Oesophageal foreign body: the importance of imaging in multiple coin ingestion

Description

A woman aged 61 years presented to a district general hospital with a 5-day history of dysphagia, regurgitation of all liquids and solids and lower sternal pain. She had a background of metastatic lung cancer with brain metastases and had previously received chemotherapy and radiotherapy. She was intermittently confused and had no recollection of ingesting a foreign body. On examination, her oral cavity, oropharynx and neck were unremarkable. Plain chest X-ray revealed a midline opaque foreign body at the level of the clavicular heads in the shape of a single coin (figure 1). A lateral soft tissue neck X-ray revealed, on close inspection, the presence of two foreign bodies and these appeared to be two coins lying on top of one another at the approximate level of T3 (figure 2). The patient was fasted and taken to theatre for a rigid oesophagoscopy. Intraoperatively, two...

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Leydig cell tumour and mature ovarian teratoma: rare androgen-secreting ovarian tumours in postmenopausal women

Androgen-secreting ovarian tumours are extremely rare accounting for <5% of all ovarian neoplasms. They are more frequent in postmenopausal women and should be suspected in the case of a rapid onset of androgenic symptoms. We report 4 cases of postmenopausal women who presented with signs of virilisation. All patients revealed increased serum levels of testosterone, normal dehydroepiandrosterone-sulfate and negative pelvic ultrasound for adnexal masses. An androgen-secreting ovarian tumour was suspected and all of them were submitted to bilateral oophorectomy. Histology confirmed the diagnosis of Leydig cell tumours in 3 patients and mature teratoma in 1. A successful response to surgery, which includes a decline in serum androgen levels and signs of hyperandrogenism, was observed in our patients. This case series demonstrates that androgen-secreting ovarian neoplasms may not be detectable by imaging studies, but should be considered in the differential diagnosis of all postmenopausal women with signs of hyperandrogenism.

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Disconnected pancreatic duct syndrome: a multidisciplinary management dilemma

Disconnected pancreatic duct syndrome is a circumferential interruption of the pancreatic duct. It usually occurs secondary to pancreatitis and carries significant diagnostic and management challenges. We present a case of disconnected pancreatic duct syndrome that represented a diagnostic and management dilemma for both medical and surgical teams. The aim of this article is to share a successful management experience of disconnected pancreatic duct syndrome with other physicians and to perform a brief but focused literature review on this challenging condition.

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Infected pseudoaneurysm of the left anterior descending artery

Primary percutaneous transluminal coronary angioplasty (PTCA) with the insertion of a stent is a well-established procedure for management of coronary artery disease. Infected pseudoaneurysms following PTCA and stenting are very rare and have poor outcomes if not managed properly. We are presenting a case of a man aged 50 years with infected pseudoaneurysm of the left anterior descending artery following multiple percutaneous interventions for coronary artery disease. In this paper, we have described the presentation, diagnosis and management of this patient and have discussed the aetiology and management options of infected pseudoaneurysm affecting coronary arteries.

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Bilateral fractures in a shoulder dystocia delivery

Description

A male neonate weighing 4170 g (99th centile) was born to a non-diabetic primigravid woman by difficult vaginal delivery at 37 weeks gestation due to right shoulder dystocia. The labour was induced and Neville Barnes forceps were employed for successful delivery. Apart from maternal obesity (body mass index of 36 kg/m²), no other risk factors for fetal macrosomia or shoulder dystocia were noted. After birth, absent right shoulder movement with asymmetrical Moro reflex was noted, raising the possibility of right clavicular fracture with possible brachial plexus injury (BPI). Although left arm mobility was reduced, neurology was normal. Both elbows and wrists were flexed with symmetrical grasp reflex. A chest radiograph was performed, confirming displaced fractures of his right clavicle and left humerus (figure 1). Examination findings at 48 hours were unchanged, and there were no signs of Horner's syndrome or respiratory distress indicating phrenic nerve injury. It was difficult...

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Advanced gastric cancer linitis plastica presented with disseminated intravascular coagulation

An old man was found unconscious; on admission found to have disseminated intravascular coagulation with concern of upper gastrointestinal bleed after he was found to have melena. Esophagogastroduodenoscopy on admission showed diffuse thickened gastric folds, and biopsy showed mucosal oedema. Bone marrow biopsy concerning for lymphoma was obtained showed adenocarcinoma. MRI of the abdomen was significant for diffuse gastric wall thickening. A repeat endoscopic ultrasound showed a diffuse gastric wall thickening of 15 mm and submucosal tunneling technique biopsy suggested high-grade, invasive, signet ring adenocarcinoma of the stomach. Oncology was consulted to initiate palliative chemotherapy. In retrospect, the patient was questioned regarding gastrointestinal symptoms; he reported gradual early satiety, dysphagia and unintentional weight loss over the course of 4 months.

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High-resolution DNA content analysis of microbiopsy samples in oral lichen planus

Abstract

Objectives

DNA aneuploidy has been reported to be a predictor of poor prognosis in both premalignant and malignant lesions. In oral lichen planus (OLP) this hypothesis remains to be proved. This study aims to determine the rate of occurrence of DNA aneuploidy in OLP patients by high-resolution DNA flow cytometry.

Methods

OLP patients were consecutively enrolled. Tissue samples were subdivided for formalin fixation and routine histological assessment and for immediate storage at −20°C for later DNA ploidy analysis, which was performed by DAPI staining of the extracted nuclei and excitation with a UV lamp. The DNA aneuploid sublines were characterized by the DNA Index.

Results

A DNA aneuploid status was observed in 2 out of 77 OLP patients (2.6%). When considering the clinical aspect of the OLP lesions, both DNA aneuploid cases had a reticular clinical aspect.

Conclusions

DNA aneuploidy is an uncommon event in OLP and less frequent compared to other non-dysplastic and non-OLP oral potentially malignant disorders. The extremely low rate of DNA aneuploidy could represent an occasional finding or reflect the low rate of malignant transformation observed in OLP patients even if the real prognostic value of DNA ploidy analysis in OLP patients remains to be confirmed.

This article is protected by copyright. All rights reserved.

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Immune Reconstitution Inflammatory Syndrome in HIV infection: taking the bad with the good

Abstract

In this review we will describe the immunopathogies of immune reconstitution inflammatory syndrome, IRIS. IRIS occurs in a small subset of HIV patient, initiating combination antiretroviral therapy (ART), where immune reconstitution becomes dyregulated, resulting in an overly robust antigen-specific inflammatory reaction. We will discuss IRIS in terms of the associated coinfections: mycobacteria, cryptococci, and viruses.

