-interventional cardiology, cardiothoracic surgery, and infectious diseases. Our case presents a patient who presented with coronary syndrome in the setting of infective endocarditis of the aortic valve.2trans-thoracic echocardiography , respiratory and neurological stability, and a fever of 38.9°. The clinical examination did not reveal any signs of cardiac insufficiency, the cardiopulmonary ausculation was normal, but we noted the presence of an inflammatory placard in front of the right wrist joint, with redness and limitation of active and passive mobility that were painful . The ECGiography  was perfOn day 4 of his admission, the patient underwent an aortic valve replacement with a mechanical SJM valve and a vegectomy, with simple postoperative follow-up and rapid withdrawal of vasopressors. The culture of the vegetations came back inconclusive, then the patient was put on Vancomycin acenocoumarol 2mg/d, ceftriaxone 2g/d for 6 weeks with good clinical evolution and normalization of the biological balance at D20 of his admission.The cytobacteriological examination of urine came back sterile, with no sign of intravenous drug abuse. The stomatological check-up showed a poor oral condition. The patient benefited from oral care. The patient was discharged home on day 26 of his admission with a negativation of the infectious balance sheet including procalcitonin at day 20.3Infective endocarditis is a multi-systemic disease that is fatal if left untreated, and is defined as an infection of the endocardial surface including the heart valves, the mural endocardium or a septal defect.Acute coronary syndrome during infective endocarditis is a rare complication with an incidence of 2.9% , and a m(a)Embolic mechanism: coronary emboli of septic origin usually occur within the first 2 weeks of infection.It is more frequent for fungal endocarditis than bacterial endocarditis because of the larger size of the vegetation. The risk of coronary embolism is increased when the vegetation is mobile, or it is larger than 10 mm, Staphylococcus aureus or streptococcus non viridans streptococcus infections and anterior embolism ,4.This cb)Coronary extraluminal compression due to coronary mycotic aneurysm or peri-annular aortic complication (abscesses and pseudoaneurysms), which are also described as a mechanism of myocardial ischemia during AR .c)Obstruction of the coronary ostium by large vegetation , as in cd)Certain situations present during AR alter the perfusion/metabolic demand balance leading to onsite myocardial ischemia; anemia, fever, and activation of the coagulation system in septic patients and the presence of severe acute aortic valve regurgitation which in itself can cause myocardial ischemia by decreased coronary perfusion pressure and reduced coronary reserve.This association can be explained by several mechanisms:The management of ACS during infective endocarditis remains controversial. Once the diagnosis of endocarditis is made, empirical antibiotic therapy should be considered while awaiting blood culture results. Although antithrombotic agents have been used successfully in the prevention and treatment of coronary embolism associated with IE, their value remains limited because bacteremia alters hemostasis which may increase the risk of intracerebral hemorrhage due to intracerebral mycotic aneurysms and cerebral infarcts (sequelae of IE) and therefore antithrombotic therapy should be used with caution .The presence of AR contraindicates the use of fibrinolytic agents due to the risk of bleeding, which makes coronary angiography a safe procedure according to some investigators with a risk of fragmenting the vegetation if the catheter comes into contact with the surface of the aortic valve or at the time of contrast injection . GuideliEmboli are usually treated by balloon embolectomy or surgery with simultaneous coronary artery bypass grafting and valve replacement taking into account the age of the patient, comorbidities and severity of the valve dysfunction. However, both techniques may increase the risk of dissemination of infection and the risk of bacterial myocarditis which may lead to wall rupture, coronary stenting with a risk of stent infection and coronary rupture. .However, the written consent to publish the clinical data of the patients was given and is available to check by the handling editor if needed.None.SOUMIA BOULOUZI: study concept or design, data collection, data analysis or interpretation, writing the paper. AMINE BOUCHLARHEM: data collection, data analysis or interpretation, writing the paper. SAIDA AMAQDOUF: data collection and data analysis. NOHA EL OUAFI: supervision and data validation. ZAKARIA BAZID: supervision and data validation.None.Written informed Consent was obtained from the patients for publication of this cases series and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This is not an original research project involving human participants in an interventional or an observational study but a cases series. This registration is was not required.Soumia Boulouiz.Not commissioned, externally peer reviewed.The authors declare no conflicts of interest.


The first purpose of this study was to assess the severity of dissociative experiences reported by adolescent inpatients with borderline personality disorder (BPD). The second purpose was to compare the severity of their dissociative symptoms to those reported by a sample of adult inpatients with BPD. The third purpose of this study was to assess a range of clinically meaningful predictors of the severity of dissociation in adolescents and adults with BPD.The Dissociative Experiences Scale (DES) was administered to a total of 89 hospitalized girls and boys aged 13–17 with BPD and 290 adult inpatients with BPD. Predictors of the severity of dissociation in adolescents and adults with BPD were assessed using the Revised Childhood Experiences Questionnaire (a semi-structured interview), the NEO, and the SCID I.Borderline adolescents and adults had non-significant differences on their overall DES scores and subscale scores. They also had a non-significant distribution of low, moderate, and high scores. In terms of multivariate predictors, neither temperament nor childhood adversity was a significant predictor of the severity of dissociative symptoms in adolescents. However, co-occurring eating disorders were found in multivariate analyses to be the only bivariate predictor to significantly predict this outcome. In adults with BPD, however, both the severity of childhood sexual abuse and co-occurring PTSD were significantly related to the severity of dissociative symptoms in multivariate analyses.Taken together, the results of this study suggest that the severity of dissociation is not significantly different in adolescents and adults with BPD. However, the etiological factors differ substantially. Dissociation has long been a clinical concern of those treating adults with borderline personality disorder (BPD) . This coMore recently, a substantial number of studies have focused on the severity of the dissociative symptoms of adult borderline patients using the Dissociative Experiences Scale (DES) –5—a 28-iIt was also found that borderline patients had a significantly higher mean score on the DES than comparison subjects with other forms of personality disorders –8. AdditIn contrast, only three studies of the severity of dissociation in adolescents with BPD have been published –14 and aTaken together, these earlier studies of adolescents only reported on the severity of the overall score of the DES, while the current study will also examine the severity of the three subtypes of dissociation and the three levels of dissociation assessed by the DES. This is important as these subtypes and levels of dissociation are qualitatively different from one another and have different treatment implications. In addition, these earlier studies were solely descriptive and did not include any predictor analyses of the severity of dissociation reported by adolescents with BPD. We have assessed predictors of severity of dissociation in both our adolescent and adult samples. We have studied childhood adversity factors, temperament, and co-occurring disorders that have their own clinical link to dissociation. This type of analysis is important to determine if the factors associated with the severity of dissociation reported by adolescents with BPD are the same as studies have found in adults with BPD.As described below in the Methods section, our adult sample was collected 17 years before our adolescent sample. However, both samples consisted of inpatients who met the same rigorous, interview-based criteria for BPD, had the severity of their dissociation assessed by the same version of the DES, and had the same three measures administered to assess predictor variables. In addition, the difference in the years that each sample was collected provide a window into how changing parental and societal attitudes concerning the