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- Dr. Babak Saedi works as an Otolaryngologist and Facial Plastic surgeon, he also serves as a Professor of Tehran Univ... moreDr. Babak Saedi works as an Otolaryngologist and Facial Plastic surgeon, he also serves as a Professor of Tehran University of Medical Sciences, he was named to Board of Certificate of Otolaryngology and Facial Plastic Fellowship ,he has been working in Field of Rhinology and Facial Plastic surgery for so many years.He has facial plastic surgery fellowship and he is the member of European Academy of Facial Plastic Surgery.edit
Background Alopecia areata is an autoimmune disease that damages hair follicles and follicular melanocytes can be involved in the autoimmune process. Therefore, similar to vitiligo, there may be a relationship between sensorineural... more
Background Alopecia areata is an autoimmune disease that damages hair follicles and follicular melanocytes can be involved in the autoimmune process. Therefore, similar to vitiligo, there may be a relationship between sensorineural hearing loss and alopecia areata. Aims/objectives This study aimed to investigate potential hearing impairments in patients with alopecia areata. Methods A total of 42 subjects with alopecia areata and 42 healthy individuals enrolled in this cross-sectional study. The hearing was evaluated by vestibular evoked myogenic potential, otoacoustic emission and pure tone audiometry tests in the patients and control subjects. Results A normal otoacoustic emission was reported in 59.5% and 100% of subjects with alopecia areata and the controls, respectively (P = 0.02). Higher speech recognition thresholds (P = 0.02) and speech discrimination scores were reported more in subjects with alopecia areata than in controls (P < 0.001); however, the most comfortable level of speech was not significantly different between the groups (P = 0.06). The greatest increase in the hearing threshold was recorded at a frequency of 8000 Hz, while at frequencies of 500 and 1000 Hz, the patients and controls did not significantly differ (P > 0.05). About 6 (14.3%) and 2 (4.8%) of patients with unilateral and bilateral involvement, respectively, demonstrated no vestibular evoked myogenic potential response in the alopecia areata group. The patients and controls did not significantly differ in terms of amplitudes of the vestibular evoked myogenic potential test (P = 0.097). Limitation Small sample size and qualitative measurement of otoacoustic emission were limitations of our study. Conclusion Hearing loss was more common in alopecia areata patients than in healthy individuals. Follicular melanocytes may be involved in the alopecia areata inflammatory process, and destroying melanocytes may impact hearing function in the inner ear. However, there was no significant relationship between the duration and severity of alopecia areata and hearing loss.
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Objective: To compare anatomical variations in sinusitis patients and control subjects. Subjects and methods: We reviewed and compared the computed tomography (CT) scans of 87 sinusitis patients after adequate medical treatment and scans... more
Objective: To compare anatomical variations in sinusitis patients and control subjects. Subjects and methods: We reviewed and compared the computed tomography (CT) scans of 87 sinusitis patients after adequate medical treatment and scans of 103 healthy subjects. All images were scored for sinusitis severity using the Lund-Mackay scoring system. Anatomical variations such as septal deviation, concha bullosa, presence of the Haller's cell, paradoxical middle turbinate, prominent agger nasi cell, and Onodi cell were also recorded. Results: Of the 190 evaluated CT images, 55.2% of the cases and 47.6% of the controls had septal deviation (p > 0.05). The prevalence of concha bullosa was 68% in patients and 61% in controls (p > 0.05). Conclusion: There were no significant differences in the evaluated anatomical variations between cases and controls in this study. Mucosal inflammation may play a more essential role than anatomical variation in the development of sinusitis.