This article is protected by copyright. All rights reserved.

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An Update on Kaposi’s Sarcoma: Epidemiology, Pathogenesis and Treatment

Abstract

Kaposi's sarcoma is an angioproliferative neoplasm which has undergone considerable epidemiologic change since the original description by Moritz Kaposi in the late 1800s. This opportunistic neoplasm gained widespread notoriety within the US during the height of the AIDS epidemic, where it was frequently found co-occurring with opportunistic infections. With the advent of modern antiretroviral therapies, as well as an increasing number of individuals on immunosuppression for autoimmune disease or organ transplantation, the landscape of the immunocompromised individual has changed. It is now important for clinicians to be mindful of Kaposi's sarcoma manifesting in a growing variety of clinical contexts.

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Effect of Therapeutic Exercise on the Activation of the Neck Extensors in People With Chronic Neck Pain

Condition:   Neck Pain
Interventions:   Procedure: General extensor therapeutic exercise;   Procedure: Emphasized extensor therapeutic exercise
Sponsor:   Moisés Giménez Costa
Recruiting - verified October 2016

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The adverse impact of surveillance intervals on the sensitivity of FDG-PET/CT for the detection of distant metastases in head and neck cancer patients

Abstract

The presence of distant metastases at initial evaluation influences treatment selection, since no effective systemic treatment for disseminated head and neck squamous cell carcinoma (HNSCC) is currently available. The reported sensitivity for the detection of distant metastases by contrast-enhanced (ce)CT and FDG-PET(/CT) differs substantially between studies. We hypothesized that these sensitivity values are highly dependent on the reference standard use, e.g., follow-up term. Therefore, we analyze our results of FDG-PET/CT (including chest ceCT) with long-term follow-up and compare these findings with data from the literature, with particular interest in the different reference standards. Forty-six HNSCC patients with high-risk factors underwent pretreatment screening for distant metastases by FDG-PET/CT (including chest ceCT). In 16 (35%) patients, distant metastases were detected during screening (6 patients) or during a mean follow-up of 39.4 months after screening (10 patients). The sensitivity and negative predictive value were 83.3 and 97.2% when 6 months, 60.0 and 89.9% when 12 months, and 37.5 and 72.2% when 30 months follow-up were used as reference standard, respectively. This is comparable with reported studies with similar reference standards. This critical appraisal on the reference standards used in our and reported studies shows room for improvement for the detection of distant metastases to refrain more patients from unnecessary extensive locoregional treatment for occult metastatic HNSCC.

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Geniculate Ganglion Tumors: Clinical Presentation and Surgical Results

Objective

Facial nerve tumors are rare lesions mostly located in the geniculate ganglion. This study aims to compare those tumors limited to the geniculate ganglion in terms of clinical features and postoperative outcomes.

Study Design

Case series with chart review.

Settings

University tertiary reference center.

Subjects and Methods

Medical charts were reviewed for 17 patients who had surgery for geniculate ganglion tumor removal (10 hemangiomas, 6 schwannomas, 1 meningioma). Hemangiomas and schwannomas were compared for preoperative facial nerve function, hearing, tumor size, and postoperative outcomes.

Results

Facial palsy was observed in all cases. Regarding the preoperative facial nerve function, severe facial palsy (House-Brackmann grades V and VI) was present in 70% of cases for hemangiomas and for no case of schwannoma (P = .01), although hemangiomas were significantly smaller tumors (P = .01). Hearing loss was observed in 4 cases (23.5%) and was related to tumor volume (P < .0001). A complete excision was achieved in all cases, and a facial nerve graft was performed immediately after interruption in 16 patients (94%). Postoperative facial nerve function was improved or stabilized in 94% of cases. A preoperative House-Brackman grade VI was shown as a negative factor for postoperative facial nerve function.

Conclusions

Differences in clinical presentations could help in establishing the good therapeutic option depending on the tumor type. Surgery, when indicated, is safe and effective, and postoperative outcomes are not related to tumor type.

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Effects of Covering Surgical Wounds with Polyglycolic Acid Sheets for Posttonsillectomy Pain

Postoperative pain is a remaining issue in tonsillectomy. Polyglycolic acid (PGA) is a biocompatible material used for absorbent suture reinforcement, and its sheet has been applied for covering defects after resection of oral carcinoma. The aim of this study is to examine whether the attachment of a PGA sheet to surgical wounds would reduce posttonsillectomy pain. In this prospective single-blind study, 17 consecutive adult patients were recruited who needed to undergo tonsillectomy, mainly due to habitual tonsillitis. Following bilateral tonsillectomies, a PGA sheet was attached with fibrin glue to only 1 side, without notification to patients of which side. Postoperative pain of each side was separately evaluated with a visual analog scale at 4 time points: before each meal and before sleep. Postoperative pain of both the PGA sheet–attached and nonattached sides was most severe before breakfast among 4 time points. Postoperative pain measured before breakfast was significantly more severe in the PGA sheet–attached side than the nonattached side. As such, this study provided solid data on the negative effects of PGA sheeting on posttonsillectomy pain.

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Muscle Tension Dysphagia: Symptomology and Theoretical Framework

Objective

To identify symptoms, common diagnostic findings, pattern of treatments and referrals offered, and their efficacy in a group of patients with idiopathic functional dysphagia in an otolaryngology setting with multiple providers.

Study Design

Case series with chart review.

Setting

Tertiary academic center.

Subjects and Methods

Following Mayo Clinic Institutional Review Board approval, a retrospective chart review was conducted of patients with dysphagia who had a videofluoroscopic swallow study between January 1, 2013, and April 30, 2015. Each patient's dysphagia symptomology, videofluoroscopic swallow study, flexible laryngoscopy, and medical chart were reviewed to identify the treatment paradigms that were utilized.

Results

Sixty-seven adult patients met the inclusion criteria. Abnormal laryngeal muscle tension was present in 97% of patients. Eighty-two percent of patients also demonstrated signs of laryngeal hyperresponsiveness. Nonspecific laryngeal inflammation was evident in 52% of patients. Twenty-seven patients were referred to speech-language pathology for evaluation. Thirteen patients completed a course of voice therapy directed toward unloading muscle tension. All 13 patients self-reported resolution of dysphagia symptoms.