possibility of abuse inside and outside the family have changed over time.The current study has three aims. The first is to describe the severity of the overall score of the DES, the levels of overall dissociation, and the severity of the three sub-scales of the DES reported by a well-defined sample of inpatient adolescents with BPD. The second is to compare their dissociative symptoms to those reported by a group of adult inpatients with BPD. The third is to study a range of clinically meaningful predictors of the severity of dissociation reported by adolescents with BPD. In addition, we will also study the same predictors of the severity of dissociation in our comparison sample of adults with BPD. We chose these three types of predictors of the severity of dissociation because either they were studied before in this context (childhood adversity), have been described as the core underlying aspect of BPD (Neuroticism), or have been recognized clinically as having their own dissociative features (co-occurring disorders).The methodology of this study (the McLean/Mount Sinai Study of Childhood Development) (MSCAD) has been presented before in detail . The insWritten informed consent was obtained from each patient. Then three diagnostic interviews were administered by research staff blind to their clinical diagnoses. The instruments were (1) the Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I ), (2) thAdolescents (aged 13–17) with presumptive BPD were recruited from four units at McLean Hospital and one unit at the Icahn School of Medicine at Mount Sinai between August 2007 and September 2012. For adolescent participants, parents provided consent and adolescents provided assent.Adolescent participants, who all met the same inclusion/exclusion criteria concerning intelligence and co-occurring disorders as adult participants, were then administered the following diagnostic assessments during their index admission: (1) the Structured Clinical Interview for DSM-IV Childhood Diagnoses  theDissociative experiences were assessed in both study groups using the Dissociative Experiences Scale (DES) . The DESTwo other measures were also administered to both study groups. One was the Revised Childhood Experiences Questionnaire (CEQ-R) —a semi-sThe other measure assessed temperament using Costa and McRae’s NEO Five Factor Inventory—a 60 item self-report measure that yields continuous scores on Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness . In thesBetween-group differences in demographic variables and predictor variables were assessed using Student’s t-test for continuous variables and Pearson’s chi-square for binary variables. Raw DES data was log transformed. Between-group comparisons concerning continuous dissociative symptomatology were conducted using linear regression and between-group comparisons concerning binary categories using logistic regression.Analyses pertaining to comparisons of adolescents and adults with BPD were conducted controlling for sex and race. Linear regression analyses were used in the predictor analyses. All bivariate predictors with a p-level of < 0.05 were then analyzed in a multivariate model using backwards deletion to attain the most parsimonious model. The significance level for this model was set at < 0.01.Two hundred and ninety subjects were adult inpatients at McLean Hospital who met both DIB-R and DSM-III-R criteria for BPD and all completed the DES. One hundred and four subjects were adolescent inpatients at McLean Hospital or Icahn School of Medicine at Mount Sinai who met both DIB-R and DSM-IV criteria for BPD and 89 of these subjects completed the DES. Due to staff error, the DES was not administered to 15 adolescents with BPD.In terms of demographic characteristics  reported by adolescents with BPD are not significantly different than those reported by adults with BPD. In terms of predictive factors, the presence of an eating disorder centered around binging was significantly related to the severity of the dissociation reported by adolescents with BPD; a finding that is not surprising as reports of binge eating often include feelings of depersonalization and derealization. In contrast with adolescents with BPD, both the severity of childhood sexual abuse and co-occurring PTSD were significant predictors of the severity of overall dissociation reported by adults with BPD, who were initially assessed in an earlier time period. These differences in predictive factors may be due, at least in part, to differing levels of childhood adversity, which in turn, may be due to the more trusting vs. hypervigilant attitudes of parents and society in general in these different time periods.


The cerebellopontine angle (CPA) is a highly complex anatomical compartment consisting of numerous nervous and vascular structures that present mutual and intricate spatial relationships. CPA surgery represents, therefore, a constant challenge for neurosurgeons. Over the years, neurosurgeons have developed and refined several solutions with the aim of maximizing the surgical treatment effects while minimizing the invasiveness and risks for the patient. In this paper, we present our integrated approach to CPA surgery, describing its advantages in treating pathologies in this anatomical district. Our approach incorporates the use of technology, such as neuronavigation, along with advanced and multimodal intraoperative neuromonitoring (IONM) techniques, with the final goal of making this surgery safe and effective. The cerebellopontine angle (CPA) is probably the most fascinating compartment in neurosurgery due to the technical challenges that this surgery implies . The anaIn CPA surgery, localizing the anatomical structures before craniotomy is of paramount importance. Adequate exposure of such structures allows an optimal surgical corridor while minimizing cerebellar retraction and manipulation. The most common surgical approach used to treat CPA diseases, namely, the retrosigmoid approach, aims to achieve an extracerebellar surgical corridor to reach the CPA. In this regard, placing the burr-hole at the transverse-sigmoid junction (TSSJ) enables an appropriate, prompt, and safe exposure of the sinuses. This brings several benefits, including less cerebellar retraction, a reduction of bone defects that would result from extensive bone drilling in the case of a burr-hole too far from the TSSJ, less operative time, and a decrease in risk of sinus injury and postoperative CSF leaks ,4,5. TraIONM techniques in CPA surgeries are widely utilized with the goal of preserving function and preventing the injury of several neural structures. In fact, during CPA surgical procedures, the brainstem and cranial nerves might be injured, with possible devastating postoperative deficits. The ideal monitoring system should provide continuous and quick feedback to the surgeon and the anesthesiologist, based on reproducible, easily interpretable data. IONM should be able to detect potentially dangerous situations and identify critical neurophysiological variations. The rapid interpretation of these data and prompt communication to the team should be adequate to revise the surgical plan and prevent irreversible neurological injuries. Moreover, the “perfect IONM technique” should indicate a detailed profile of injury localization, gravity, timing, and prognosis for recovery.Somatosensory evoked potentials (SEPs);Motor evoked potentials (MEPs);Cortico-bulbar motor evoked potentials (cMEPs);Brainstem auditory evoked potentials (BAEPs);Free-running electromyography (EMG);Lateral spread response (LSR);Direct electrical stimulation (DES) of the nerves.In order to obtain a standardized method as close as possible to this hypothetical model, our IONM protocol in CPA surgery includes:As suggested by the Italian recommendations from the interdisciplinary panel of the Italian Society of Clinical Neurophysiology and the Italian Society of Neurosurgery , the tecAfter skin cleaning, monopolar needle electrodes are inserted into the target muscles and fixed with tape or Tegaderm™ following the belly-tendon montage technique, with the active electrode inserted within the belly muscle and the reference electrode close to the tendon. The target muscles listed below are selected to register valid corticospinal and cortico-bulbar responses and any electromyographic changes involving cranial nerves.Biceps brachii;Abductor pollicisbrevis muscles;Tibialis anterior;Quadriceps;Abductor hallucis.For upper and lower limbs bilaterally:Orbicularis oris (VII C.N);Orbicularis oculi (VII C.N);Masseter (V C.N);Trapezius (IX C.N);® EMG Tube (Medtronic)) (X C.N);Vocal cords (using The NIM TriVantageTongue (XII C.N).For motor cranial nerves:Skin disc-adhesive electrodes are placed to stimulate the median nerve in the middle of the volar wrist. Nine corkscrew electrodes  are placed at the scalp, following the International 10–20 system. As reported , the “prIn SEPs registration is used for monitoring the intracranial