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Research Interests: Surgery, Adolescent, Medicine, Endoscopy, Humans, and 15 moreBlood Pressure, Male, Young Adult, The, Clinical Sciences, Adult, Time Factors, Health Care Costs, X ray Computed Tomography, Resection, Angiofibroma, Postoperative Complications, Embolization, Otology and laryngology., and Intraoperative complications
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Introduction: The surgical management of chronic frontal sinus disorders remains a challenge for rhinologists. The aim of this study was to evaluate the result of Draf III in a series of patients who underwent this procedure. Materials... more
Introduction: The surgical management of chronic frontal sinus disorders remains a challenge for rhinologists. The aim of this study was to evaluate the result of Draf III in a series of patients who underwent this procedure. Materials and methods: Twenty patients were included in this study. Demographic data, history of prior surgery, asthma, aspirin sensitivity and Lund-Mackay score were recorded. A visual analog scale was used for frontal-related symptoms. Patients were followed for a mean duration of 17.5 months and the patency of the frontal sinus ostium was closely monitored. Results: Fifteen patients with chronic frontal sinusitis, two patients with mucoceles, two with malignancy, and one with osteoma underwent Draf III. The mean symptoms score significantly decreased from 5.9 to 3. No ostial closure was seen in the follow-up period. Among 15 patients with chronic frontal sinusitis, 12 had patent ostia of whom three had significant stenosis. All patients with mucocele and osteoma had patent ostia in the follow-up period but patients with sinonasal malignancy showed significant stenosis. Conclusion: Draf III frontal sinusotomy is successful in alleviating patient symptoms and the frontal sinus neo-ostium will remain patent in long-term follow-up of most patients. Revision surgery will be required in some cases, which seems to be related to the nature of the underlying chronic sinus diseases.
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Objectives: Chronic sinusitis with polyposis (CSWP) is associated with high direct and indirect annual costs. This condition affects several aspects of daily life, and CSWP patients usually suffer from decreased quality of life (QOL).... more
Objectives: Chronic sinusitis with polyposis (CSWP) is associated with high direct and indirect annual costs. This condition affects several aspects of daily life, and CSWP patients usually suffer from decreased quality of life (QOL). Treatment with functional endoscopic sinus surgery (FESS) is reported to improve the QOL of patients with CS. Here we evaluated the factors that affected QOL improvement in CSWP patients who were candidates for FESS. Methods: All patients with CSWP who were treated at the Imam Khomeini Hospital Complex in Tehan, Iran that were candidates for FESS were recruited. Patients with systemic or neurologic diseases that could affect their QOL were excluded. Clinical signs were recorded before and after FESS using the sinonasal outcome test (SNOT-22) and QOL questionnaires. The patient's history of allergic rhinitis, aspirin sensitivity, asthma and smoking was recorded. QOL and associations with clinical features were evaluated within twelve months after FESS. Results: The study included 47 patients with a mean age of 39.5 +/- 15.4 years (61.7% women). FESS resulted in significant improvements in QOL based on the SNOT-22 and QOL questionnaires (p = 0.0001 for both). Septal deviation was the only single characteristic that was significantly associated with QOL improvements. Conclusion: FESS significantly improved the QOL of patients with CSWP. However, patients with septal deviation benefited the most from FESS.
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Background Internal nasal valve collapse is a preventable complication of rhinoplasty, for which the spreader graft is the gold standard. More recently, the spreader flap technique has been espoused as an alternative to spreader grafting.... more
Background Internal nasal valve collapse is a preventable complication of rhinoplasty, for which the spreader graft is the gold standard. More recently, the spreader flap technique has been espoused as an alternative to spreader grafting. Here, we evaluated the efficacy of this technique in a randomized trial setting. Methods The autospreader was used in 32 patients who were candidates for primary rhinoplasty; 34 who did not undergo a spreader flap procedure were recruited as a control group. Acoustic rhinometry was used in every patient preoperatively and 1 year postoperatively. Average volume and minimal cross-sectional area (MCA) of the nose and findings were collected. Also, the pre- and postoperative patients’ subjective assessment about their satisfaction from their appearance and nasal obstruction were evaluated according to visual analog scale (VAS). Results Among the study group patients, 46 (69.7%) were female and 20 (30.3%) were male subjects. Their mean age was 50/5 ± 6/24 years. The difference in MCA in the control group was-0.1 and +0.6 (on right and left sides, respectively), and in the spreader flap group it was-0.03 and +0.05, which showed an increase in MCA in the left side and a decrease in the opposite side of both groups. However, their difference was not statistically significant (p = 0.50). Also, the differences between preoperative and postoperative VAS were not significant in either nasal obstruction (p = 0.68) and cosmetic satisfaction (p = 0.38). Conclusion Spreader flap is an attractive technique in preserving the middle vault in nasal plastic surgery. However, its effect needs more evaluation.
