Tracheoesophageal Voice Prosthesis Use and Maintenance in Laryngectomees

Abstract Tracheoesophageal speech is the most common voicing method used by laryngectomees. This method requires the installation of tracheoesophageal prosthesis (TEP), which requires continuous maintenance to achieve optimal speaking abilities and prevent fluid leakage from the esophagus to the trachea. The present manuscript describes the available types of TEPs, the procedures used to maintain them, the causes for their failure due to fluid leakage, and the methods used for their prevention. Knowledge and understanding of these issues can assist the otolaryngologist in caring for laryngectomees who use tracheoesophageal speech.

C2 Fractures in the Elderly: Single-Center Evaluation of Risk Factors for Mortality

STUDY DESIGN: Retrospective cohort study. PURPOSE: The aim of this study was to identify features associated with increased mortality risk in traumatic C2 fractures in the elderly, including measures of comorbidity and frailty. OVERVIEW OF LITERATURE: C2 fractures in the elderly are of increasing relevance in the setting of an aging global population and have a high mortality rate. Previous analyzes of risk factors for mortality have not included the measures of comorbidity and/or frailty, and no local data have been reported to date. METHODS: This study comprises a retrospective review of 70 patients of age >65 years at Waikato Hospital, New Zealand with traumatic C2 fractures identified on computed tomography between 2010 and 2016. Demographic details, medical history, laboratory results on admission, mechanism of injury, and neurological status on presentation were recorded. Medical comorbidities were also detailed allowing calculation of the Charlson Comorbidity Index (CCI) and the modified Frailty Index (mFI). RESULTS: The most common mechanism of injury was a fall from standing height (n=52, 74.3%). Mortality rates were 14.3% (n=10) at day 30, and 35.7% (n=25) at 1 year. Bivariate analysis showed that both CCI and mFI correlated with 1-year mortality rates. Reduced albumin and hemoglobin levels were also associated with 30-day and 1-year mortality rates. Forward stepwise logistic regression models determined CCI and low hemoglobin as predictors of mortality within 30 days, whereas CCI, low albumin, increased age, and female gender predicted mortality at 1 year. CONCLUSIONS: The CCI was a useful tool for predicting mortality at 1 year in the patient cohort. Other variables, including common laboratory markers, can also be used for risk stratification, to initiate timely multidisciplinary management, and prognostic counseling for patients and family members.

Acute Effects of Ultrasonic Shears and Monopolar Electrosurgery on Sciatic Nerve Electrophysiology.

Background: When using energized surgical devices in the vicinity of nerves, care must be taken to reduce the risk of thermal or electrical injury. For example, during thyroidectomy, it is critical to avoid damage to the recurrent laryngeal nerve while dissecting and coagulating nearby tissue. Methods: We compared use of Harmonic ACE+ and Focus ultrasonic shears and monopolar electrosurgery to scissors as a control applied to make incisions in muscle 2 mm from the sciatic nerve in rats. Via electrophysiological monitoring, the compound action potential and conduction velocity were determined over a three hour post-application period. Neuromuscular response was observed by von Frey hair stimulation. Leukocyte infiltration was measured via H&E staining, and impaired axonal transport via β-APP immunohistology. Results: None of the energized devices had a significantly different compound action potential than scissors, although electrosurgery exhibited prolonged depolarization and repolarization times. Electrosurgery had significantly slower conduction velocity and increased von Frey stimulation force compared to scissors, whereas both ultrasonic devices were not different from the control. No difference was observed between devices for leukocyte infiltration, but electrosurgery had significantly greater β-APP levels than scissors, while again ultrasonic devices were not different. Conclusion: Electrosurgery caused significantly more neurophysiological damage than scissors. In contrast, the ultrasonic shears were not statistically different than scissors in terms of nerve injury. Harmonic ACE+ and Focus can be used to cut and coagulate tissue near nerves with a low risk of electrophysiological injury.