lemniscal sensory system as it traverses the brainstem and cerebral hemispheres . For stuMEPs monitoring allows the ongoing assessment of motor tract function during the operative procedure . TranscrEven though the anatomical details of cortico-bulbar tracts are still poorly known, cMEPs are a relatively new and valuable IONM technique to monitor the functional and anatomical integrity of cranial nerves during CPA surgery. Generally, the chosen cathode position is Cz and the anode is placed in C3 or C4 in order to stimulate the motor area contralateral to the tumor side. Since transcranial electrical stimulation is applied at the scalp over the motor area representing those muscles innervated by cranial motor nerves, the parameters of stimulation to obtain the cMEPs are identical for all cranial motor nerves. As reported by our team for extra-axial CPA tumors , the stiBAEPs allow the study of the integrity of the auditory pathway, monitoring the circuitry of the brainstem and the auditory nerve response. The stimulus is a “click” at high frequency 19–21 Hz) and high intensity (80–100 dB), administered at the external auditory canal by means of specific electrodes. The recording is carried out with electrodes positioned on the ear lobe bilaterally, referring to a cephalic electrode placed in the Cz′ position. The short latency BAEP involves a complex polyphasic wave, with different components numbered from I to V. Analyzing this response, it is possible to evaluate the potentials generated from, respectively, the cochlear nerve (I), the root entry zone (II), the nuclear complex (III), the superior olive (IV), and the lateral lemniscus (V). These responses are registered within 6msec after the stimulus. Because of the modality and number of acquisitions (1000 stimuli in our practice) and the artifacts generated by neural manipulation, the debate concerning the usefulness of intraoperative BAEPs is still ongoing. Although BAEPs reportedly give accurate feedback on brainstem damage, their reliability in predicting hearing preservation is more questionable ,21. The  Hz and hContinuous EMG is used to record evident changes in voluntary motor unit potentials and represents relatively non-invasive real-time information regarding the integrity of motor neurons . Every mAberrant electric activity of the facial nerve can be detected and registered in the case of surgery for hemifacial spasm. This pathological condition is characterized by intermittent contractions of the muscles innervated by the facial nerve due to the vascular compression of the nerve root entry zone. From a neurophysiological point of view, the stimulation of a branch of the facial nerve spreads to muscles innervated by other branches. This phenomenon, known as the LSR, can be continuously monitored during microvascular decompression surgery to confirm the adequacy of surgical maneuvers . AlthougIn our clinical practice, the stimulation is provided from the mandibular and temporal branches of the facial nerves and registered at the OOc, OOr, and mentalis muscles. The stimulus is delivered at low frequency and at an intensity of 3 to 10 mA. The anomalous registration is detected at the level of the OOc in the case of mandibular stimulation and at the level of the mentalis and/or OOr in the case of temporal stimulation.DES of the cranial nerves can be used to correctly identify the neural structures . When possible, DES performed on the portion of the nerve proximal to the tumor can confirm the integrity of the nerve throughout the procedure leading the surgeon to a safer and adaptable operating strategy . This teMonopolar constant-current low-frequency stimulation is used for DES. An intensity of stimulus at 0.1 mA, delivered on the nerve surface, is enough to record a CMAP. The need for higher stimulus intensity might indicate a relative distance to the neural structure or the presence of a relevant tissue barrier between the probe and the nerve. The more the motor response is evoked with low intensity, the more the surgeon is working close to the nerve. At the end of the surgery, especially for the facial nerve function, a proximal stimulation at a low threshold (0.1–0.3 mA) seems to correlate with a favorable facial nerve outcome . The absA progressive multimodal approach to CPA surgery has evolved in the last decade. The application of neuronavigation has almost become a standard of care in order to design a tailored and safe approach to the posterior fossa, avoiding possible damage to vascular structures and reducing the risk of suboptimal exposure. In CPA surgery, sinus exposure can be a demanding procedure, requiring significant bone drilling and loss. Moreover, the position of the asterion, which is the main bone landmark, corresponds to the TSSJ in only 23% of cases . The useIn this work, we tried to provide a rapid review of different techniques we routinely use in CPA surgery. Neuronavigation is a useful tool that makes the CPA surgical approach faster and safer to perform. The different IONM techniques should be implemented in CPA surgery, especially in the cases of CPA tumors. Close communication and collaboration between the surgical team, the neurophysiologist, and the anesthesiologist are mandatory to obtain high-quality neuromonitoring, prevent neurologic injuries, and decrease the risk of misinterpretation of the neurophysiological changes.


FASE  consists of comprehensive assessment, Attachment-Based Family Therapy (ABFT), and community linkages for people presenting with suicide or self-harm in emergency departments of tertiary hospitals.Suicide is a substantial public health concern for countries worldwide. Effective preventive and curative interventions for self-harm behavior (SHB) are imperative for nations with an alarmingly high rate of suicide and self-harm behaviors. The intervention protocol named This article reports the design and protocol for a cluster randomized control trial for suicide prevention and management. After the developed intervention is pilot tested in a tertiary hospital in Kerala, the intervention will be scaled up to be implemented in various tertiary hospitals in Kerala. Each hospital emergency department will be considered a cluster, and these clusters will be randomized to the intervention group and control group in a 1:1 ratio. The eligible people from the intervention clusters will undergo a baseline assessment, a structured moderate intense intervention with twelve sessions spread across 6 months by the trained social workers supervised by the Mental health team, and a follow-up assessment at the end. Participants will be recruited after obtaining consent and explaining the study. The primary outcome includes suicidality measured by the Depressive Symptom Inventory–Suicidality Subscale (DSI-SS), Depression, Anxiety and Stress Scale (DASS), MOS Social Support Survey, and Brief resilience scale (BRS).Knowledge generated from this trial can significantly affect new programmatic policy and clinical guidelines that will improve the reduction of suicide rates in the country.Prospectively registered in Clinical Trial Registry India (ICMR-NIMS) on 18/10/2021 (ref number- REF/2021/10/048264). Suicide is a global and significant public health concern worldwide, and its prevention has become a priority on the international public health agenda. Moreover, an aspirational Sustainable Development Goal (SDG) of a one-third reduction in the suicide death rate (SDR) by 2030  compels Alarmingly high suicide rates, global commitments, and paradigm shifts in government policies in India call for an urgent yet well-coordinated suicide prevention and management model to consider the issue of suicide a priority condition. Though the study of suicide and suicidal behavior has been approached from various theoretical models, including cognitive , 9 and dThe comprehensive mental health assessment and active post-hospital psychosocial care by appropriately trained personnel are the primary prevention strategy to reduce future suicidal ideation and self-harm . As a seThis study will be conducted among an identified at-risk and vulnerable group of people presented at emergency. Existing evidence shows that the effective management of self-harm Behavior (SHB) to reduce the risk of subsequent suicide must be an essential element of suicide prevention strategies since self-harm is the most potent risk factor for future suicide .The research has two aims, to build evidence on the effectiveness of an Attachment-Based Family Therapy and Resource linkage model to prevent suicide in people presenting with self-harm behaviors in emergency departments at tertiary hospitals in Kerala; Secondly, to evaluate the efficacy of the process of delivery of services and assess the cost-effectiveness of sharing the care task with the social work trainees supervised by the mental health team, through a continuum of care from critical health care to family-based services. The research team has been developing