Endoscopic laryngeal findings in patients undergoing thyroid and parathyroid surgery.

OBJECTIVES: This study aimed to report the pre- and post-operative laryngeal endoscopic findings in patients referred by non-otolaryngologists who are undergoing thyroid and/or parathyroid surgery, and to determine the number and nature of referrals before and after the release of the clinical practice guideline for improving voice outcomes after thyroid surgery. METHODS: This retrospective cohort study, conducted at a tertiary care academic hospital, comprised adult patients referred by the endocrine surgery service for laryngoscopy from 2007 to 2018 (n = 166). Data regarding patient demographics, reason for referral and endoscopic findings were recorded. RESULTS: The number of referrals increased significantly after the release of the practice guideline. The most common indication for referral pre- and post-operatively was voice change. The most common finding during laryngoscopy was normal examination findings (pre-operatively) and unilateral vocal fold immobility (post-operatively). CONCLUSION: Peri-operative thyroid and/or parathyroid patients have laryngoscopic findings other than vocal fold immobility. Laryngoscopy to detect structural and functional pathology is warranted.

Submucosal neoplasms of the laryngeal introitus.

BACKGROUND: The differential diagnosis of endolaryngeal mesenchymal neoplasms includes a wide spectrum of benign and malignant pathologies, which have been rarely photo-documented and assessed as a group. METHODS: Non-epithelial neoplasms of the endolarynx seen at our centre from 2002 to 2011 (n = 38; 36 treated at our institution) were retrospectively reviewed, with attention to clinical presentation, radiographic imaging, operative management, histology, and pre- and post-operative endoscopy. Submucosal squamous cell carcinomas, mucosal cysts, amyloid and Teflon granulomas were excluded. RESULTS: Twenty-three of a total of 36 patients underwent definitive endoscopic surgical treatment. Supraglottic pathologies included lymphoma, lipoma, neuroendocrine carcinoma, lymphangioma, oncocytoma, haemangioma, synovial cell sarcoma and benign spindle cell neoplasm. Transglottic pathologies included synovial cell sarcoma and granular cell tumour. Glottic pathologies included granular cell tumour, osteoma, rhabdomyoma, rhabdomycosarcoma and myofibroblastic sarcoma. Subglottic pathologies included chondrosarcoma, neurofibroma, adenoid cystic carcinoma and vascular malformation. CONCLUSION: The site of origin, degree of malignant behaviour and sensitivity to adjuvant treatment determined the course of surgical management, i.e. endolaryngeal versus transcervical, and limited removal versus wider resection.

Saturn's curiously corrugated C ring.

In August 2009 the Sun illuminated Saturn's rings from almost exactly edge-on, revealing a subtle corrugation that extends across the entire C ring. This corrugation's amplitude is 2 to 20 meters and its wavelength is 30 to 80 kilometers. Radial trends in the corrugation's wavelength indicate that this structure--like a similar corrugation previously identified in the D ring--results from differential nodal regression within a ring that became tilted relative to Saturn's equator plane in 1983. We suggest that this initial tilt arose because interplanetary debris struck the rings. The corrugation's radial extent implies that the impacting material was a dispersed cloud of debris instead of a single object, and the corrugation's amplitude indicates that the debris' total mass was ~10(11) to 10(13) kilograms.

An evolving view of Saturn's dynamic rings.

We review our understanding of Saturn's rings after nearly 6 years of observations by the Cassini spacecraft. Saturn's rings are composed mostly of water ice but also contain an undetermined reddish contaminant. The rings exhibit a range of structure across many spatial scales; some of this involves the interplay of the fluid nature and the self-gravity of innumerable orbiting centimeter- to meter-sized particles, and the effects of several peripheral and embedded moonlets, but much remains unexplained. A few aspects of ring structure change on time scales as short as days. It remains unclear whether the vigorous evolutionary processes to which the rings are subject imply a much younger age than that of the solar system. Processes on view at Saturn have parallels in circumstellar disks.

Value and utility of 532 nanometre pulsed potassium-titanyl-phosphate laser in endoscopic laryngeal surgery.