Prevalence of ittestinal parasitism and associated symptomatology among hemodialysis patients / Prevalência de parasitismo intestinal e sintomatologia associada em pacientes hemodialíticos

Intestinal parasites are an important cause of morbidity and mortality. Immunocompromised individuals may develop more severe forms of these infections. Taking into account the immunity impairment in patients suffering from chronic renal failure (CRF), we will determine the prevalence and associated symptoms of intestinal parasites in these patients. Controls without CRF were used for comparison. Stool samples were collected and processed for microscopic identification of parasites using the Formalin-ether concentration method. For Cryptosporidium diagnosis, the ELISA technique was used. One hundred and ten fecal samples from hemodialysis patients were analyzed, as well as 86 from a community group used as control group. A result of 51.6% of intestinal parasites was observed in hemodialysis patients and 61.6% in the control group. Cryptosporidium and Blastocystis were the most common infections in patients with CRF (26.4% and 24.5%, respectively). Blastocystis was the most common infection in the control group (41.9%), however no individual was found positive for Cryptosporidium. Among the CRF patients, 73.6% were symptomatic, 54.3% of these tested positive for at least one parasite, in contrast to 44.8% in asymptomatic patients (p = 0.38). The most common symptoms in this group were flatulence (36.4%), asthenia (30.0%) and weight loss (30.0%). In the control group, 91.9% were symptomatic, 60.8% of these tested positive for at least one parasite, in contrast to 71.4% in asymptomatic patients (p = 0.703). A significant difference between the two groups was observed with regard to symptoms, with bloating, postprandial fullness, and abdominal pain being more frequent in the control group than in the hemodialysis group (all p < 0.05). Comparing symptomatic with asymptomatic, there was no association in either group between symptoms or the prevalence of parasitic infection, nor with the type of parasite or with multiple parasitic infections. Patients with chronic renal failure are frequent targets for renal transplantation, which as well as the inherent immunological impairment of the disease itself, results in immunosuppression by medication. For this reason, carriers of intestinal parasites with pathogenic potential can develop serious clinical complications influencing the success of transplantation. This fact, coupled with the high prevalence of intestinal parasites and the dissociation between symptoms and infection in CRF patients, suggests that the stool test should be incorporated in routine propedeutics. Furthermore, preventive measures for the acquisition of parasites through the fecal-oral contamination route should be introduced.

Doenças parasitárias infectam grande número de indivíduos em todo o mundo. Manifestações clínicas mais severas podem se apresentar em pacientes imunocomprometidos. Considerando o importante comprometimento imunológico observado em pacientes com insuficiência renal crônica (IRC), foi determinada a prevalência e sintomas associados a parasitoses intestinais nesses pacientes em comparação a controles saudáveis. Foram coletadas amostras fecais de cada participante e processadas para identificação microscópica dos parasitas pelo método de concentração por formol-éter. Foi utilizada a técnica de ELISA para identificar coproantígenos de Cryptosporidium. Foram analisadas 110 amostras fecais de pacientes em hemodiálise e 86 de um grupo controle comunitário. Cryptosporidium e Blastocystis foram as infecções mais freqüentes nos pacientes em hemodiálise (26,4% e 24,5%, respectivamente). Blastocystis foi a infecção mais freqüente no grupo controle (41,9%), entretanto nenhum indivíduo positivo para Cryptosporidium foi identificado. Considerando os pacientes com IRC, 73,6% eram sintomáticos, sendo 54,3% positivos para algum parasita, contra 44,8% nos assintomáticos (p = 0,38). Os sintomas mais frequentes neste grupo foram flatulência (36,4%), adinamia (30,0%) e perda de peso (30,0%). No grupo controle, 91,9% eram sintomáticos, sendo 60,8% positivos para algum parasita, contra 71,4% nos assintomáticos (p = 0,703). Em relação aos sintomas, houve diferença significativa entre os dois grupos, sendo que flatulência, plenitude pós-prandial, e dor abdominal foram mais freqüentes no grupo controle que nos pacientes em hemodiálise (todos p < 0,05). Comparando-se sintomáticos com assintomáticos, não houve associação entre a sintomatologia e a prevalência de parasitose, nem com o tipo de parasita, e nem com o poliparasitismo, nos dois grupos. Considerando que pacientes com IRC são frequentes alvos de transplante renal, resultando em imunossupressão por medicamentos, que é somada à deficiência imunológica inerente à própria doença. Os portadores de parasitas intestinais com potencial patogênico podem desenvolver sérias complicações clínicas que influenciam o sucesso do transplante. Este fato, aliado a alta prevalência de parasitas intestinais e dissociação entre os sintomas e infecção nesses pacientes, sugerem a incorporação do exame de fezes na propedêutica de rotina dos mesmos, juntamente com medidas preventivas para a aquisição de parasitas com rota de contaminação fecal-oral.

A patient experiencing pseudoseizures: a case report / Paciente con pseudo-ataques epilépticos: reporte de caso

Pseudoseizures are a relatively complex problem of unknown aetiology and prognosis. They can at times resemble genuine seizure attacks but they have no abnormal electroencephalograpic (EEG) activity. Understanding the patient's unique psychological background appears to be fundamental in managing seizure frequency. Pseudoseizures can be disruptive to a person's lifestyle, limiting their ability to function and progress in society, particularly when it comes to employment or social interaction. The case discussed involves a 59-year old man who presents with what is believed to be seizure-related activity but through the course of clinical evaluation, this turned out to be pseudoseizures.