Research Interests: Surgery, Treatment Outcome, Medicine, Humans, Female, and 14 moreMale, Follow-up studies, Patient Satisfaction, Rhinoplasty, Clinical Sciences, Visual Analogue Scale, Middle Aged, Adult, Randomized Controlled Trial, Nose, Nasal Obstruction, Acoustic Rhinometry, Visual Analog Scale, and Surgical Flaps
The ability to attain accurate and predictable changes in the contour and position of the nasal tip is still one of challenging aspects of rhinoplasty; however, little evidence supports the choice of suture material for this technique in... more
The ability to attain accurate and predictable changes in the contour and position of the nasal tip is still one of challenging aspects of rhinoplasty; however, little evidence supports the choice of suture material for this technique in rhinoplasty. This study was conducted to compare the effect of nylon and polydioxanone(PDS) on tip projection and rotation of rhinoplasty patients. Sixty rhinoplasty candidates were included in this clinical trial study and evaluated prospectively. They were randomly allocated to two groups according to the use of nylon or PDS. The outcome measures were achieving and maintaining tip projection and rotation in the long term. Standardized photos were taken before and after the surgery to compare the final outcomes between the two groups, which were evaluated for tip rotation and projection. Moreover, visual analogue scale (VAS) and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHONS) were used for assessment of patients’ satisfaction with beauty and nasal obstruction. Thirty patients underwent surgery using nylon sutures, while the PDS was used in the same number of cases. Tip rotation, tip projection, and other characteristics were not significantly different between the two groups preoperatively. None of evaluated variables was significantly different between the two groups. It appears that both nylon and PDS are appropriate suture materials in maintaining tip projection and rotation in the tongue-in-groove technique. Using absorbable sutures may decrease unwanted reactions in longer patient follow-ups. Clinical trial Registration number: IRCT20080820001056N4 Level of Evidence: Level I, therapeutic study
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Objective Septal spurs are exceedingly common structural deformities that contribute to nasal obstruction and often require surgical correction. The posterior extension of the quadrangular cartilage (PEQC) and its relationship with septal... more
Objective Septal spurs are exceedingly common structural deformities that contribute to nasal obstruction and often require surgical correction. The posterior extension of the quadrangular cartilage (PEQC) and its relationship with septal spurs have not been previously examined. We seek to examine the anatomic and histologic relationship of the PEQC and concurrent septal spurs in patients undergoing septoplasty. Study Design Prospective cohort study. Setting Facial plastic and rhinology center in tertiary hospital setting. Subject and Methods Thirty patients with septal deviation are described in this series. The quadrangular cartilage and associated septal spur were removed en bloc from patients undergoing septoplasty. The length of the PEQC, the side of spur deviation, and the relationship of the PEQC to the spur (ipsilateral vs contralateral) were recorded. Results The mean length of the PEQC, beyond the bony-cartilaginous junction, was 30.06 ± 6.06 mm. The PEQC was present on the ipsilateral side of the spur deviation in all 30 patients (100%). Conclusion At sites of septal spur formation, the quadrangular cartilage possesses an average 3-cm extension beyond its junction with the bony components of the septum. This cartilaginous extension is exclusively found on the same side of spur deviation. These findings have implications on our understanding of the ontogeny of commonly found septal spurs and deviations, as well as treatment strategies and cartilage graft harvesting.
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The relationship between asthma and sinusitis has been proposed in many reports but the role of sinus surgery in their treatment is still controversial. Therefore, the effect of functional sinus surgery in patients with controlled asthma... more
The relationship between asthma and sinusitis has been proposed in many reports but the role of sinus surgery in their treatment is still controversial. Therefore, the effect of functional sinus surgery in patients with controlled asthma was evaluated. Fifty six patients with a history of sinusitis in whom maximum medical treatment had failed and also those with a history of asthma who were in a stable condition at time of surgery and were candidates for endoscopic sinus surgery were selected. All those who underwent functional endoscopic sinus surgery were re-evaluated at last one year later for pulmonary and sinus status. The patients' characteristics were prospectively recorded during the study period from January 2007 to November 2009. Finally, the results of the assessments were analyzed. Among 56 studied patients, 35 (62.5%) were female and 21 (37.5%) male. Preoperative imaging, evaluated according to Lund Mac Kay score, had a mean score of 19.5±5. The average effect of FESS in asthma improvement was 69.6%. Asthma improvement had a significant relationship with the duration of asthma and sinusitis before surgery. Functional endoscopic sinus surgery can effectively treat sinusitis in asthmatic patients. Earlier intervention in the course of pulmonary disease may warrant a better outcome.