this model for over the past 2 years. The results of this feasibility trial would provide insights into the model's effectiveness in responding to multiple and complex psychological and social precipitants to deliberate self-harm that are currently ignored in general health services.The major objectives of the study includeEvaluate the contribution of psychosocial factors to self-harm behavior and the role of psychosocial aspects in preventing suicide.Develop the ABFT and Community Linkage model for the prevention of suicide in a group of people presenting with self-harm behavior at emergency departments;Compare the treatment (TAU) as the usual plus FASE intervention with the TAU using a cluster RCT design framework;Develop the systems and processes appropriate to deliver the services for people presenting with self-harm behavior at emergency to integrate a psychosocial intervention that would have broad relevance and application nationally and in low and middle-income countries;Assess the proposed model's cost-effectiveness for managing self-harm behavior focused on a seamless continuum of care from acute health to community services.The study involves three phases;Phase 1: development of a family-based intervention with the three components, Comprehensive psychosocial assessment and assertive engagement, Attachment-Based Family Therapy (ABFT), and community resource linkages.Phase 2: the feasibility trial of the developed intervention, andPhase 3: the cluster randomized control trial of suicide prevention intervention among randomly selected tertiary hospitals in Kerala.In phase one, the development of intervention components includes a need assessment survey followed by a rapid systematic review of the preventive interventions for suicide and self-harm. A qualitative and quantitative need assessment was conducted among 44 patients who presented with self-harm behaviors in a tertiary hospital in Kerala between October and December 2020 (results submitted elsewhere). The rapid systematic review and the assessment findings guided the components of the intervention. In the second phase, the developed intervention will be tested for feasibility and effectiveness in a tertiary hospital in Kerala using a pre-post interventional design. Phase three comprises the experimental trial of the finalized care package using a cluster-randomized trial in different tertiary hospitals in Kerala.A list of NABH  Accredited hospitals from Kerala state, India, will be prepared to select the intervention clusters. The inclusion criteria for selecting hospitals will be any NABH accredited Tertiary referral multi-speciality hospital with a minimum of 500 inpatient beds. Eligible hospitals will be randomized to intervention or control groups in a 1:1 allocation ratio. We will sign a referral agreement with the emergency department in charge and their team after explaining to them the purpose. Emergency departments of the chosen hospitals will be considered as individual clusters, and all those who presented to the emergency departments of these hospitals after serious suicidal attempts will be assessed by the professional social workers working in the department. The Social Workers will induct the people and their family members after educating them about the purpose of the study and getting informed consent. The consented people from the experimental cluster will receive the treatment as usual (TAU) plus FASE intervention, and the people belongs the control clusters will receive the treatment as usual (TAU) interventions. The stages of enrolment, intervention, and assessment can be seen in A feasibility trial will be performed in one of the clusters among patients presenting with self-harm behaviors at their emergency department. Social workers under the supervision of the head of the department of critical care and emergencies in the hospital and the project lead will form a multidisciplinary team to run the project. Professional social workers employed in the hospital are responsible for recruitment, baseline and follow-up assessments, and initial interventions. The mental health team will confirm the caseness of each potential participant after scrutiny of the filled-up assessment framework. The disagreements, if any, will be sorted out by the confirmatory assessment by the mental health team. As part of their field placement, a pool of social work trainees from the social work institutions across the State will deliver the follow-up telephonic interventions. Baseline and 6-month follow-up assessments will be performed using a set of standardized questionnaires. After completing the 6-month-long feasibility trial, the intervention will be tested in the emergency departments of randomly selected clusters.Criteria for the participants of the cluster-randomized trial include:via the actual or expected physical consequences” , in the study, assuming that despite their constant contact with the medical facility and frequent hospital admissions due to their physical conditions, the system insensitivity could result in patients slipping through the mental health or suicidal ideation detection gateways.Exclusion criteria for the patients include:We will exclude the patients with parasuicidal pauses and parasuicidal gestures to ensure the groups' homogeneity to test the intervention's effectiveness.Patients who do not have a consenting family member to participate will be excluded.We will exclude patients admitted to the psychiatric wards 14 days after the index attempt and the patients with schizophrenia spectrum disorders, severe bipolar, and severe dementia, assuming that they would require inpatient and intense care to manage their disorders, and this will prevent confounders and mixed-effects .Considering the huge treatment gap for mental disorders in India , the newThe study received the Institutional Ethics Committee (IEC) approval on September 15, 2021: Rajagiri Institutional Ethics Committee. Ref No: RCSS/IEC/009/2021. All study participants and one of the participating family members will provide written consent to participate. Further participants will be informed about confidentiality, the voluntary nature of participation and their right to withdraw from participation at any point of study.The initial phase would focus on developing a collaborative family approach within the unique cultural milieu of Kerala, India, to maximize acceptability. The team will perform the forward/back-translation of standardized scales and indexes into the local language . This phase would also involve the development of an accompanying fidelity scale to guide and test the implementation of the ABFT model in the selected population so that mediators for good outcomes could be evaluated. Social Work Trainees (SWTs) supervised by the professional mental health team consisting of a psychiatrist, clinical psychologist, psychiatric social workers and psychiatric nurses would assess and provide intervention. The mental health team has supervisory, trouble-shooting, and evaluative functions. Social worker trainees would record qualitative observations regarding processes and outcomes to complement the measurement tools to enhance the overall evaluation. Focus group discussions would also be employed to review progress and address any treatment issues. The feasibility trial phase would last up to 6 months until SWTs demonstrated reasonable competence in the use of measurement tools and the intervention packages. The last phase will involve a cluster-randomized trial with a targeted sample size of 158 people who has SHB presenting at emergency departments at selected clusters in Kerala. The ABFT model will be implemented bi-weekly for 6 months, and the results will be compared with a treatment-as-usual (TAU) comparison group .Study outcomes are assessed at baseline and 6-month follow-up. Demographic characteristics measured at baseline include age, gender, marital status, education, occupation, and family income. The following information on the clusters selected will be collected: number of hospital beds, patients, social workers, primary treatment modalities, and the average length of stay at the hospital. Measurement domains and time points are summarized in The primary outcome will be the total suicidality score measured by the Depressive Symptom Inventory–Suicidality Subscale (DSI-SS) . The DSISecondary outcomes to be measured include depression, anxiety, mental well-being, social support, resilience, customer satisfaction, and appropriate use of primary care and community resources.DASS 21 is a shortened version of Depression, Anxiety and stress scale developed by Lovibond and Lovibond . ParticiSocial support will be measured using the Medical Outcomes Study (MOS) Social Support Survey, a 19-item questionnaire measuring the availability of support in different life domains. The scale was evaluated to be reliable  and valid .The Brief Resilience Scale (BRS) measures the ability to bounce back from stressful