Los pseudo-ataques de epilepsia son un problema relativamente complejo de etiologia y prognosis desconocidas. En ciertos momentos pueden parecer genuinos ataques epilépticos, pero no muestran actividad electroencefalográfica (EEG) anormal alguna. Entender el especial trasfondo psicológico del paciente parece ser fundamental a la hora de manejar la frecuencia de los ataques. Los pseudoataques pueden tener un efecto disociador en el estilo de vida de una persona, limitando su habilidad para funcionar y progresar socialmente, en particular cuando se trata de empleos o interacción social. El caso que se analiza corresponde a un hombre de 59 anos de edad que acude con lo que se cree que es una actividad relacionada con un ataque epiléptico, pero en el curso de la evaluación clinica, resultó ser una pseudoepilepsis.

Relationship of body mass index and related anthropometric measurements on the image quality of thallium-201 and technetium-99m sestamibi myocardial perfusion imaging

The study aims to determine the relationship of body mass index (BMI) and related anthropometric measurements on the image quality of Tl-201 and Tc-99m sestamibi myocardial perfusion scans (MPS). A total of 163 scans were analyzed. A blinded experienced physician performed visual analysis on the scans image quality on two different occasions. Quantitative parameter used was the heart-to-lung ratio (HLR). Regression analysis was done to determine the association of HLR with BMI and myocardial tracer uptake, ROC curves were generated to establish BMI and HLR cut-off points. Increasing BMI was associated with visually poorer images in the Tl-201 MPS group (p 0.003) but not for the Tc-99m MPS group (p 0.065). It was also associated with decrease HLR and myocardial tracer upatake for both tracers (p <0.001). ROC curves revealed BMI cut-off points of 28 (Tl-201 p 0.000; Tc99m sestamibi p 0.004) for both procedures; HR cut-off values of 3.0 for Tl-201 )p 0.295) and 2.5 for Tc-99m sestamibi (p 0.875). the image quality of Tl-201 scans begins to deteriorate at a BMI of 28 and HLR of 3.0 with myocardial count density reduction (less than or equal to 6000 counts) translating to visually poorer images. On the other hand , image quality of Tc-99m sestamibi scans also tend to deteriorate similarly at a BMI of 28. However, in contrast to Tl-201, the lower HLR cut-off of 2.5 suggests a relatively higher myocardial count density (greater than or equal to 9000 counts) rendering the image quality to be still satisfactory for subjective assessment.

Perioperative hypotension and myocardial ischemia: Diagnostic and therapeutic approaches.

Although perioperative hypotension is a common problem, its true incidence is largely unknown. There is evidence that postoperative outcome, including the incidence of myocardial adverse events, may be linked to the prolonged episodes of perioperative hypotension. Despite this, there are very few comprehensive resources available in the literature regarding diagnosis and management of these not so uncommon clinical occurrences, especially during non-cardiac surgery. Most anesthesia providers consider intraoperative hypotension to be caused by systemic vasodilatation and relative hypovolemia and so treat it empirically. The introduction of new monitoring devices including transesophageal echocardiography and arterial pressure waveform based stroke volume measurement have provided additional tools to narrow the differential diagnoses and initiate optimal treatment measures. Understanding the basic pathophysiology of hypotension and myocardial ischemia can further assist in providing goal directed management. This article serves as a comprehensive guide for anesthesiologists to diagnose and treat hypotension and myocardial ischemia. A summary of available techniques to monitor perioperative myocardial ischemia and their limitations are also discussed.

Resolving hypoplastic dilemma: Lung perfusion scintigraphy in a case of congenital cystic adenomatoid malformation (CCAM)

Congenital cystic adenomatoid malformation is a rare bronchopulmonary malformation resulting from an arrest in lung development between 4th and 7th week of fetal life. It typically presents as respiratory distress in the neonatal period and recurrent pulmonary infections in adults; and is sometimes associated with other congenital abnormalities [especially CCAM Type II]. Chest roentgenograms and CT scan are the usual modalities of choice in its initial evaluation and histopathology done post-operatively establishes the diagnosis. Ventilation-Perfusion [VQ] scintigraphy is of paramount importance in the routine assessment of CCAM patients but is often disregarded. This paper presents the incremental value of doing a lung perfusion scintigraphy and aims to emphasize the significance of performing a VQ scan in such cases.