Conclusion

The study results suggest that laryngeal muscle tension may be a factor in the underlying etiology in patients with idiopathic functional dysphagia. We propose the diagnostic term muscle tension dysphagia to describe a subset of patients with functional dysphagia. Further prospective studies are needed to better evaluate potential gastroesophageal confounders in this group of patients and to identify an effective paradigm for treatment. In our limited series, speech-language pathology intervention directed toward unloading muscle tension appears effective.

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Decisional Conflict and Regret in Parents Whose Children Undergo Tonsillectomy

Objective

To determine if decisional regret (DR) in parents following tonsillectomy/adenotonsillectomy (TA) in their children is related to preoperative decisional conflict, perceived outcome of surgery, complications of surgery, or other factors.

Study Design

Observational analytic cohort study.

Setting

Tertiary care children's hospital.

Subjects and Methods

Preoperative decisional conflict (DC) and SURE tests were administered to a parent of a child scheduled for TA between July 2014 and July 2015. The DR tests were given 1 to 3 months postoperatively. Data were collected on patient age, sex, perceived outcome of surgery, complications (including bleeding), emergency room visits, and clinic phone calls.

Results

A total of 102 families were studied, including 48 female and 54 male patients with an average age of 6.29 years. Parental respondents included 83 mothers, 14 fathers, and 5 grandmothers. Overall, DC and DR were both low in this group, with a median of 0 for each (means: 7.74 for DC and 8.78 for DR). DC was higher in parents who canceled surgery or failed to keep follow-up appointments (27.19) versus parents who brought their children for surgery (6.78; P < .05). DR was significantly higher in parents with DC (20.00 vs 7.59; P < .05). It was not related to age of the patient, sex, parental perception of resolution of preoperative complaints, complications (including bleeding or dehydration), emergency department visits, or parental phone calls to the otolaryngology clinic. SURE tests indicated that every parent was confident of his or her decision on the day of surgery.

Conclusion

Preoperative DC is likely the most important factor in determining parental DR after the child undergoes TA.

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Cricohyoidoepiglottopexy in Laryngeal Trauma

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Tumor Debulking in the Management of Laryngeal Cancer Airway Obstruction

Patients presenting with advanced aerodigestive malignancy and respiratory compromise often undergo tracheotomy as initial airway management. Tumor debulking is a potential alternative. We present a case series with chart review to communicate our institutional experience with this technique. T3/4 glottic and supraglottic cancers treated between 2004 and 2014 underwent review, and 14 patients were identified for this study. Of these, 5 (35.7%) required subsequent tracheotomy, and 9 (64.3%) did not. Patients requiring subsequent tracheotomy had a delay in initiating definitive treatment when compared with those who did not (83.3 vs 31.3 days, P = .0025). No patient required a tracheotomy after initiation of definitive treatment. Our experience suggests that tumor debulking may be a viable option in select patients but that a delay in initiating treatment is associated with patients requiring tracheotomy subsequent to debulking. Further research is needed to better delineate patient scenarios in which tumor debulking alone is sufficient.

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Improving Access to Head and Neck Cancer Surgical Services through the Incorporation of Associate Providers

Objective

The urgent nature of head and neck cancer referrals often results in overbooked schedules, access delays, and patient, physician, and staff dissatisfaction. The goal of this study is to examine how incorporation of associate providers (APs) into a head and neck tumor clinic (HNTC) can improve access.

Methods

Scheduling data for the Dartmouth-Hitchcock HNTC 2 years prior (January 2011 to December 2012) and 2 years subsequent (January 2013 to December 2014) to program initiation were abstracted, including number of new patients seen per month, third available for new and established patients, overbooked hours, surgeon productivity, and patient satisfaction scores.

Results

New patients seen per month increased from 44 ± 4 to 60 ± 5 (P < .001). Third available for new patients decreased from 56 ± 4 to 27 ± 2 days and from 43 ± 3 to 35 ± 2 days for follow-ups (P < .001). Overbooked hours decreased from 14.7 ± 3.1 to 8.6 ± 1.7 hours (P < .001). Surgeon productivity remained stable (109% ± 11% vs 113% ± 6%, P = .56). Patient satisfaction in seeing APs versus surgeons was comparable (94 ± 2 vs 94 ± 3, P = .79).

Discussion

Incorporation of APs into the HNTC increases the number of new patients seen by the surgeon, decreases wait times for all appointments, and decreases overbooking while maintaining patient satisfaction and surgeon productivity.

Implications for Practice

AP incorporation significantly improves access to head and neck surgical services. With improved access, new cancer patients could start treatment sooner, potentially affecting outcome.

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Genetic and Environmental Determinants of Otitis Media in an Indigenous Filipino Population

Objective

To identify genetic and environmental risk factors for otitis media in an indigenous Filipino population.

Study Design

Cross-sectional study.

Setting

Indigenous Filipino community.

Subjects and Methods

Clinical history and information on breastfeeding, tobacco smoke exposure, and swimming were obtained from community members. Heads of households were interviewed for family history and personal beliefs on ear health. Height and weight were measured. Otoscopic findings were described for the presence and character of perforation or discharge. An A2ML1 duplication variant that confers otitis media susceptibility was Sanger sequenced in all DNA samples. Co-occurrence of middle ear bacteria detected by 16S rRNA gene sequencing was determined according to A2ML1 genotype and social cluster.

Results

The indigenous Filipino population has a ~50% prevalence of otitis media. Young age was associated with otitis media (4 age strata; P = .004); however, age was nonsignificant as a bistratal or continuous variable. There was no association between otitis media and sex, body mass index, breastfeeding, tobacco exposure, or deep swimming. In multivariate analyses, A2ML1 genotype is the strongest predictor of otitis media, with an odds ratio of 3.7 (95% confidence interval: 1.3-10.8; P = .005). When otitis media diagnoses were plotted across ages, otitis media was observed within the first year of life, and chronic otitis media persisted up to adulthood, particularly in A2ML1-variant carriers.

Conclusion

Among indigenous Filipinos, A2ML1 genotype is the primary risk factor for otitis media and main determinant of disease progression, although age, the middle ear microbiome, and social clusters might modulate the effect of the A2ML1 genotype.