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Objective The outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation. Subjects and Methods Three... more
Objective The outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation. Subjects and Methods Three hundred and sixty-seven patients who underwent rhinoplasty using TIG from 2016 to 2020 were included in this study. SEG was used if the caudal segment of the septum was not suitable for TIG. All patients were photographed pre- and postoperatively . Columellar Facial angle (CFA) and Nasolabial angle (NLA) were measured preoperatively at three intervals including up to six months after the operation (early or T1), up to one year after T1 (midterm or T2), and up to two years after T2 (late or T3). Results Two hundred and nine patients (56.94%) underwent TIG and the rest of them (43.06%) received SEG plus TIG (SEG+TIG). The TIG group had a mean CFA of 95.9±7.56 degrees preoperatively, 106.5±6.77 degrees at T1, 105.4±6.48 degrees at T2, and 104.8 ±7.52 at T3. The SEG+TIG had a mean CFA of 98.9±7.65 degrees preoperatively, 108.8±6.58 degrees at T1, 107.7±6.86 degrees at T2, and 106.2 ±15.6 at T3. Comparison of T1, T2, and T3 showed that the CFA changes were less than 1%, indicating a nonsignificant difference. The same results were obtained for NLA as well. Conclusion Adding of SEG to TIG may be an effective technique to create and maintain a stable rotation comparing to TIG independently. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Discussion | The SCHNOS demonstrated overall perfect ability to distinguish different levels of perceived nasal symptoms. The SCHNOS-O score was effective at differentiating between patients with and without symptoms, whereas the SCHNOS-C... more
Discussion | The SCHNOS demonstrated overall perfect ability to distinguish different levels of perceived nasal symptoms. The SCHNOS-O score was effective at differentiating between patients with and without symptoms, whereas the SCHNOS-C score was most effective when discriminating symptoms at higher severity levels. Although the sample was large, it was limited to one university clinic with predominantly younger and female patients. Thus, similar studies should be completed in other settings. The high similarity between information curves and difficulty estimates of different items of the SCHNOS may signal redundancy in items on the scale. This possibility can be tested with confirmatory factor analysis in a subsequent study. Both the SCHNOS-O and SCHNOS-C had perfect discrimination ability. The SCHNOS-O demonstrates ideal results regarding its capability to distinguish patients with even mild nasal obstruction from those without obstruction. As such, the SCHNOS-O may serve as both a screening and clinical tool for nasal obstruction. The SCHNOS-C was especially effective among patients with more severe perceived cosmetic disadvantages; thus, it is probably more reliable as a clinical rather than a screening tool.
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DIAGNOSTIC EFFICACY OF FINE NEEDLE ASPIRATION IN PAROTID MASS RAZMPA EBRAHIM,SAEDI BABAK*,PARTOMANESH MAJID * IMAM KHOMEINI HOSPITAL, TEHRAN UNIVERSITY OF MEDICAL SCIENCES, TEHRAN, IRAN Introduction: The preoperative ...
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Lateral crural cut and overlay (LCC) or medial crural cut and overlay (MCC) are two of the many techniques applied to ensure an adequate nasal tip projection and rotation, but little evidence supports their long-term efficacy. Fifty-four... more
Lateral crural cut and overlay (LCC) or medial crural cut and overlay (MCC) are two of the many techniques applied to ensure an adequate nasal tip projection and rotation, but little evidence supports their long-term efficacy. Fifty-four rhinoplasty candidates were studied prospectively in this randomised clinical trial. The subjects were randomly divided into two groups according to the use of LCC or MCC. The outcome measures were gaining and maintaining tip projection and rotation in the long term. Standardised photographs taken before and at three and 12 months after surgery were used to compare nasolabial angle and projection between groups. Patients' satisfaction with the cosmetic results and nasal obstruction were evaluated using the Standardised Cosmesis and Health Nasal Outcomes Survey (SCHNOS). LCC and MCC were each used in 26 cases. Preoperatively, the nasolabial angle, tip projection, and other characteristics were not significantly different between the groups. There was no significant difference in tip rotation stability (p = 0.624) and projection (p = 0.329) between the groups postoperatively, but patients' satisfaction with the cosmetic results was significantly higher in the MCC group (p = 0.046). It seems that both LCC and MCC are effective techniques in rhinoplasty. Compared with LCC, the use of MCC in qualified hands may increase the patients' satisfaction with the cosmetic results.