Lutembacher's syndrome and persistent left superior vena cava in a young female

We report the case of a 28-year-old woman with ostium secundum atrial septal defect, mitral stenosis and a persistent left superior vena cava, who developed heart failure at age 17 and was admitted at different institutions for shortness of breath. The patient had one complicated pregnancy at age 25 in which she presented with worsening heart failure. She was able to deliver her baby via spontaneous vaginal delivery under epidural anesthesia, but had to stay admitted for an additional 3 weeks. Two-dimensional echocardiogram with doppler studies showed an ostium secundum atrial septal defect, severe rheumatic mitral stenosis (Mitral Valve Area = 0.60 cm2 by planimetry and 0.90 cm2 by pressure half-time), severe tricuspid regurgitation, mild aortic regurgitation, pulmonary regurgitation with severe pulmonary hypertension, and a dilated coronary sinus. During bubble contrast study, micro-bubbles from the agitated saline appeared initially in the coronary sinus before appearing in the right sided chambers, suggesting the presence of a persistent left superior vena cava. Cardiac magnetic resonance imaging confirmed the initial echocardiographic findings. Cardiac catheterization and venography confirmed the presence of a persistent left superior vena cava which was draining into a markedly dilated coronary sinus, a severe mitral stenosis (MVA=0.86 cm2), an atrial septal defect with a left-to-right shunt (Qp:Qs = 2:1), and severe pulmonary hypertension. The combination of an atrial septal defect and mitral stenosis is rare, with an incidence ranging from 0.6 to 4% among those with congenital disease. The incidence of the combination of the three lesions - ASD, mitral stenosis and persistent left superior vena cava - is unknown. Since the pulmonary vascular disease was still reversible based on the hemodynamic studies, the plan was to have the patient undergo mitral valve replacement, tricuspid valve annuloplasty, and patch closure of the atrial septal defect. Before any surgical procedure could be done however, the patient succumbed to heart failure.

Myocardial perfusion scintigraphy in tetralogy of fallot prior to total correction of a non-patent shunt

This paper presents a clinical situation in which a Technetium 99m sestamibi myocardial perfusion scintigraphy (MPS) with dipyridamole was used as part of the preoperative evaluation in a 15 year old female with Tetralogy of Fallot. MPS revealed no evident inducible myocardial ischemia, depressed LV wall function and RVH but with good RV function. There are many different techniques for imaging and studying patients with Tetralogy of Fallot (TOF). Echocardiography, ventriculography and invasive angiography remain the mainstay in its evaluation. However, the presence of coronary anomalies in these patients is very common and has negative effect on myocardial perfusion, either preoperatively or postoperatively. Hence, MPS plays an essential role in providing complete assessment in this group of patients.

Mannitol extravasation during partial nephrectomy leading to forearm compartment syndrome

We present the first known complication of forearm compartment syndrome after mannitol infusion during partial nephrectomy. We stress the importance of excellent intravenous catheter access and constant visual monitoring of the intravenous catheter site during and after mannitol infusion as ways to prevent this complication. Prompt recognition of compartment syndrome with appropriate intervention can prevent long-term sequelae.

Hypoglycemic and other related effects of Boswellia glabra in alloxan-induced diabetic rats.

The hypoglycemic effect of the aqueous extract of the leaves and roots of Boswellia glabra was examined using alloxan-induced diabetic rats. A single oral administration of Boswellia glabra leaf and root extract decreased the blood glucose level. The continued use of leaf and root extract for 28 days produced significant hypoglycemic effects; also there was a decrease in serum glucose, cholesterol, triglyceride, urea and creatinine levels and enzyme activities (alkaline phosphatase and glucose-6-phosphatase). Ultra structural studies of beta cell of alloxan-induced diabetic rats treated with root extract showed numerous granulated sacs in comparison to rats treated with leaf extract. Thus, rats treated with root extract showed less degranulated sacs and more number of filled secretory granules in comparison to diabetic rats. Thus the use of aqueous extract of Boswellia glabra increased the synthesis of secretory granules in the beta-cell.