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Programmatic Assessment of a Comprehensive Quality Improvement Curriculum in an Otolaryngology Residency

To date, there is minimal literature discussing quality improvement curricula in otolaryngology. Herein, we present our program, including didactic, web-based, and experiential learning, developed in the setting of a preexisting institutional quality and safety policy. Nine otolaryngology residents were evaluated with assessments focused on learner satisfaction, learner attitudes, and knowledge acquisition according to the Kirkpatrick framework. Wilcoxon signed-rank test was used to compare results. While the total score increased across all assessments, it was significant for only the Quality Improvement Knowledge Application Tool Revised (P < .05). We find our initial learning outcomes encouraging and hope that our comprehensive curriculum can serve as a resource to other programs, which can be adapted to fit within the context of variable training environments. Furthermore, it is imperative to consider continuous assessment and refinement of any educational program, using the same quality improvement principles that we endeavor to teach.

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Maxillofacial gunshot wounds and diagnostic tests for lead in the blood

Publication date: Available online 31 October 2016
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): G. Guzzi, F. Spadari, G.P. Bombeccari, P.D. Pigatto




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Effect of noise on tasks in operating theatres: a survey of the perceptions of healthcare staff

Publication date: Available online 31 October 2016
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): A.D. Padmakumar, O. Cohen, A. Churton, J.B. Groves, D.A. Mitchell, P.A. Brennan
Noise in the operating theatre has an adverse impact on healthcare professionals, both physically and psychologically. It can be distracting, make communication difficult, and contribute to a perceived increase in stress. Staff in theatre must deliver high quality care, and overlook noise as a potentially damaging influence. The aim of this survey was to obtain further information about the perspective of healthcare professionals on how noise can affect their practice and whether it affects their work in theatre. We distributed six closed-ended questions in the form of a Survey Monkey^® questionnaire to about 50 hospitals across the UK and target groups such as medical students, the Leeds Advanced Trauma Life Support faculty group, the Court of Examiners of the Royal College of Surgeons of England, and surgical trainees sitting the Member of the Royal College of Surgeons examination.We received 519 responses of which 415 respondents (83%) thought that noise contributed to human errors. A total of 282 participants (57%) thought that the theatre was the noisiest area within the theatre suite. Both communication among staff (n=400, 80%) and concentration (n=384, 77%) were thought to be adversely affected by noise. However, 385 (78%) did not feel that music adversely affected their performance. The results provide insights into the interplay of noise and its effect on people. Although the role of music remains contentious, our results suggest that it might have a calming influence.



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Collagen Content Limits Optical Coherence Tomography Image Depth in Porcine Vocal Fold Tissue

Objective

Vocal fold scarring, a condition defined by increased collagen content, is challenging to treat without a method of noninvasively assessing vocal fold structure in vivo. The goal of this study was to observe the effects of vocal fold collagen content on optical coherence tomography imaging to develop a quantifiable marker of disease.

Study Design

Excised specimen study.

Setting

Massachusetts Eye and Ear Infirmary.

Subjects and Methods

Porcine vocal folds were injected with collagenase to remove collagen from the lamina propria. Optical coherence tomography imaging was performed preinjection and at 0, 45, 90, and 180 minutes postinjection. Mean pixel intensity (or image brightness) was extracted from images of collagenase- and control-treated hemilarynges. Texture analysis of the lamina propria at each injection site was performed to extract image contrast. Two-factor repeated measure analysis of variance and t tests were used to determine statistical significance. Picrosirius red staining was performed to confirm collagenase activity.

Results

Mean pixel intensity was higher at injection sites of collagenase-treated vocal folds than control vocal folds (P < .0001). Fold change in image contrast was significantly increased in collagenase-treated vocal folds than control vocal folds (P = .002). Picrosirius red staining in control specimens revealed collagen fibrils most prominent in the subepithelium and above the thyroarytenoid muscle. Specimens treated with collagenase exhibited a loss of these structures.

Conclusion

Collagen removal from vocal fold tissue increases image brightness of underlying structures. This inverse relationship may be useful in treating vocal fold scarring in patients.

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Quality Indicators for Head and Neck Oncologic Surgery: Academic versus Nonacademic Outcomes

Objectives

to determine national benchmarks for established quality indicators in head and neck cancer (HNCA) surgery, focusing on differences between academic and nonacademic institutions.

Study Design

Cross-sectional analysis of national database.

Subjects and Methods

HNCA surgery admissions from the 2009-2011 Nationwide Inpatient Sample were analyzed for preoperative characteristics and postoperative outcomes. Multivariate analyses were used to identify factors influencing quality indicators after HNCA surgery. Quality metrics—including length of stay (LOS), inpatient death, return to the operating room (OR), wound infection, and transfusion—were compared for academic versus nonacademic institutions.

Results

A total of 38,379 HNCA surgery inpatient admissions (mean age, 56.5 years; 52.4% male) were analyzed (28,288 teaching vs 10,091 nonteaching). Nationally representative quality metrics for HNCA surgery were as follows: mean LOS, 4.26 ± 0.12 days; return to OR, 3.3% ± 0.2%; inpatient mortality, 0.7% ± 0.1%; wound infection rate, 0.9% ± 0.1%; wound complication rate, 4.3% ± 0.2%; and transfusion rate, 4.3% ± 0.3%. HNCA surgery patients at teaching hospitals had a greater proportion of males, radiation history, and high-acuity procedures and greater comorbidity scores (all P < .001). Multivariate analyses adjusting for age, sex, income, payer, prior radiation, comorbidity scores, and procedural acuity demonstrated that teaching hospitals had a slightly increased LOS (+0.30 days; P = .009) and odds ratio for wound infection (1.54; 95% CI: 1.22-1.94) versus nonteaching hospitals. There were no significant differences in return to OR (P = .271), inpatient mortality (P = .686), or transfusion rate (P = .960).

Conclusion

Despite caring for substantially more complex HNCA surgery patients with greater comorbidities, teaching hospitals demonstrate only a marginally increased LOS and wound complication rate versus nonteaching hospitals, while other established quality metrics are similar.

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Successful Implementation of a Clinical Care Pathway for Management of Epistaxis at a Tertiary Care Center

Objective

We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost.

Study Design

Single prospective analysis with historical control.

Setting

Tertiary academic hospital.

Subjects and Methods

Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing.

Results

Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented.

Conclusions

Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.

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ACS NSQIP Risk Calculator: An Accurate Predictor of Complications in Major Head and Neck Surgery?