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Background: Orofacial cleft is one of the most common congenital malformations of craniofacial region. Otitis media with effusion causing conductive hearing loss is a considerable challenge for many children with cleft lip and palate. The... more
Background: Orofacial cleft is one of the most common congenital malformations of craniofacial region. Otitis media with effusion causing conductive hearing loss is a considerable challenge for many children with cleft lip and palate. The aim of this study was to evaluate the prevalence of hearing disorders and associated malformations in these patients. Methods: The research population consisted of patients with cleft palate, between years 2012 and 2014, who were referred to Children’s Medical Center and Vali-e-Asr hospital in Tehran, Iran. Otoscopic examination, tympanometry, pure tone audiometry and echocardiography were performed for each patient. Results: Among patients with cleft palate, 73% suffered from hearing disorders. There was no relationship between prevalence of hearing loss and sex, presence of other congenital anomalies and degree of cleft, but middle ear diseases were significantly higher in children younger than 2 years. Among patients with cleft lip or palate, 10...
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Introduction: Sphenoid sinus can be considered a key element in advanced sinus and skull base surgery. Due to its importance, many researchers tried to document its characteristics and evaluate possible differences among different races... more
Introduction: Sphenoid sinus can be considered a key element in advanced sinus and skull base surgery. Due to its importance, many researchers tried to document its characteristics and evaluate possible differences among different races and populations. Materials and Methods: This study was conducted between March 2017 and December 2018 on 60 fresh adult cadavers in Tehran Forensic Medicine Center, Tehran, Iran. The evaluated variables were distances between nasal spines, posterior wall of the sphenoid, pituitary gland, and the distance between the anterior and posterior ethmoid artery and optic nerve, which were calculated using a flexible ruler through the direct length in millimeter. Another important variable was dehiscence, which was evaluated in optic and carotid artery canals. Results: After dissecting 120 sphenoid sinuses, the carotid artery was dehiscent in 24 (20%) cases, and optic nerve dehiscence was observed in 15 (12.5%) cadavers. The mean distance between the anterior...
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Background: Objective: The aim of this study was to assess the quality of the surgical field, amount of blood loss, and duration of surgery following induced hypotension with labetalol, nitroglycerin, and high dose propofol in patients... more
Background: Objective: The aim of this study was to assess the quality of the surgical field, amount of blood loss, and duration of surgery following induced hypotension with labetalol, nitroglycerin, and high dose propofol in patients undergoing FESS under general anesthesia. Methods: One hundred and eight patients scheduled for FESS under general anesthesia were recruited in this randomized trial and were allocated to one of the three study groups: 1) Nitroglycerine (NTG) group: nitroglycerine with a dose of 2-5 μg/kg/min was administered; 2) Labetalol (LAB) group: an IV bolus dose of labetalol (20 mg) was injected at first and then IV infusion of labetalol at a rate of 1-2 mg/min; 3) High dose propofol plus normal saline (0.5-1 ml/min) group. Hemodynamic variables and the amount of bleeding were recorded intraoperatively and the surgeons' satisfaction was asked following each surgery considering the surgical field quality using a 5-item Likert scale. Results: The average bloo...