situations in life . BRS is The project team will measure customer satisfaction regarding the services at the end of the follow-up measurement using a set of questions measuring overall efficiency, professionalism, accessibility, and the overall administration of benefits.Participants allotted to the intervention group will receive 12 sessions of biweekly interventions spread across 6 months. Following the baseline assessment, the initial sessions will include two psycho-educative sessions for both patient and family members, focusing mainly on post-hospital engagements and crisis intervention. The introductory sessions will focus on detailed Bio-Psycho-Socio-Cultural-and-Economic assessments exploring the stressors, current coping strategies, and social support, and addressing the priority issues and crisis domains through psychological first aid. The initial sessions are followed by Attachment-Based Family Therapy involving the patients and their significant family member(s) using a structured intervention module. The intervention module will have four major components; relational reframe, developing alliance, repairing attachment, and promoting autonomy . SelecteThe last sessions of the intervention focus on facilitating the linkages with formal and informal community resources available in their locality. The intervention's various components and delivery mechanisms are detailed in Participants recruited to the control group will receive usual care from the hospital. The usual treatment consisted of the medical management of the injuries and referral to various medical specialities and services based on their needs. Often, emphasis on the medical model makes the health system insensitive to the critical psychosocial factors associated with self-harm behavior. In Kerala, the family members or significant people accompany them and motivate them to continue the treatment. However, the option of after-treatment care will be available to patients from both groups, but they will not be assertively engaged with the intervention care package. Psychoeducation about the need for pharmacological treatment will continue in both groups whenever relevant. The family will be given additional information about the early warning signs of suicidal thoughts and ideation to their family members to detect the risk and suicidal intent. Baseline, interim, and follow-up measurements will be done using the same standardized tools for both groups.The multidisciplinary team for the development and implementation of the project includesthe lead investigators,medical professionals of the department of critical care and emergencies,professional mental health team in the hospitals and SWTs.Social Work Trainees specializing in medical and psychiatric social work will be recruited from the educational institutions based on their readiness to volunteer for this project. The volunteered trainees will be placed in the emergency departments of the hospitals as part of their field practicum under the supervision of the mental health team and the project lead in implementing the intervention. The trainees will be encouraged to refer their participants, if necessary, to the mental health team for pharmacological and other intense therapeutic interventions.R2 is 0.3 with 95% power, a two-sided alpha of 5% with a cluster effect of 0.05 results in a sample size of 256. The 95% power and additional 10% respondents would allow us to maintain at least the 80% power even after the 20% loss to follow-up. Thus, we aim to recruit 282 participants for this study.A sample size of 282 will be collected from 10 clusters, with an average of 28 required from each of the 10 clusters. The clusters receiving the FASE intervention and the clusters receiving the usual care will be randomized 1:1 ratio and 28 samples will be recruited for the study allowing for a 20 % loss in follow-up rate. The Critical z is 1.64 and Hard copies of data will be stored in a secure place, while soft data will be stored securely using file locks and passwords. Basic descriptive statistics will be computed for outcomes. The main effects of the interventions will be assessed on primary and secondary outcomes at different time points before and after the intervention. With the SPSS and R software, we will run the multiple regression modeling to determine the overall fit of the model and the relative contribution of each of the predictors to this variance. Multinomial Logistic Regression will be applied to study the exposure variables that are likely to contribute to the variation on the outcome variables, and discriminant analysis will be used to determine whether the clusters differ with regard to the predictors.Resource utilization will be recorded on all aspects of intervention implementation. Social Workers' salary, printed intervention manuals and brochures, telephone recharge expenses, train hall rent, transportation, scribbling pad and recording facility will be provided and the expenses will be documented to evaluate the cost-effectiveness of the project. Apart from 10 professional social workers employed in each cluster, no additional human resource expenses are expected as we focus on task sharing with the existing health workforce in the hospitals for implementing and supervising the intervention. The follow-up intervention by the second-year psychiatric social work students as part of their field placement reduces the human resource cost. Therefore, we will not calculate this cost within the trial. We will call or make home visits (if needed), to the participants to ensure they do not incur any additional telephone recharge costs or travel expenses. Per person cost will be calculated by total expenses divided by the number of people who received the FASE intervention. The anticipated savings from loss of life or the hospitalization costs, which the families largely incur due to repeated attempts alone, would likely offset the costs of paying social workers' salaries. If this approach proves promising in Kerala, more rigorous testing and nationwide dissemination could be possible with the support of more than 540 Schools of Social Work, most of which have field placement agreements with nearby hospitals. This family-focused model could be customized to suit the socio-cultural context of the locality. This model can be incorporated into the social work curricula through MSW internship training and post-graduate practice. Within a few years, India would have general hospital-based mental health services where virtually none currently exist. A national social work mental health organization could codify the credentialing of practice standards.Self-harm behavior is one of the most common reasons for admissions to emergency departments. It is alarming to note that the risk of suicide increases 50 to 100 times within the first 12 months after an episode of SHB than the general population risk , 29. At Socio-environmental, psychological, cultural and politico-economic factors are more relevant to studying suicide than mental disorders and biological factors in the south-east Asian region (SEAR) countries . Psycho-The tertiary prevention models of intervention programs to prevent and manage suicide are dismal in India , with juLack of consensus about what constitutes effective management strategies is a barrier to designing an appropriate care package. Psychological interventions developed in secondary care have shown some benefits. However, there are a need for such interventions to be evaluated in large populations, low and middle-income countries, especially within the setting of emergency departments, where they may need to be modified or tailored to the multidisciplinary and sensitive nature of the environment, along with the reality of time constraints.The major component of this primary, secondary and tertiary suicide prevention model is attachment-based family therapy (ABFT), which is proven effective among adolescents . The priAlthough no large-scale rigorously controlled trials of family interventions have been conducted in India to date, similar approaches are promising –43. TeamThe role of a brief multidimensional intervention model focusing on family functioning and connectedness and its integration into the public health system has not been explored. Thus, further development and wide dissemination of this care package could dramatically impact post-hospitalization care of people with suicidality by helping them learn coping skills within their milieu, reducing repeated attempts. Our strategy answers the perennial call to facilitate the transfer of knowledge from clinical research into routine care that includes integrated evaluation procedures as part of the practice. The interventions focusing on enhancing follow-up care for suicide reduce the burden on the patients and their caregivers and the more extensive healthcare system. It is also hoped to develop best practices in health interventions for at-risk clients. The experience gained in conducting this study will remain with the health service and improve the service staff's skill and knowledge base to detect and manage people with self-harm behaviors.The study is approved by the Institutional Ethics Committee of Rajagiri College of Social Sciences (Reference Number: RCSS/IEC/009/2021). The study will be conducted according to the guidelines of the Declaration of Helsinki. Participants will be recruited after obtaining consent and explaining the study.SD: conceptualization, methodology, funding acquisition, and writing—original draft. LJ: supervision and writing—review and editing. JV: conceptualization. LS, AB, and NC: writing—review and editing. All authors contributed to the article and approved the submitted version.This study will be funded by the Rajagiri College of Social Sciences (Autonomous). Funders have no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. This work is supported by Rajagiri Hospital, Aluva and Rajagiri College of Social Sciences (Autonomous).