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator is meant to provide an estimation of perioperative risk. Our goal was to determine the clinical applicability of the calculator in major head and neck surgery. A retrospective chart review was completed for major head and neck operations performed at 1 institution from 2013 to 2014. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. Overall, the ACS NSQIP calculator had little predictive value for pneumonia, surgical site infection, 30-day return to operating room, or length of stay within this cohort (P > .05). The calculator appears to have some value predicting total numbers of complications but has poor performance predicting an individual's risk of suffering a perioperative complication. In conclusion, in our small cohort of patients, the ACS NSQIP calculator was a poor predictor of perioperative complications following major head and neck operations.

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The History and Evolution of Surgery on the Vestibular Labyrinth

The history of surgery on the vestibular labyrinth is rich but sparsely documented in the literature. The story begins over a century ago with the labyrinthectomy in an era that consisted exclusively of ablative surgery for infection or vertigo. Improved understanding of vestibular physiology and pathology produced an era of selective ablation and hearing preservation that includes semicircular canal occlusion for benign paroxysmal positional vertigo. An era of restoration began with a discovery of superior semicircular canal dehiscence and its repair. The final era of vestibular replacement is upon us as the possibility of successful prosthetic vestibular implantation becomes reality.

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Use of Lean and CAHPS Surgical Care Survey to Improve Patients Experiences with Surgical Care

Objectives

(1) Measure patients' experiences with surgical care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey. (2) Use lean thinking to analyze and improve quality of patient care.

Study Design

A prospective quality improvement study.

Setting

Hospital-based otolaryngology clinic.

Subjects and Methods

The CAHPS Surgical Care Survey was distributed to 17 surgical patients to determine their perception of the current state of care. Survey results were analyzed with lean thinking, and changes were made to improve critical areas. A second set of surveys was distributed to 10 patients to assess the success of the interventions immediately and 2 months later. The data were analyzed with the Mann-Whitney U test.

Results

Seventeen patients completed the CAHPS Surgical Care Survey to determine the initial state. A3 Thinking was used to analyze the results and design an improvement. Overall positive patient experience was 57% at the postoperative visit with 3 key aspects of care: time spent during visit, encouragement to ask questions, show of respect to the patient. Two causes were postulated; then, solution approaches were developed and tested in a series of rapid experiments. Two groups of 10 patients completed the CAHPS Surgical Care Survey to determine the postintervention state. Overall positive patient experience significantly improved to 93% (U = 474, P < .001) and 83% (U = 546, P = .009) immediately and 2 months later, respectively.

Conclusion

Lean thinking helps to eliminate defects by breaking down complex problem solving into a scientific process. When combined with the CAHPS Surgical Care Survey, it can be successfully used to improve patients' surgical experiences.

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Electrophysiologic Evaluation of the Facial Nerve and Blink Reflex Pathways in Asymptomatic Cochlear Implant Users

Objective

To evaluate the functional integrity of the facial nerve and blink reflex (BR) pathways in asymptomatic patients who underwent cochlear implantation (CI).

Study Design

Case series with planned data collection.

Setting

Tertiary referral center.

Subjects and Methods

Twenty-four deafened patients with unilateral CI who had no complications were enrolled. Bilateral compound muscle action potentials (CMAPs) of the facial nerve were recorded over the nasalis and occipitalis muscles, whereas BR responses were recorded over the orbicularis oculi after supraorbital nerve stimulation. All recordings were performed when the external part of the implant was in place (CIp) and after its removal (CIr), except occipitalis recordings, which were performed only after removal. The amplitude and latency of CMAP were measured to evaluate the axonal integrity of the zygomatic and posterior branches of the facial nerve. Latency, amplitude, and duration of the BR were measured to investigate the integrity of trigeminofacial connections.

Results

The amplitude and latency of CMAP over the nasalis muscle were bilaterally normal, and the difference between CIp and CIr was not statistically significant. No CMAP of the occipitalis muscle was recorded in 4 (16.7%) patients, and low-amplitude responses were recorded on the implant side of 20 (83.3%). Amplitudes of the contralateral R2 response were higher in the CIp condition versus the CIr condition (P = .031). There were no differences among other BR components.

Conclusion

During functioning of the CI system, excitability of the facial circuit may increase either through the facial motor nucleus or through removal of the inhibitory effect of the descending pathway.

http://ift.tt/2f8HDq1

Developing Quality Measures for Adult Cochlear Implant Centers: Preliminary Findings

The study objective was to develop quality measures for adult cochlear implant centers. A modified Delphi design beginning with focus groups of surgeons and audiologists was used, as adapted from the American College of Cardiology / American Heart Association method for creating quality measures. Two academic cochlear implant programs and 1 private program participated. Qualitative focus group analysis yielded 58 candidate measures. An additional 5 candidate measures were added from a systematic review of the literature. After exclusion of pediatric measures, structure measures, and process measures and discussion of details and implications of each measure, 8 measures remained as the preliminary Adult Cochlear Implant Outcome (CI-OUTCOME) Measure Set. This study provides a preliminary set of measures for evaluating the quality of adult cochlear implant centers, based on input from implant surgeons and audiologists. The next step will be to gather feedback from implant patients.

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Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy: A Cross-Sectional Survey

Objectives

To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications.

Study Design

Case series with planned data collection.

Setting

Multihospital network.

Subjects and Methods

The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children's pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits.

Results

The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger (P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only (P < .001) and ibuprofen with narcotics (P = .002). Those taking ibuprofen alone returned to normal activity (P < .001) and diet (P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone.

Conclusions

For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.

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Medical Information Exchange: Pattern of Global Mobile Messenger Usage among Otolaryngologists

Objective

Information technology has revolutionized health care. However, the development of dedicated mobile health software has been lagging, leading to the use of general mobile applications to fill in the void. The use of such applications has several legal, ethical, and regulatory implications. We examined the experience and practices governing the usage of a global mobile messenger application (WhatsApp) for mobile health purposes in a national cohort of practicing otolaryngologists in Israel, a known early adaptor information technology society.

Methods

Cross-sectional data were collected from practicing otolaryngologists and otolaryngology residents via self-administered questionnaire. The questionnaire was composed of a demographic section, a section surveying the practices of mobile application use, mobile health application use, and knowledge regarding institutional policies governing the transmission of medical data.

Results

The sample included 22 otolaryngology residents and 47 practicing otolaryngologists. Of the physicians, 83% worked in academic centers, and 88% and 40% of the physicians who worked in a hospital setting or a community clinic used WhatsApp for medical use, respectively. Working with residents increased the medical usage of WhatsApp from 50% to 91% (P = .006). Finally, 72% were unfamiliar with any institutional policy regarding the transfer of medical information by personal smartphones.