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Objective:The present study was conducted to determine the rate of level IV lymph node involvement among node-negative (N0) necks in patients with squamous cell carcinoma of the tongue.Methods:The study comprised 32 patients with squamous... more
Objective:The present study was conducted to determine the rate of level IV lymph node involvement among node-negative (N0) necks in patients with squamous cell carcinoma of the tongue.Methods:The study comprised 32 patients with squamous cell carcinoma of the tongue, with tumour–node–metastasis staging of T1–3N0M0, who were admitted to the Otolaryngology Department at Tehran University of Medical Sciences from March 2012 to March 2014. After a complete diagnostic evaluation, wide primary tumour excision (with 1.5–2 cm margins) and extended supraomohyoid neck dissection (levels I–IV) were accomplished.Results:Occult metastasis was found in 28 per cent of the patients. Level I, II and III metastases were the most common (18.75, 18.75 and 15.62 per cent, respectively). Level IV metastasis was found in 6.25 per cent of patients.Conclusion:Supraomohyoid neck dissection appears to be an appropriate treatment for N0 tongue squamous cell carcinoma and there is no need for level IV lymph no...
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Busulfan is a chemotherapeutic drug that induces sterility, azoospermia and testicular atrophy. To induce degeneration of spermatogenesis, we used different amounts of busulfan. Adult male C57Bl/6 mice were treated with 15, 30 and... more
Busulfan is a chemotherapeutic drug that induces sterility, azoospermia and testicular atrophy. To induce degeneration of spermatogenesis, we used different amounts of busulfan. Adult male C57Bl/6 mice were treated with 15, 30 and 45 mg kg(-1) of busulfan. After 5 weeks, animals had daily injections of 7.5 IU human follicle-stimulating hormone (hFSH) and 12.5 μg kg(-1) oestradiol benzoate (EB), separately or simultaneously. After this time, the animals were killed and blood samples were taken through cardiac puncture. Testes were used for histopathology experiments, DNA flow cytometry and RNA extraction for expression of c-kit and cyclin B1 genes. EB unlike FSH has induced stimulatory effects on spermatogenesis, increased the level of serum testosterone 2-fold and caused a 2-fold increase in the number of haploid cells. The result showed that hFSH with EB multiplied EB stimulatory effects on spermatogenesis up to four times. Expression of c-kit and cyclin B1 genes increased in EB and hFSH+EB groups. These findings suggest that EB regulates spermatogonial stem cells via hFSH. hFSH with EB had synergistic effect on regeneration of spermatogenesis.
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Objective: to evaluate the characteristics of post-laryngectomy patients, including nasal endoscopy, in subjective smell improvement in the post-surgical period. Subjects and Methods: Thirty patients who had undergone total laryngectomy... more
Objective: to evaluate the characteristics of post-laryngectomy patients, including nasal endoscopy, in subjective smell improvement in the post-surgical period. Subjects and Methods: Thirty patients who had undergone total laryngectomy participated in at least three sessions of smell rehabilitation program under the supervision of a speech-language pathologist who taught them NAIM. In addition to patients' characteristics, their nasal endoscopy findings were evaluated. Results: Participants experienced an improvement of 61% in smelling ...
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Several surgical techniques used for rhinoplasty can change the upper lip form over the long term. By eliminating the membranous septum and causing dysfunction of the depressor septi nasi muscle and performing other maneuvers, the... more
Several surgical techniques used for rhinoplasty can change the upper lip form over the long term. By eliminating the membranous septum and causing dysfunction of the depressor septi nasi muscle and performing other maneuvers, the tongue-in-groove (TIG) technique can exaggerate changes in the upper lip shape, length, and slope. This study was conducted to compare the effects of the TIG technique with and without a septal extension graft (SEG) on lip slope and aesthetic angles on the profile view. A retrospective review was performed on 367 patients who underwent primary rhinoplasty using the TIG technique from 2016 to 2020. The upper lip angle (ULA), the nasolabial angle (NLA), and the columellar facial angle (CFA) were measured for comparison pre-and post-operatively. Of 367 patients, 209 underwent TIG, while the rest underwent TIG over SEG (TIG+SEG). Comparison of pre-and post-operative ULAs showed significant changes in both groups. Although mean ULAs increased in both groups, some of the patients in each group experienced a decrease in ULA. The percentage of the patients with increased post-operative ULA significantly grow with increase in the pre-operative NLA (p < 0.05). However, no significant correlation was found between pre-operative CFA and post-operative ULA. The present study suggests that TIG with and without SEG can change the lip slope on the profile view, possibly due to the shift of the subnasal point superiorly and posteriorly. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.