OBJECTIVES: Recently, the 532 nm pulsed potassium-titanyl-phosphate laser has emerged as an effective angiolytic laser for treating mucosal lesions of the larynx in the operating theatre and clinic. We sought to assess the current impact of potassium-titanyl-phosphate laser on our laryngeal surgery practice. STUDY DESIGN: Retrospective review of 710 patients undergoing endoscopic laryngeal surgery over a one-year period. METHODS: Medical records of the endoscopic laryngeal procedures were reviewed; 386/710 had been performed in the clinic and 324/710 in the operating theatre under general anaesthesia. Indications for the procedures were classified by pathology. RESULTS: Pulsed potassium-titanyl-phosphate laser was used in 209/386 clinic procedures. The indications for these procedures were: dysplasia (114/209 procedures), papillomatosis (89/209), varices or ectasia (three of 209), and 'other' (three of 209). Pulsed potassium-titanyl-phosphate laser was used in 178/324 operating theatre endoscopic laryngeal procedures. The indications for these procedures were: cancer (54/178 procedures), dysplasia (52/178), papillomatosis (38/178), varices or ectasia (13/178), polyps (six of 178), nodules (six of 178), stenosis (five of 178), granulation (three of 178), and amyloid (one of 178). CONCLUSIONS: Due to its versatility, the 532 nm pulsed potassium-titanyl-phosphate laser is our most commonly utilised instrument for performing endoscopic laryngeal surgery.

Hyperion's sponge-like appearance.

Hyperion is Saturn's largest known irregularly shaped satellite and the only moon observed to undergo chaotic rotation. Previous work has identified Hyperion's surface as distinct from other small icy objects but left the causes unsettled. Here we report high-resolution images that reveal a unique sponge-like appearance at scales of a few kilometres. Mapping shows a high surface density of relatively well-preserved craters two to ten kilometres across. We have also determined Hyperion's size and mass, and calculated the mean density as 544 +/- 50 kg m(-3), which indicates a porosity of >40 per cent. The high porosity may enhance preservation of craters by minimizing the amount of ejecta produced or retained, and accordingly may be the crucial factor in crafting this unusual surface.

Cassini observes the active south pole of Enceladus.

Cassini has identified a geologically active province at the south pole of Saturn's moon Enceladus. In images acquired by the Imaging Science Subsystem (ISS), this region is circumscribed by a chain of folded ridges and troughs at approximately 55 degrees S latitude. The terrain southward of this boundary is distinguished by its albedo and color contrasts, elevated temperatures, extreme geologic youth, and narrow tectonic rifts that exhibit coarse-grained ice and coincide with the hottest temperatures measured in the region. Jets of fine icy particles that supply Saturn's E ring emanate from this province, carried aloft by water vapor probably venting from subsurface reservoirs of liquid water. The shape of Enceladus suggests a possible intense heating epoch in the past by capture into a 1:4 secondary spin/orbit resonance.

Comparison of processes and intermediate outcomes between South Asian and European patients with diabetes in Blackburn, north-west England.

BACKGROUND: Diabetes and its complications are more prevalent among South Asians than people of European origin and there is some evidence that patients of South Asian origin with diabetes receive poorer quality care. METHODS: Longitudinal study of patients with diabetes in Blackburn, UK. Processes of care indicators [measurement of blood pressure (BP), cholesterol and glycosolated haemoglobin (HbA1c)] and values of these intermediate outcomes were extracted for all patients registered on a diabetes information system for the period 1995-2001. Differences in processes of care indicators and intermediate outcomes between ethnic groups were estimated after adjusting for the potential confounding factors of sex, age and socioeconomic status (SES). Generalized estimating equations were used to model trends and to test for differences in trends over time. RESULTS: Process of care was similar in South Asian and European patients. Mean BP and cholesterol concentration fell during the study period. South Asians had a higher level of HbA1c throughout the study period. South Asians had lower levels of BP and cholesterol in 1995 but the differences diminished or were abolished over time. SES did not explain differences between ethnic groups. Analyses stratified by baseline levels of intermediate outcomes (above or within target) demonstrated improvements among above target patients were greater among European patients. CONCLUSIONS: Processes of care indicators are similar in diabetic patients of South Asian and European origin, irrespective of SES. However, there are worrying differences in improvements over time in the intermediate outcomes, and glycaemic control remained poorer among patients of South Asian origin patients throughout.

Cassini Imaging Science: initial results on Saturn's rings and small satellites.

Images acquired of Saturn's rings and small moons by the Cassini Imaging Science Subsystem (ISS) during the first 9 months of Cassini operations at Saturn have produced many new findings. These include new saturnian moons; refined orbits of new and previously known moons; narrow diffuse rings in the F-ring region and embedded in gaps within the main rings; exceptionally fine-scale ring structure in moderate- to high-optical depth regions; new estimates for the masses of ring-region moons, as well as ring particle properties in the Cassini division, derived from the analysis of linear density waves; ring particle albedos in select ring regions; and never-before-seen phenomena within the rings.