Discussion

Mobile health is becoming an integral part of modern medical systems, improving accessibility, efficiency, and possibly quality of medical care.

Implications for Practice

The need to incorporate personal mobile devices in the overall information technology standards, guidelines, and regulation is becoming more acute. Nonetheless, practices must be properly instituted to prevent unwanted consequences.

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Highlights from the Current Issue: November 2016

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Are Online Zenkers Diverticulum Materials Readable and Understandable?

Objective

Patients use a multitude of resources to learn about Zenker's diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability.

Methods

The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability.

Results

The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability (r = –0.62, P < .05). Fleiss' interrater reliability for the raters demonstrated substantial agreement between the 4 raters ( = 0.64).

Conclusion

Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels.

Implications for Practice

Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.

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Gene Methylation Profiling in Sinonasal Adenocarcinoma and Squamous Cell Carcinoma

Objective

To identify epigenetic events in intestinal-type sinonasal adenocarcinoma (ITAC) and sinonasal squamous cell carcinoma (SNSCC) and to evaluate their relation to clinicopathologic features and follow-up data.

Study Design

Retrospective study.

Setting

Academic research hospital.

Subjects and Methods

The methylation status of 23 genes in 50 ITACs and 32 SNSCCs was analyzed by methylation-specific multiplex ligation-dependent probe amplification and its relation to clinicopathologic features and follow-up data.

Results

Gene methylation was observed in 50% of all tumors. Recurrent methylated genes in SNSCC were RASSF1 and CDH13 (for both, 6 of 32 cases), CHFR (4 of 32 cases), and TIMP3 (2 of 32 cases). None of these genes showed significant correlation to clinicopathologic features or overall survival. In ITAC, recurrent methylated genes were CDH13 (18 of 50 cases), ESR1 (13 of 50 cases), APC (7 of 50 cases), TIMP3 (5 of 50 cases), CASP8 (3 of 50 cases), and HIC1 and RASSF1 (for both, 2 of 50 cases). Papillary and colonic ITAC subtypes carried a mean of 1.26 gene methylations per tumor versus 0.63 in solid and mucinous subtypes. Methylation of TIMP3 was associated with a significantly worse survival in ITAC patients.

Conclusion

ITAC carries a higher number and a different profile of gene methylations as compared with SNSCC. Gene methylation plays a greater role in papillary and colonic ITAC subtypes, which may indicate a different tumorigenic pathway for these ITAC subtypes. These findings could be used as prognosticators and may have implications for future individualized therapies based on epigenetic changes.

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Stapedotomy vs Cochlear Implantation for Advanced Otosclerosis: Systematic Review and Meta-analysis

Objectives

To compare the hearing outcomes of stapedotomy vs cochlear implantation in patients with advanced otosclerosis.

Data Sources

PubMed, EMBASE, and The Cochrane Library were searched for the terms otosclerosis, stapedotomy, and cochlear implantation and their synonyms with no language restrictions up to March 10, 2015.

Methods

Studies comparing the hearing outcomes of stapedotomy with cochlear implantation and studies comparing the hearing outcomes of primary cochlear implantation with salvage cochlear implantation after an unsuccessful stapedotomy in patients with advanced otosclerosis were included. Postoperative speech recognition scores were compared using the weighted mean difference and a 95% confidence interval.

Results

Only 4 studies met our inclusion criteria. Cochlear implantation leads to significantly better speech recognition scores than stapedotomy (P < .0001). However, this appears to be due to the variability in outcomes after stapedotomy. Cochlear implantation does not lead to superior speech recognition scores compared with the subgroup of successful cases of stapedotomy plus hearing aid (P = .47). There is also no significant difference with respect to speech recognition between primary cochlear implantation and those secondary to a failed stapedotomy (P = .22).

Conclusions

Cochlear implantation leads to a statistically greater and consistent improvement in speech recognition scores. Stapedotomy is not universally effective; however, it yields good results comparable to cochlear implantations in at least half of patients. For cases of unsuccessful stapedotomy, the option of cochlear implantation is still open, and the results obtained through salvage cochlear implantation are as good as those of primary cochlear implantation.

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Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar

Objective

Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection.

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects and Methods

This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results.

Results

Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection.

Conclusions

Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.

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Head and Neck Manifestations of Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review

Objective

To conduct the first and only systematic review of the existing literature on head and neck manifestations of eosinophilic granulomatosis with polyangiitis to guide clinical decision making for the otolaryngologist.

Data Sources

PubMed, Cochrane Library, Scopus, and LILACS.

Review Methods

A systematic review of the aforementioned sources was conducted per the PRISMA guidelines.

Results

From an initial 574 studies, 28 trials and reports were included, accounting for a total of 1175 patients with eosinophilic granulomatosis with polyangiitis. Among clinical and cohort studies, 48.0% to 96.0% of all included patients presented with head and neck manifestations. In a distinct group of patients detailed in case reports describing patients presenting with head and neck manifestations, patients on average fulfilled 4.6 diagnostic criteria per the American College of Rheumatology. Furthermore, 95.8% of reported cases were responsive to steroids, and 60% required additional therapy.

Conclusion

Otolaryngologists are in a unique position for the early diagnosis and prevention of late complications of eosinophilic granulomatosis with polyangiitis. The American College of Rheumatology criteria should be relied on in the diagnostic workup. Close surveillance of these patients in a multidisciplinary fashion and with baseline complete blood counts, chest radiographs, and autoimmune laboratory tests is often necessary. Such patients with head and neck manifestations of the disease are nearly always responsive to steroids and often require additional immunosuppressive therapy or surgical intervention in cases of cranial neuropathies, temporal bone involvement, and refractory symptoms.

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The Role of Helicobacter pylori in Laryngopharyngeal Reflux: A Systematic Review and Meta-analysis

Objective

The primary objective was to determine the prevalence of Helicobacter pylori among patients with laryngopharyngeal reflux. The secondary objective was determining if H pylori eradication leads to greater symptom improvement in patients with laryngopharyngeal reflux as compared with standard proton pump inhibitor therapy alone.

Data Sources

EMBASE, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov.