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Minor salivary gland ultra-high frequency ultrasonography (UHFUS) has recently been introduced for the evaluation of patients with suspected primary Sjögren’s Syndrome (pSS). At present, ultrasonographic assessment of major salivary glands is performed using the Outcome Measures in Rheumatology (OMERACT) scoring system. Previous reports have explored the possibility of applying the OMERACT scoring system to minor salivary glands UHFUS, with promising results. The aim of this study was to test the inter-reader concordance in the assignment of the OMERACT score to minor salivary gland UHFUS. The study was conducted on 170 minor salivary glands UHFUS scans of patients with suspected pSS. Three independent readers performed UHFUS image evaluation. Intraclass correlation coefficient (ICC) was employed to assess inter-reader reliability. Bland and Altman analysis was employed to test the agreement with a gold standard examiner. ICC values > 0.9 were found for scores 0 and 1, while score 2 and score 3 presented ICCs of 0.873 and 0.785, respectively. The measurements performed by the three examiners were in agreement with the gold standard examiner. According to these results, UHFUS interpretation showed good inter-observer reliability, suggesting that OMERACT score can be effectively used for the evaluation of glandular alterations, even for minor salivary glands. Primary Sjögren’s Syndrome (pSS) is a systemic autoimmune disease characterized by the progressive impairment of exocrine salivary and lachrymal glands. Glandular dysfunction results from the development of chronic lymphocytic infiltration in the glandular parenchyma . The diaThe 2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria are reliably employed to diagnose the presence of pSS in patients with subjective ocular and/or oral dryness and/or a positive item on the EULAR Disease Activity Index for pSS (ESSDAI) ,4. Five It has been hypothesized that major salivary gland ultrasonography (SGUS) can improve the performance of the ACR/EULAR classification criteria . The worUltrasonography is increasingly employed in the investigation of various conditions of the oral cavity, due to the unique characteristics that make this diagnostic imaging modality a valid alternative to ionizing radiations . RecentlThe aim of the present study was to evaluate the intra- and inter-reader reliability of minor salivary glands UHFUS, as evaluated with the OMERACT scoring system.The study involved the evaluation of minor salivary glands UHFUS scans belonging to patients with suspected pSS and who completed the diagnostic work-up. Cases with incomplete data or who did not obtain a final diagnosis were excluded. All patients whose cases were utilized signed an informed consent form. The study protocol was approved by the Institutional Review Board of the University Hospital of Pisa  and was conducted in accordance with the principles outlined in the Declaration of Helsinki. The manuscript was prepared according to the EQUATOR research reporting guidelines .Score 0: normal glandular parenchyma in the absence of alterations;Score 1: presence of fine echogenicity in the absence of clear alterations, or slight, diffuse glandular hypoechogenicity, mild glandular alteration;Score 2: presence of focal hypoechoic areas, but partial conservation of normal glandular parenchyma, moderate glandular alteration;Score 3: diffuse presence of hypoechoic areas in the absence of normal glandular parenchyma, or the presence of glandular fibrosis, severe glandular alteration.The scoring system employed for the evaluation of minor salivary glands UHFUS was described in detail in the original report . Brieflyhttps://horosproject.org (accessed on 15 February 2022)).A single examiner performed all UHFUS scans under standard conditions using a standardized acquisition protocol, previously described in the original report . Minor sThree examiners participated in this reliability study. Prior to the study beginning, the UHFUS scoring system of minor salivary glands described in the original report  was explThe examiners then received B-mode videos for each study case of suspected pSS, with the dataset including 170 progressively numbered cases. B-mode videos were prepared by an examiner not taking part in the reliability assessment. All videos maintained the original standardized 1:1 ratio and the original image quality. The brightness, contrast, and color of the images were not adjusted. The examiners were blinded to the study cases and were not provided with any additional information, in order to further reduce the risk of bias. The highest score detected on the exam was assigned to each case, as described in previous reports on OMERACT score assignment to ultrasound images of major salivary glands . A gold p-value was set as p < 0.05.Intraclass correlation coefficient (ICC) was employed to assess the inter-reader reliability. The Bland and Altman test was used to verify the possible agreement between with the gold standard examiner . All staOne hundred and seventy minor salivary gland UHFUS scans were analyzed in total. The study sample was composed of 159 females  and 11 males . A diagnosis of pSS was confirmed in 88 cases, while the remaining 82 patients were diagnosed with sicca syndrome. No differences in terms of age and gender distribution were found between pSS and sicca patients.Higher ICC values were encountered for scores 0 and 1 . In Score 2, 0.873 ICC was found. Score 3 presented the lowest ICC, with a value of 0.785 .The confidence interval (CI) of the distortion included zero when comparing the measurements of the three examiners with the gold standard examiner. In The application of the OMERACT scoring system to UHFUS of minor salivary glands showed good inter-reader reliability. Interestingly, a higher concordance was detected for scores 0 and 1; thus, suggesting that the OMERACT scoring system can discriminate between normal glands and incipient glandular alteration. The lowest concordance was detected for score 3, presumably related to the tendency to underestimate glandular alteration.The role of ultrasonography in the diagnostic work-up of pSS has been repeatedly discussed in the literature. However, the lack of consensus on the evaluation of salivary gland elementary lesions and, subsequently, on the scoring system have hindered the inclusion of SGUS in pSS classification criteria . The pathologic changes occurring in the course of pSS, which eventually result in glandular damage, can be detected with SGUS as hypo/anechoic areas and hyperechoic bands ,20,21. IThe issue of the reliability of ultrasonographic scores has been discussed in previous literature with regards to SGUS ,23. SpecThe evidence on the reliability of the OMERACT scoring system in SGUS was the rationale behind the application of these classification criteria to UHFUS of minor salivary glands . UHFUS iHowever, the present study has some limitations. First, the study was conducted on previously recorded scans and, due to technical issues, UHFUS performance is likely to introduce systematic and non-systematic errors in global assessment. Second, the OMERACT scoring system is usually employed for the evaluation of major salivary glands, and the highest score from the three compartments was chosen. Although in the previous literature the application of the most affected salivary gland criterion has been employed for score assignment, further assessment and adjustment to the classification may be advised. Nevertheless, if these results are confirmed, UHFUS has the potential to become a valuable tool for the screening of patients with suspected pSS.The evaluation of minor salivary gland UHFUS with the OMERACT scoring system showed good inter-observer reliability. These results appear extremely promising and pave the way for further investigations of the use of UHFUS to improve the morphological assessment of minor salivary glands in pSS.