Cassini Imaging Science: initial results on Phoebe and Iapetus.

The Cassini Imaging Science Subsystem acquired high-resolution imaging data on the outer Saturnian moon, Phoebe, during Cassini's close flyby on 11 June 2004 and on Iapetus during a flyby on 31 December 2004. Phoebe has a heavily cratered and ancient surface, shows evidence of ice near the surface, has distinct layering of different materials, and has a mean density that is indicative of an ice-rock mixture. Iapetus's dark leading side (Cassini Regio) is ancient, heavily cratered terrain bisected by an equatorial ridge system that reaches 20 kilometers relief. Local albedo variations within and bordering Cassini Regio suggest mass wasting of ballistically deposited material, the origin of which remains unknown.

Cassini Imaging Science: initial results on Saturn's atmosphere.

The Cassini Imaging Science Subsystem (ISS) began observing Saturn in early February 2004. From analysis of cloud motions through early October 2004, we report vertical wind shear in Saturn's equatorial jet and a maximum wind speed of approximately 375 meters per second, a value that differs from both Hubble Space Telescope and Voyager values. We also report a particularly active narrow southern mid-latitude region in which dark ovals are observed both to merge with each other and to arise from the eruptions of large, bright storms. Bright storm eruptions are correlated with Saturn's electrostatic discharges, which are thought to originate from lightning.

Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial.

OBJECTIVE: To determine the effectiveness of specialist nurse delivered education in primary care to improve control of hypertension and hyperlipidaemia in patients with diabetes. DESIGN AND SETTING: Practice-level randomized controlled trial, Salford, England. SUBJECTS: From 44 practices, 10 303 subjects presenting in general practice with raised blood pressure (= 140/80 mmHg), raised total cholesterol (= 5.0 mmol/l) or both. INTERVENTIONS: Practices were randomized to receive either the intervention for hyperlipidaemia or for hypertension; practices acted as control for the intervention not received. Specialist nurses arranged a schedule of visits with general practitioners and general practice nurses, reminding them of diabetes protocols and clinical targets. They provided educational materials and protocols used in secondary care for nurse and doctor interventions including stepping up pharmacotherapy when necessary. Practices received a list of patients in their practice who were poorly controlled at their last annual review; new and recalled patients were targeted. OUTCOME MEASURES: At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register for patients from participating practices. RESULTS: Overall, specialist nurse-led educational outreach to primary care was associated with no improvement in patients achieving target after 1 year-odds ratio (OR): 1.03 (95% CI 0.95-1.11; P = 0.52). Similar results were achieved with hyperlipidaemia OR: 1.04 (95% CI 0.88-1.23; P = 0.62) and hypertension OR: 1.01 (95% CI 0.80-1.27; P = 0.93). CONCLUSION: This study provides evidence that the use of specialist nurses to perform educational outreach to improve target adherence to patients with diabetes in primary care is not effective.

Botulinum toxin type a for dysthyroid upper eyelid retraction.

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS: : Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.

Nasolacrimal obstruction secondary to I(131) therapy.

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with I(131) therapy for thyroid carcinoma from an updated and expanded cohort. METHODS: Patients with a history of epithelial derived thyroid carcinoma who had tearing were offered referral for evaluation by an oculoplastic surgeon. Patients underwent nasolacrimal probing and irrigation procedures with localization of their nasolacrimal obstruction. Therapy for the site of obstruction was instituted. RESULTS: Clinically significant tearing was identified in 26 patients, all of whom had previously undergone I(131) therapy (n = 563). Nineteen patients were evaluated and confirmed to have nasolacrimal drainage system obstruction; 7 have yet to be formally evaluated. Areas of obstruction included nasolacrimal duct, common canaliculus, and, rarely, distal upper and lower canaliculi. Patients were treated with a variety of modalities including silicone intubation, balloon dacryoplasty, dacryocystorhinostomy, and conjunctival dacryocystorhinostomy. CONCLUSIONS: The use of I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented nasolacrimal drainage obstruction and an overall 4.6% incidence of documented or suspected obstruction. The true incidence may be higher, since - I(131) treated individuals were neither systematically evaluated nor questioned about tearing. It has yet to be established if the obstructions result from local toxicity caused by the passive flow of radioactive iodine containing tears through these tissues or the active uptake and concentration of I(131) in lacrimal drainage system tissues through the sodium/iodide supporter.

Variations in process and outcomes of diabetes care by socio-economic status in Salford, UK.