Review Methods

A systematic review was performed of studies assessing the diagnosis or treatment of H pylori among patients with laryngopharyngeal reflux. Randomized controlled trials, cohort studies, case-control studies, and case series were included. A meta-analysis of prevalence data and assessment of heterogeneity was performed on relevant studies.

Results

Fourteen studies were analyzed in the review, with 13 eligible for the meta-analysis. We determined that the prevalence of H pylori among patients with laryngopharyngeal reflux was 43.9% (95% confidence interval, 32.1-56.5). The heterogeneity of studies was high, with an overall I ² value of 92.3%. We were unable to quantitatively assess findings for our secondary outcome, since H pylori identification and treatment were not the primary focus of the majority of studies.

Conclusion

There is a high rate of H pylori infection among patients with laryngopharyngeal reflux. The infection rate in North America and Western Europe has not been adequately studied. There is insufficient evidence to make a recommendation regarding the testing and treatment of H pylori infection among patients with laryngopharyngeal reflux.

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Effect of Botulinum Toxin and Surgery among Spasmodic Dysphonia Patients: A Systematic Review

Objective

The effect of botulinum toxin among patients with adductor spasmodic dysphonia (AdSD) is temporary. To optimize long-term treatment outcome, other therapy options should be evaluated. Alternative treatment options for AdSD comprise several surgical treatments, such as thyroarytenoid myotomy, thyroplasty, selective laryngeal adductor denervation-reinnervation, laryngeal nerve crush, and recurrent laryngeal nerve resection. Here, we present the first systematic review comparing the effect of botulinum toxin with surgical treatment among patients diagnosed with AdSD.

Data Sources

MEDLINE (PubMed), EMBASE, and the Cochrane Library.

Methods

Articles were reviewed by 2 independent authors, and data were compiled in tables for analysis of the objective outcome (voice expert evaluation after voice recording), the subjective outcome (patient self-assessment scores), and voice-related quality of life (Voice Health Index scores).

Results

No clinical trials comparing both treatment modalities were identified. Single-armed studies evaluated either the effect of botulinum toxin or surgical treatment. Thirteen studies reported outcomes after botulinum toxin treatment (n = 419), and 9 studies reported outcomes after surgical treatment (n = 585 patients). A positive effect of bilateral botulinum toxin injections was found for the objective voice outcome, subjective voice outcome, and quality of life. The duration of the beneficial effect ranged from 15 to 18 weeks. Surgical treatment had an overall positive effect on objective voice improvement, subjective voice improvement, and quality of live.

Conclusion

No preference for one treatment could be demonstrated. Prospective clinical trials comparing treatment modalities are recommended to delineate the optimal outcomes by direct comparison.

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Bilateral Ocular Decompression Retinopathy after Ahmed Valve Implantation for Uveitic Glaucoma

Case Report: We report the case of a 29-year-old man who underwent Ahmed valve implantation in both eyes as treatment for uveitic glaucoma, subsequently presenting with bilateral ocular decompression retinopathy in the postoperative period. Discussion: Ocular decompression retinopathy is a rare complication of filtering surgery in patients with glaucoma; however, the course is benign in most cases, with spontaneous resolution of bleedings and improvement of visual acuity.
Case Rep Ophthalmol 2016;7:227–232

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Erratum to: Two-weeks-sustained unresponsiveness by oral immunotherapy using microwave heated cow’s milk for children with cow’s milk allergy

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Evaluation of salivary catalase, vitamin C, and alpha-amylase in smokers and non-smokers: a retrospective cohort study

Background

Saliva and its defence systems such as antioxidants and minerals are very important in the pathogenesis of different diseases. Cigarette smoking has many destructive effects. Oxidative stresses play an important role in the side effects of smoking. This study assessed the effect of cigarette smoking on salivary levels of catalase, vitamin C, and α-amylase.

Methods

This retrospective cohort study was carried out in Hamadan, Iran, on 510 subjects; 259 subjects were smokers (the exposed group) and 251 were non-smokers (the unexposed group). Five microliters of unstimulated saliva was collected by spitting method. Catalase, vitamin C, and α-amylase salivary levels were determined by spectrophotometric assay. Data were analyzed with t-test using STATA 12.

Results

Vitamin C level in smokers was significantly lower than that in non-smokers. The salivary catalase levels were lower and α-amylase levels were higher in smokers, but the differences were not statistically significant (P = 0.416 and P = 0.265, respectively). Smokers were younger than non-smokers.

Conclusion

Smoking resulted in a change in salivary antioxidant levels. Changes in antioxidant levels can influence the deleterious effects of smoking on oral mucosa; it might also indicate systemic changes and changes in the serum levels of oxidative agents. Further studies are necessary to understand the mechanisms and real effects of smoking, to determine the benefits of supplementary antioxidants for treatment and to reduce the dangerous side effects of smoking.

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Double-injection technique assisted by a nerve stimulator for ultrasound-guided supraclavicular brachial plexus block results in better distal sensory-motor block: A randomised controlled trial.

BACKGROUND: To evaluate the efficacy of a nerve stimulator when used with ultrasound-guided double injection in supraclavicular brachial plexus block. OBJECTIVES: We hypothesised that targeting the inferior trunk of the plexus guided by a nerve stimulator would obtain a higher success rate of ulnar nerve blockade than the traditional double-injection technique. DESIGN: A blinded randomised controlled study. SETTING: Conducted at the University Hospital from October 2015 to January 2016. PATIENTS: Ninety patients undergoing upper extremity surgery were randomised into two equal groups. INTERVENTIONS: Patients were randomly allocated to a modified double-injection group (MDI group) or a traditional double-injection group (DI group). All patients received 23 ml of a 1 : 1 mixture of 2% lidocaine and 1% ropivacaine during ultrasound-guided supraclavicular brachial plexus block. In the MDI group (n = 45), half the volume was deposited within the brachial plexus sheath guided by ultrasound, next to the inferior trunk and verified by nerve stimulation; the remaining volume was deposited in the main neural cluster. In the double-injection group (n = 45), the first half volume was deposited on ultrasound guidance alone. Sensory-motor blockade of the musculocutaneous, median, radial, ulnar nerves and surgical anaesthesia, performance time, number of needle passes and complications were recorded. MAIN OUTCOME MEASURES: The success rate of complete sensory block of the ulnar nerve within 15 min after local anaesthetic injection. RESULTS: Compared with the DI group the MDI group had higher success rates of complete sensory block of the ulnar nerve (93 vs 67%, P = 0.002) and complete anaesthesia (80 vs 56%, P = 0.014) at 15 min, whereas the average performance time was significantly longer (5.08 +/- 1.41 vs 4.10 +/- 0.64 min, P

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Comparative analysis of resuscitation using human serum albumin and crystalloids or 130/0.4 hydroxyethyl starch and crystalloids on skeletal muscle metabolic profile during experimental haemorrhagic shock in swine: A pilot study.