Lapa Vermelha IV Hominid 1: morphological affinities of the earliest known american

Diversos estudos sobre afinidades morfológicas extracontinentais de esqueletos paleoíndios, executados independentemente na América do Sul e do Norte, têm indicado uma ocupaçäo inicial do continente americano por näo-mongolóides. Os primeiros sul-americanos demonstram uma clara semelhança com populaçöes sul-pacíficas e africanas, enquanto os primeiros norte-americanos parecem encontrar-se em uma posiçäo indefinida entre sul-pacíficos e europeus. Em nenhuma destas análises os primeiros americanos demonstraram qualquer similaridade com populaçöes modernas do nordeste asiático ou com índios americanos atuais. Até entäo, estes estudos haviam incluído esqueletos datados de 8.000 a 10.000 anos atrás. Neste trabalho, as afinidades extra-continentais de um esqueleto paleoíndio bem contextualizado entre 11.000 e 11.500 anos atrás (Lapa Vermelha IV Hominídeo 1, ou Luzia) säo investigadas, usando como amostras de referência as séries mundiais de Howells (1989) e a coleçäo de fósseis de hominídeos do Pleistoceno tardio de HabGood (1985). A comparaçäo entre Lapa Vermelha IV Hominídeo 1 e as séries de Howells baseou-se em análises de variáveis canônicas incluindo 45 variáveis craniométricas corrigidas quanto ao tamanho, enquanto a comparaçäo com hominídeos fósseis foi baseada em análise de componentes principais incluindo 16 variáveis também corrigidas. No primeiro caso, Lapa Vermelha IV Hominídeo 1 exibiu afinidade morfológica indiscutível, primariamente com africanos e, em seguida, com populaçöes sul-pacíficas. Na segunda comparaçäo, o mais antigo esqueleto americano conhecido apresentou maior similaridade com os primeiros australianos, Zhoukoudian UC103 e Taforalt 18. Os resultados obtidos confirmam claramente a idéia de que o continente americano foi inicialmente colonizado por uma populaçäo de Homo sapiens generalizados que habitaram o leste asiático no final do Pleistoceno, antes da definiçäo da morfologia mongolóide clássica.

Cutaneous malignant melanoma--clinical epidemiology and survival.

Melanoma of the skin is rare in the Asian population. However, this malignancy results in a high mortality due to the inadequacies in the referral pattern and management. India is one of the low incidence regions of the world. Cancer registries in India report that the age specific incidence rates for cutaneous malignant melanoma (CMM) are less than 0.5 per 1,000,000. There are only few reports in the literature on CMM in the Asian population. The Regional Cancer Centre at Trivandrum registers about 6000 new cancer cases per year and CMM forms 0.5% of them. This paper presents the clinical epidemiology and survival of 79 cases of CMM registered in the hospital cancer registry during the period 1985-90. The peak age frequency was in the 7th decade. The male:female ratio was 1.6:1. All cases had undergone a surgical manipulation in a peripheral centre, before being referred to this centre. This has posed limitation in staging and in deciding the extends of surgical excision. The overall 5-year survival rate was 25.2% (95% confidence intervals, or, CI, 14%-38%). CMM in the low incidence regions may have a different aetiology and needs to be addressed in epidemiological studies.

Analisis factorial de la EIWN-R de Puerto Rico, con ninos de 11 niveles de edad, entre los 6 y los 16 anos / Factor analysis of the EIWN-R (Weschler Inteligence Scale for Children-Revised) Puerto Rico, with children of 11 age levels, from 6 to 16 years old

En 1975 Alan Kaufman reportó sus hallazgos del análisis factorial del WISC-R usando los datos de estandarización de la escala. Kaufman identificó tres factores significativos: Comprensión Verbal, Organización Perceptual y Libertad de Distracción con el fin de explicar los datos de 1975 del WISC-R. Demostró también la estabilidad de los factores por medio de diferentes procedimientos de análisis factorial a través del rango de edades de 6 y medio años a 16 y medio años. Con los datos de la estandarización de la EIWN-R (Escala de Inteligencia Wechsler para Niños Revisada) de Puerto Rico se llevó a cabo una semi-replicación del estudio de análisis factorial de Kaufman con el WISC-R (1975). Replicamos parcialmente la metodología de Kaufman y formulamos las mismas preguntas que él formuló, para determinar si era significativo un factor emergente en la EIWN-R de Puerto Rico. Los datos se analizaron factorialmente para las edades de 6 a 16-1 1 (N = 200 para cada grupo de edad). La estructura factorial fue notablemente consistente en todo el rango de edad, con tres factores que emergieron para cada grupo: Comprensión Verbal, Organización Perceptual y Libertad de Distracción. Estos factores son identicos a los identificados por Kaufman (1975) para el WISC-R. La estabilidad de la estructura factorial se estableció a través de los rangos de edad y también tiende a confirmar la dicotomía del Wechsler entre Verbal y Ejecución. Los resultados del estudio se discuten en términos de sus aplicaciones clínicas, especialmente de los perfiles de la EIWN-R en Puerto Rico.