AIMS/HYPOTHESIS: Our aim was to investigate trends in provision and outcomes of care by socio-economic status among patients with diabetes in Salford, United Kingdom. METHODS: Salford is a deprived urban area in North West England. Data for people with diabetes who were younger than 20 years of age (4034 patients in the year 1993 and 5671 by the year 2000) were extracted from the Diabetes Information System. Age-standardised means, proportions and attainment of targets were calculated for: processes of care indicators, intermediate outcomes and prescribing of preventive drug treatments in 1993 to 1994 and in 2000 to 2001 by quintiles of Townsend deprivation score. We did comparisons of means and proportions using age-adjusted linear regression and of trends using generalised estimating equations. Rate ratios for first microvascular and first macrovascular complication were estimated from proportional hazards models. RESULTS: Marked improvements occurred in all indicators. For patients managed in primary care, blood pressure and cholesterol measurement increased from 53% to 64% (p<0.001) and 27% to 61% (p<0.001) respectively; whilst mean systolic blood pressure decreased from 147 to 140 mmHg (p<0.001) and cholesterol concentrations from 6.0 to 5.1 mmol/l (p<0.001). Mean HbA(1c) increased from 7.8 to 8.1% (p<0.001). Prescribing of aspirin, anti-hypertensive and lipid-lowering drugs increased greatly. Trends varied little by socio-economic status. Patients from more affluent areas generally received more frequent clinical monitoring and preventive treatments, and had a lower BMI (29.5 vs 30.2 kg/m(2); p=0.009) and HbA(1c) (7.8 vs 8.2% p=0.006), though risks of first microvascular or macrovascular complications were similar. CONCLUSION/INTERPRETATION: Improvements in process and outcomes of care are possible for patients from all socio-economic groups. Socio-economic deprivation does not preclude high quality diabetes care.

Nitrogen-fixing phylotypes of Chesapeake Bay and Neuse River estuary sediments.

Sediments often exhibit low rates of nitrogen fixation, despite the presence of elevated concentrations of inorganic nitrogen. The organisms that potentially fix nitrogen in sediments have not previously been identified. Amplification of nifH genes with degenerate primers was used to assess the diversity of diazotrophs in two distinct sediment systems, anoxic muds of Chesapeake Bay and shallow surficial sediments of the Neuse River. Phylogenetic analysis revealed that sequences obtained from mid-Chesapeake Bay, which receive high organic loading and are highly reducing, clustered closely with each other and with known anaerobic microorganisms, suggesting a low abundance of aerobic or facultative diazotrophs in these sediments. Sulfate reduction dominates in the surface, but methanogenesis becomes more important with depth. A thin (<1 cm) oxidized layer is present only in the spring. No archaeal nifH sequences were obtained from Chesapeake Bay. Sequences of nifH amplified from surficial sediments of the Neuse River were distant from Chesapeake Bay sequences and included nif phylotypes related to sequences previously reported from marine mats and the Spartina rhizosphere. Differences in environmental site characteristics appear to select for different types of sediment diazotrophs, which is reflected in the phylogenetic composition of amplified nifH sequences.

Discovery of 12 satellites of Saturn exhibiting orbital clustering.

The giant planets in the Solar System each have two groups of satellites. The regular satellites move along nearly circular orbits in the planet's orbital plane, revolving about it in the same sense as the planet spins. In contrast, the so-called irregular satellites are generally smaller in size and are characterized by large orbits with significant eccentricity, inclination or both. The differences in their characteristics suggest that the regular and irregular satellites formed by different mechanisms: the regular satellites are believed to have formed in an accretion disk around the planet, like a miniature Solar System, whereas the irregulars are generally thought to be captured planetesimals. Here we report the discovery of 12 irregular satellites of Saturn, along with the determinations of their orbits. These orbits, along with the orbits of irregular satellites of Jupiter and Uranus, fall into groups on the basis of their orbital inclinations. We interpret this result as indicating that most of the irregular moons are collisional remnants of larger satellites that were fragmented after capture, rather than being captured independently.

The beta2, alpha4, alpha5 integrins and selectins mediate chemotactic factor and endotoxin-enhanced neutrophil sequestration in the lung.