BACKGROUND: Protection against acute skeletal muscle metabolic dysfunction and oxidative stress could be a therapeutic target in volume expansion for severely bleeding patients. OBJECTIVES: This experimental pilot study in swine aims at comparing 130/0.4 hydroxyethyl starch (HES) with 4% albumin along with crystalloid perfusion for first-line volume expansion in haemorrhagic shock with a particular emphasis on oxidative stress and muscular mitochondrial function. DESIGN: Randomised, experimental study. SETTING: Digestive Cancer Research Institute Preclinical Laboratory, Strasbourg University Hospital, France, from February 2012 to June 2013. ANIMALS: Twenty large white pigs. INTERVENTION: Pressure-controlled haemorrhagic shock and volume resuscitation using either 4% human serum albumin or 130/0.4 HES along with crystalloid perfusion were performed in 20 large white pigs. MAIN OUTCOME MEASURES: Muscular biopsy of gastrocnemius muscle was performed for metabolomics screening, mitochondrial respiratory chain assessment and electron spin resonance reactive oxygen species production along with arterial and venous reactive oxygen species production at baseline, at the completion of shock, at 90 min and at 180 min after volume expansion. RESULTS: There was no difference between the two groups in measurements of skeletal muscle superoxide production. In a pooled analysis, there was a statistically significant decrease in gastrocnemius muscle creatine content from baseline to 90 min (P

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Patient-completed, preoperative web-based anaesthetic assessment questionnaire (electronic Personal Assessment Questionnaire PreOperative): Development and validation.

BACKGROUND: Worldwide, guidelines support the routine use of anaesthetic preoperative assessment (POA), a process that is frequently supported by pro formas and unvalidated questionnaires. Electronic questionnaires can provide reliable data. A local initiative has seen the development of a computerised electronic Personal Assessment Questionnaire (ePAQ). OBJECTIVE: To develop and validate a novel electronic instrument for POA. DESIGN: The content and face validity were evaluated in 30 patients. The questionnaire was then modified and completed by a further 300 patients, evaluating the reliability of its items and scoring algorithms for BMI and American Society of Anesthesiologists (ASA) physical status. The study was approved by the South Yorkshire Regional Ethics Committee (REC 09/H1308/127). SETTING: The study was conducted in a tertiary teaching hospital in the United Kingdom between January 2011 and February 2012 and was funded by a research grant from the Charitable Trustees of Sheffield Teaching Hospitals National Health Service Foundation Trust. PATIENTS: A total of 330 patients aged 18 years or older, listed for surgery and able to read and understand English, were recruited. Neurosurgery; ear, nose and throat; orthopaedics; gynaecology; general and plastic surgery; ophthalmology and urology patients were included. All participants provided written consent. MAIN OUTCOME MEASURES: Validation including test-retest analysis, assessment of patient value and burden, assessment of accuracy, mean score difference of BMI estimation and comparison of inter-rater ASA grading. RESULTS: In all, 77% of patients reported that the ePAQ helped with communication, 99% that it was easy to complete and 98% that they would be happy to use it again. ePAQ preoperative assigned ASA grades matched consultant-assigned grades more frequently than nurse-assigned grades. Self-reported BMI classification was correct in 78% of patients and within one WHO category in a further 21%. Test-retest scores were good. CONCLUSION: Initial evaluation suggests that ePAQ is acceptable to patients. Data collected using the system were found to be reliable, and its intrinsic scoring systems for ASA and BMI are comparable with values assigned by clinicians. (C) 2016 European Society of Anaesthesiology

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Laryngeal tube suction II or endotracheal intubation for laparoscopic radical prostatectomy in a head down position: A randomised controlled trial.

BACKGROUND: The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration. OBJECTIVES: To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy. DESIGN: Randomised, controlled, blinded and single-centre study. SETTING: Academic tertiary care centre in Leipzig from April 2014 to May 2015. PATIENTS: It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway. INTERVENTIONS: All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation. MAIN OUTCOME MEASURES: The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy. RESULTS: In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group. CONCLUSION: Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy. TRIAL REGISTRATION: DRKS00008985 (German Clinical Trials Register). (C) 2016 European Society of Anaesthesiology

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What's the best way to match the implant to the breast? Evidence on implant size selection systems reviewed

How should plastic surgeons choose the best implant type and size for women undergoing breast augmentation surgery?

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Electrically Evoked Medial Olivocochlear Efferent Effects on Stimulus Frequency Otoacoustic Emissions in Guinea Pigs

Abstract

Stimulus frequency otoacoustic emissions (SFOAEs) are produced by cochlear irregularities reflecting energy from the peak region of the traveling wave (TW). Activation of medial olivocochlear (MOC) efferents reduces cochlear amplification and otoacoustic emissions (OAEs). In other OAEs, MOC activation can produce enhancements. The extent of MOC enhancements of SFOAEs has not been previously studied. In anesthetized guinea pigs, we electrically stimulated MOC fibers and recorded their effects on SFOAEs. MOC stimulation mostly inhibited SFOAEs but sometimes enhanced them. Some enhancements were not near response dips and therefore cannot be explained by a reduction of wavelet cancelations. MOC stimulation always inhibited auditory-nerve compound action potentials showing that cochlear-amplifier gain was not increased. We propose that some SFOAE enhancements arise because shocks excite only a small number of MOC fibers that inhibit a few scattered outer hair cells thereby changing (perhaps increasing) cochlear irregularities and SFOAE amplitudes. Contralateral sound activation is expected to excite approximately one third of MOC efferents and may also change cochlear irregularities. Some papers suggest that large SFOAE components originate far basal of the TW peak, basal of the region that receives cochlear amplification. Using a time-frequency analysis, we separated SFOAEs into components with different latencies. At all SFOAE latencies, most SFOAE components were inhibited by MOC stimulation, but some were enhanced. The MOC inhibition of short-latency SFOAE components is consistent with these components being produced in the cochlear-amplified region near the TW peak.

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Ashy dermatosis or ashy dermatosis-like pigmentation caused by omeprazole?

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