Amygdaloid cysts are benign dysembryological cystic tumors that develop in the antero-lateral part of the neck; they represent 2% of laterocervical tumors of the neck; they are among the most frequent gill anomalies; they represent 6.1% to 85.2% of second cleft anomalies. They are due to the persistence of the cervical sinus during the differentiation of the branchial apparatus. They are manifested by a laterocervical swelling located at the anterior edge of the sterno-cleido-mastoid muscle. Their cystic nature is confirmed by ultrasound and CT. Treatment consists of surgical excision.We report the case of a 33-year-old man who consulted for a huge right laterocervical swelling that had been evolving for 16 months without any other associated symptoms. An exploratory cervicotomy with an anatomo-pathological study was performed, and the histological diagnosis retained was an amygdaloid cyst without signs of malignancy.The objective of this work is to analyze the anatomo-clinical characteristics and discuss the methods of management and the therapeutic indications of this affection. Amygdaloid cysts are among the most common gill anomalies, accounting for 6.1% to 85.2% of second cleft anomalies. They are due to the persistence of the cervical sinus during the differentiation of the branchial apparatus. The usual site is the middle third of the anterior border of the sterno-cleido-mastoid muscle, but they can be located at any point from the middle constrictor muscle of the pharynx to the supraclavicular region. We report this rare case of a huge laterocervical amygdaloid cyst [A 33-year-old patient with chronic smoking and occasional alcoholism and no other notable pathological history presented for 16 months with a right laterocervical swelling that gradually increases in volume without associated otological or rhinological signs; clinical examination revealed an enormous right laterocervical tumefaction stretching from the tip of the mastoid above to the supraclavicular region below, painless, slightly mobile, non-pulsatile, measuring almost 70 mm in long axis, of renitent consistency, its full limit was impossible to specify, the adjacent skin was healthy. Examination of the oropharynx, nasopharynx, and pharyngolarynx was normal. Contrast-enhanced computed tomography objectified the presence of Figure The cervico-facial MRI found a cystic mass under the right angulo-mandibular wall with a thick wall in its upper part of the same dimensions associated with lymph nodes in the territories of IIa and IIb, suggesting a cyst in the second branchial cleft Figure .The PET scanner Figure  shows a Histological examination confirmed the diagnosis of an amygdaloid cyst without signs of malignancy Figure .Cysts and fistulas of the face and neck are uncommon and poorly understood congenital malformations. The ENT specialist must recognize these lesions early to allow for appropriate management ,2. TonsiClinically, a cervical sinus cyst presents as an oval kidney swelling, mobile with respect to the superficial plane, usually located near the carotid bifurcation in a subhyoid position ,5. The lCT or MRI are particularly indicated to differentiate the lesion from other parapharyngeal tumors: hemangioma, lymphangioma, metastatic adenopathy, whose distinction with a degenerated amygdaloid cyst or an intracystic metastasis is very difficult and the confirmation remains anatomopathological after a surgical removal ,2. MagneHistologically, the tonsillar cyst is lined by an epithelium that is most often squamous , but it Amygdaloid cysts are benign dysembryologic cystic tumors developing in the anterolateral portion of the neck. They mostly result from branchial cleft abnormalities. They are due to the persistence of the cervical sinus during the differentiation of the branchial apparatus. They manifest as a laterocervical swelling in the anterior edge of the sternocleidomastoid muscle. Their diagnosis is suspected based on physical examination oriented by imaging data and confirmed by an anatomopathological examination. Therapeutic management is always surgical and should be performed as early as possible to limit the risk of inflammatory changes related to infectious episodes.


Generally, glomus tumors are considered tumors of the autonomic system arising from chromaffin cells of the parasympathetic paraganglia of the skull base and neck. Glomus tympanicum is the most common primary tumor of the middle ear cavity and it arises from the paraganglia of the middle ear.We present a case of glomus tympanicum presented in a 70-year-old woman, complicated with facial nerve palsy which at first sight was misdiagnosed as cholesteatoma. Patient presented in our clinic because of otorrhea, pulsatile tinnitus and hearing loss in the right ear. However, facial nerve function was good in the first examination (40 days before the surgery). Eventually, she treated successfully with a canal wall down mastoidectomy. Technique had been chosen because of the mass size and the involvement of external auditory canal, after a discussion with the patient.Although histologically benign, glomus tympanicum is slow growing and destructs adjacent tissues potentially. The two most common complaints are hearing loss (conductive) and pulsatile tinnitus. These neoplasms are more common in women and they can be diagnosed by CT or MRI scan. It is of high importance physicians suspect a glomus tumor when patient ‘s clinical findings are hearing loss and pulsatile tinnitus and use an intravascular agent in imaging so that the differential diagnosis will be supported. Glomus tympanicum is the most common primary tumour of the middle ear cavity  therefor A 70-year-old woman presented at our Ear, Nose, and Throat (ENT) clinic complaining about bad smell and otorrhea, pulsatile tinnitus and sense of ear fullness on the right side over the last 12 months. Her past medical history was otherwise normal. On otomicroscopy, there was identified a mass occupying completely the external auditory canal, which rendered impossible the overview of the tympanic membrane. Moreover, there was a mild and painless mastoid redness respectively. A pure tone audiometry was performed and it revealed a moderate mixed hearing loss in right ear and a mild sensorineural hearing loss in left ear . A computed tomography (CT) was scheduled revealing soft tissue density in the whole middle ear cavity with expansion in the mastoid and the external auditory canal (EAC), soft tissue ossification elements and smooth erosions of petrous part of temporal bone . Radiology report attributed these findings to middle ear cholesteatoma. The patient was prescribed local antibiotics with the aim to resolve otorrhea. Because of the excessive mass size, which occupied the whole middle ear and seemed to had affected the bone structure in CT scan and because our team wanted to be certain about the complete exclusion of the tumor, a radical mastoidectomy was planned one month later. The night before the surgery the patient presented facial nerve palsy (House-Brackmann III) . There was administrated intravenous steroid (methylprednisolone 500 mg) immediately. The following day, at the beginning of the surgery, fragments of the tumor of the EAC were biopsied. Biopsy caused continuous bleeding and the attempt for hemostasis doubled the surgical time. Eardrum perforation and ossicular erosions  had been found during the operation. Frozen section reported possible malignancy with concomitant inflammatory elements, without covering epithelium. Αn uncomplicated canal wall down mastoidectomy was performed. Facial nerve palsy resolved postoperatively (House-Brackmann I) . The finAn MRA and MRI was performed postoperatively (after 1 month) which revealed no evidence of disease in the vascular system, the presence of chronic inflammatory lesions in petrous part of temporal bone and some fluid in mastoid cells, that can be justified from the surgery and it is expected to be absorbed . At 1-yeGlomus tumor or chemodectoma or paraganglioma, constitute the most common primary neoplasm of the middle ear, and the second most common tumor of the temporal bone, called glomus tympanicum . There aAround 5% to 10% of these tumors secrete catecholamines  causing hypertension, headaches, flushing and cardiac arrhythmias  of the temporal bone and skull base ,9. AdditIt is of high importance that every otolaryngologist should recognize such a tumor and be aware of a possible disastrous bleeding event in case of probing in clinic. An imaging technique with intravascular contrast media would be necessary and helpful for an accurate diagnosis in future similar cases. The treatment is individualized since for older patients with poor physical condition radiotherapy is the treatment of choice, while younger ones are candidates for surgical removal after angiography and embolism ,12-14. Physicians should also be open to other modalities of treatment, including use of the gamma knife. Method of consent was verbal for this article.