Intravascular chemotactic factor activation of neutrophils (polymorphonuclear leukocytes; PMNLs), associated with actin polymerization resulting in PMNL stiffening, induces rapid and transient sequestration in the pulmonary vasculature and lung dysfunction. Recent studies have proposed that this sequestration is mediated by physical lodging of PMNLs because of loss of deformability. To examine the contribution of cell adhesion molecules in this process, we used blocking monoclonal antibodies (mAbs) to rat selectins and integrins in a model of PMNL margination (reflected by acute blood neutropenia) induced by N-formyl-met-leu-phe (FMLP) chemotactic factor infusion in normal or lipopolysaccharide (LPS)-primed rats. Blood PMNL levels dropped by 70% within 1 minute and for the duration of FMLP infusion (20 minutes) in normal or by 90% in LPS-primed rats. Pretreatment with mAbs to beta2(WT.3), VLA-4(TA-2 F(ab)(2)), and VLA-5 (HMalpha5 F(ab)(2)) in combination inhibited the decrease by 50% and to a greater degree than beta2 blockade alone (35% inhibition). F(ab)(2) mAbs to L-(HRL-3), P-(RMP-1), plus E-(RME-1) selectins had no effect but they potentiated inhibition by anti-beta2 + anti-VLA-4 + anti-VLA5 mAb treatment (69% inhibition, P < 0.05). Similar results were observed in the first 6 minutes in LPS-primed rats with complete inhibition of sequestration thereafter by combined selectin and integrin blockade. These results indicate that besides PMNL stiffening because of actin polymerization, both selectins and integrins substantially contribute to activated PMNL sequestration in the lung.

The alpha 4 beta 1 (very late antigen (VLA)-4, CD49d/CD29) and alpha 5 beta 1 (VLA-5, CD49e/CD29) integrins mediate beta 2 (CD11/CD18) integrin-independent neutrophil recruitment to endotoxin-induced lung inflammation.

The beta(2) integrin cell adhesion molecules (CAM) mediate polymorphonuclear leukocyte (PMNL) emigration in most inflamed tissues, but, in the lung, other yet to be identified CAMs appear to be involved. In Lewis rats, the intratracheal injection of Escherichia coli-LPS induced acute (6-h) PMNL accumulation in the lung parenchyma (280 x 10(6) by myeloperoxidase assay; PBS control = 35 x 10(6)) and bronchoalveolar lavage fluid (BALF = 27 x 10(6); PBS = 0.1 x 10(6)). Parenchymal accumulation was not inhibited by a blocking Ab to beta(2) integrins and only minimally inhibited (20.5%; p < 0.05) in BALF. We examined the role of alpha(4)beta(1) and alpha(5)beta(1) integrins and of selectins in this PMNL recruitment. Treatment with mAbs to alpha(4)beta(1) or alpha(5)beta(1), even in combination, had no effect on PMNL accumulation induced by intratracheal LPS. However, anti-alpha(4) combined with anti-beta(2) mAbs inhibited PMNL recruitment to the parenchyma by 56% (p < 0.001) and to BALF by 58% (p < 0.01). The addition of anti-alpha(5) mAb to beta(2) plus alpha(4) blockade inhibited PMNL accumulation further (by 79%; p < 0.05). In contrast, blockade of L-, P-, and E-selectins in combination or together with beta(2), alpha(4), and alpha(5) integrins had no effect. LPS-induced BALF protein accumulation was not inhibited by treatment with anti-beta(2) plus alpha(4) mAbs, but was prevented when alpha(5)beta(1) was also blocked. Thus, while selectins appear to play no role, alpha(4)beta(1) and alpha(5)beta(1) function as major alternate CAMs to the beta(2) integrins in mediating PMNL migration to lung and to pulmonary vascular and epithelial permeability.

Performance of children with and without learning disabilities on Canter's Background Interference Procedure and Koppitz's scoring system for the Bender test.

Performance of 66 children, 30 with and 36 without learning disabilities, in four ways using the Bender Visual-motor Gestalt Test was compared. First, the test with the standard Koppitz scoring procedure, second with the Canter Background Interference Procedure sheet using the standard Koppitz scoring procedure; third, the Bender test on a standard sheet of paper using Canter scoring procedure; and fourth, the Canter Background Interference Procedure (BIP) sheet using the Canter scoring procedure. The effectiveness of the Canter procedure was examined when scored with an age-appropriate normative scoring system. This was accomplished by combining the Canter BIP interference sheet with the Koppitz scoring system. The children ranged in age from 6 to 10 years. Using discriminant analysis, all four methods correctly categorized statistically significant percentages of both types of students but there was a significant difference on the Canter BIP sheet using the Canter scoring procedure. This procedure classified students with the least absolute number and percentage of either false negatives or false positives when compared with the other three methods, suggesting that using this scoring method with the Bender Gestalt may be better for identifying younger children with learning disabilities.