Laparoscopic pancreatectomy is currently a widely used approach for benign and malignant lesions of the pancreas.The Clockwise Technique. This study aimed to describe how to perform a laparoscopic distal pancreatectomy using The Clockwise Technique. An 18-year-old female patient presented with a well-defined tumor in the pancreatic body with 4 cm in diameter that suggested a diagnosis of solid pseudopapillary tumor (Frantz’s tumor). The patient was recommended for laparoscopic distal pancreatectomy by using  The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure.The Clockwise Technique provides satisfactory outcomes. A laparoscopic distal pancreatectomy performed using  Minimally invasive surgery is currently a widely used approach for benign and malignant lesions of the pancreas,,Recent systematic reviews and meta-analysis of studies comparing LPD and open distal pancreatectomy (ODP) have suggested superior short-term outcomes and benefits for patients, including less intraoperative blood loss, shorter postoperative hospital stay, less morbidity, and reduced time to functional recovery for LPD compared to ODPThe Clockwise Technique.The objective of this study was to describe how to perform an LDP using An 18-year-old female patient presented with abdominal pain in the upper quadrants. An abdominal ultrasound, a diffusion-weighted imaging, and pancreatic magnetic resonance imaging (MRI) scan showed the presence of a well-defined tumor arising from the pancreatic body with a greater diameter of 4 cm, suggesting the diagnosis of solid pseudopapillary tumor (Frantz’s tumor). The patient was recommended for LDP, using a clockwise technique . PostopeThe operation is initiated with the patient in a modified right lateral decubitus position that would allow for rotation to the left or right during the procedure. The surgeon stands to the right of the operating table. The ports are placed as shown in The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure. The procedure is performed through the following steps :Step 1: Mobilization of the splenic flexure of the colon and exposure of the pancreas.Step 2: Dissection along the inferior edge of the pancreas and choosing the site for pancreatic division.Step 3: Pancreatic parenchymal division and ligation of the splenic vein and artery.Step 4: Dissection along the superior edge of the pancreas.Step 5: Mobilization of the spleen and specimen removal.The total operative time was 300 min with no transfusion. The surgical specimen was removed through a small suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. Recovery was uneventful and patient was discharged on postoperative day 4. Postoperative MRI showed no evidence of the disease 12 months after the procedure.The Clockwise Technique consists of a systematized approach, aiming to facilitate the surgical procedure in a uniform method and well-defined steps,,The Clockwise Technique in the laparoscopic approach to pancreatic lesions were initially described in 2011The Clockwise Technique and observed a very low conversion rate (5%), reserved for situations in which the surgeon had difficulty with the anatomy, being mainly early and in the curve of learning,LPD is a safe and effective method for surgical approach of the pancreas and has significant advantages compared to ODP. The advantages of Abu et al.The Clockwise Technique, and this systematic approach demonstrated this technique as a reproducible, safe method with low complication rates and, as a consequence, lower morbidity and mortality to the management of lesions on the left side of the pancreas.LPD was performed using


Two theoretical assumptions motivate the choice of the present Research Topic focused on the role of “socio-emotional” skills in the development of interpersonal relationships from preschool to adolescence:1. The assumption that the emotional dimension plays a key role in the psychological development of a person;2. The importance of peers' interactions in the structuring/expression of socio-cognitive and self-regulatory skills, essentials for the individual and collective wellbeing.In the following, we reflect on possible explanations of the mentioned assumptions.1. In the field of developmental psychology, the attention on socio-emotional skills has been addressed relatively late compared to other psychological abilities, such as, specifically, cognitive abilities. In fact, the development of intelligence has traditionally been considered more qualifying and distinctive for the human experience.Moreover, psychological science focused on the study of general competencies, like cognitive and linguistic skills, that are considered fundamental for the development of more specific competencies , primary school (N = 1), to adolescence (N = 4) and late adolescence (N = 2); 1 study analyses the entire age span from preschool (5 years) to the late adolescence (17 years).This special issue presents 13 studies covering a wide range of ages, from preschool  on the association between the dark triad  and prosocial sustainability, declined in terms of altruism and equity. Main findings suggest that TEI might reduce the malevolent effects of the dark triad on altruism and equitable behavior in late adolescence.In their study with Italian adolescents, Salerni and Caprin present research that enrolled 160 Italian pre-schoolers and their teachers. The study investigates whether the early day-care experience can influence the prosocial behaviors that children exhibit during free-play social interactions with peers; and the associations between the enactment of prosocial behaviors and social-emotional and behavioral competence. The findings are interesting in light of the possible associations between socialization outside of the family context, prosocial behavior, and children's socio-emotional skills. Di Norcia et al. examine the representations on friendship among Italian children aged 6–11 years by depicting themselves with a close friend in two relational situations: wellbeing and distress. Some indices of children's drawings were predictive of their tendency to enact physical and verbal aggression: for instance, the capacity to relate with one's own friend even in difficult times predicts lesser aggression with peers.Farina and Belacchi explore the longitudinal effects of interpersonal variables  and personal variables (empathy and understanding of emotions) on role-taking in bullying episodes  in the transition between kindergarten and primary school. The study highlights the existence of independent effects of two social status indices on the participant role-taking in bullying episodes.Cigala and Mori's paper. The study contributes to the limited and controversial research on this topic. The perspective-taking represents a significant protective factor that improves the social adaptation of preschool children who are victims of psychological abuse.An intervention study aimed to promote perspective-taking ability in Italian children who are victims of psychological maltreatment, is presented in Grazzani et al. investigate the role of socio-emotional skills and resilience in explaining mental health in 778 Italian adolescents, during the COVID-19 pandemic. The paper fits in the field of studies which contribute to explore the consequences of the pandemic and point out that resilience may be an important protective factor against the incidence of internalized disorders in the face of adversity.Simon and Nader-Grosbois in their explorative study, carried out in Belgium, examine parents' representations of their preschool child's empathy, personality, and social adjustment. Main findings reveal no significant differences between mothers' and fathers' representations of their child, but significant gender differences emerge, with girls being more skilled in affective empathy and boys in cognitive empathy. In general, empathy emerges to be positively related to social adjustment.Shin examines the additive and interactive effects of 677 early adolescents' social achievement goals and perceived relational support from teachers and peers on their social behavior, in South Korea. Findings indicate that individual differences in psychological processes of social goals and perceived relatedness matter for youth's social adjustment. The findings also emphasize the need to consider adolescents' social goals in conjunction with their perceptions of the relational features of their interpersonal environments.Fernández-Martín et al. contribute with their work to synthesize research on the efficacy and effectiveness of socio-emotional skills programs in Ibero-American contexts in early childhood. The systematic review of 22 empirical studies shows that the social and emotional learning (SEL) variables with the highest incidence and significant results are: self-awareness; social awareness; self-control; relationship skills; decision-making; school climate; wellbeing; and academic achievement. The study also identifies some factors that can ensure the success of future SEL programs.Bølstad et al. present a pilot study on the first experimentation in the Scandinavian population of an emotion-focused intervention “Tuning in to Kids (TIK)” addressed to parents. Their findings suggest an effect on the improvement in parents' emotion coaching and their appraisal of child externalizing problems, while children's self-regulation showed mainly normative developmental improvements.Wang et al. investigate the relationship between emotional intelligence and prosocial behavior among Chinese adolescents, examining the mediating effect of social support and the moderating effect of self-esteem in this relationship. They found a positive association between emotional intelligence and prosocial behavior; furthermore, the more social support college students receive, the more they tend to engage in prosocial behavior, especially in students with high self-esteem.Deng et al. conducted a meta-analysis on the association between empathy and defending behavior in adolescent bullying. Main results highlight a significant correlation between the two variables, whose strength was moderated by the kind of empathy (affective empathy has a stronger association than cognitive) and by the evaluator of defending behavior .Xiong et al. explore the association between the sense of deprivation and prosocial tendencies in a large sample of 1,630 Chinese children who migrate from rural to urban areas and may experience social exclusion, prejudice, and discrimination. The study offers evidence that can be relevant for parents, educators, and other members of the society who are concerned about migrant children's psychosocial adaptation.In conclusion, this Research Topic is intended to provide a broad and articulated overview of current research on the role of emotional-social skills in altruistic and/or hostile behaviors among peers. We realize that there is a heterogeneity of both the age groups considered (from preschool to adolescence) and the aspects investigated . Therefore, we would like to encourage researchers to carry out systematic and specific reviews on studies over the various aspects investigated in this Research Topic.All authors equally contributed to the conception and the writing of this editorial. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.