Lack of association between cervical dysplasia and IBD: a large case-control study.

BACKGROUND: It has been variously reported that women with inflammatory bowel disease (IBD) have an increased risk of cervical dysplasia. We aimed to assess in a large, accurately phenotyped, case-controlled population whether women with IBD had increased rates of abnormal cervical smears and if this was affected by immunosuppressant therapy or disease phenotype. METHODS: Women with IBD diagnosed prior to the age of 60 were studied at a single tertiary referral center in Scotland. Full cervical smear histories were available on 411 women (204 Crohn's disease, 207 ulcerative colitis, median age at diagnosis 28.4 years, median current age 44.1 years). All the cases were matched 1:4 to healthy controls (n = 1644) from the same geographical location. RESULTS: There was no difference in rates of abnormal smears between patients with IBD (80.5% negative, 10.5% low-grade, and 9.0% high-grade dysplasia) and controls (85.4%, 7.7%, and 6.9%, P = 0.37). The use of immunosuppressant therapy had no impact on rates of cervical dysplasia or neoplasia. Furthermore, there was no effect of disease location, behavior, or oral contraceptive use. However, there were significantly more abnormal cervical smears in IBD patients who were current smokers compared with exsmokers and those who had never smoked (27.4% versus 11.4%, P = 0.001, odds ratio = 2.95, 95% confidence interval = 1.55-5.50). CONCLUSIONS: Women with IBD are not at increased risk of abnormal cervical smears unless they smoke. These data suggest that young women with IBD should be managed as per the background population; attending for regular smear testing, and undergoing vaccination against cervical cancer when available.

Clinics in diagnostic imaging (111): X-linked congenital mixed deafness syndrome.

Two siblings, boys aged five and six years old, presented with mixed hearing loss. Computed tomography of the temporal bones showed bulbous dilatation of the internal auditory canals and incomplete separation with the basal turn of the cochlear, consistent with the diagnosis of X-linked congenital progressive mixed deafness syndrome. The diagnosis and management of this rare condition is discussed.

Endolymphatic sac tumour: a rare cause of recurrent vertigo.

Endolymphatic sac tumour occurring in a 32-year-old man presenting with Meniere's like symptoms of recurrent vertigo, hearing loss and tinnitus is described. Magnetic resonance imaging and computed tomography showed a vascular bone tumour centred over the retrolabyrinthine aspect of the temporal bone where the endolymphatic sac was located. Surgical excision via a translabyrinthine approach was performed. Endolymphatic sac tumours are rare papillary adenocarcinomas that arise from the endolympatic sac. It can be mistaken both on radiology and histology for other tumours such as paragangliomas, renal or papillary thyroid carcinoma metastases. Surgical excision is the treatment of choice but sacrifice of the auditory and facial nerve may be needed in advanced cases to achieve tumour clearance.

Surgical morbidity associated with radical trachelectomy and radical hysterectomy.

OBJECTIVES: To examine intra-operative, short and longer term morbidity associated with Radical Trachelectomy (RT) within our cohort of patients, compared with conventional Radical Hysterectomy (RH). METHODS: A retrospective case note review comprising 29 RT and 50 RH patients. Patients who required adjuvant treatment were excluded. Operative data, short-term and long-term complications were recorded. Long-term problems were included only if they had been of persistent nature. RESULTS: The median age and follow up period for the RH group were 40 years and 60 months and for RT group 30.5 years and 25 months. There were significant differences between RH and RT groups in median operative time (260 versus 187 min), blood loss (1000 versus 400 ml), transfusion requirement (75% versus 12%), analgesic requirement (8 versus 3.5 days) and hospital stay (11 versus 6 days). Bladder hypotonia requiring prolonged catheterisation was more frequent in RH group (P = 0.004). There was no apparent difference in psychosexual problems between the two groups (17 versus 16%). Complications of deep dyspareunia (P = 0.009), excessive vaginal discharge (P = 0.01), and upper thigh parasthesia (P = 0.05) were noted to be significantly higher in the RT group. Specific problems encountered in the RT group included; dysmenorrhea (24%), irregular menstruation (17%), recurrent candidiasis (14%), cervical suture problems (14%), isthmic stenosis (10%) and prolonged amenorrhea (7%). CONCLUSION: RT is associated with less operative and short-term morbidity compared with conventional RH. In addition to specific complications associated with RT, in our experience, there are long-term morbidities that are not as commonly observed in RH.

Vestibular rehabilitation therapy for the dizzy patient.

A customised vestibular rehabilitation therapy (VRT) programme is an important treatment modality in patients with vestibular dysfunction resulting in motion-provoked vertigo, oscillopsia (gaze instability), disequilibrium and gait disturbances. We discuss in this paper the patient selection criteria for VRT, rehabilitation strategies for unilateral and bilateral vestibular deficits, and some of the compelling evidence to support the use of VRT in treating such patients.

Why generic and disease-specific quality-of-life instruments should be used together for the evaluation of patients with persistent allergic rhinitis.

BACKGROUND: The importance of assessing health-related quality of life (HRQL) of patients with allergic rhinitis (AR) has been well established, but the specific roles of rhinitis-specific or general health instruments have not been delineated. OBJECTIVE: We analysed the psychometric properties of a disease-specific instrument, the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) and the general health instrument, the Medical Outcome Short-Form 36 (SF-36) as they are employed in combination in patients with persistent AR in clinical practice. METHOD: We analysed the data collected from a prospective study of 43 newly diagnosed patients with persistent AR and 44 controls. We interviewed the patients four times, at baseline, weeks 4, 8 and 10. RESULTS: The RQLQ and SF-36 have good discriminative property, internal consistency, and test-retest reliability. The RQLQ is superior to the SF-36 as an evaluative instrument because more of its domains respond to change, the magnitude of change was greater, and the response was faster. The SF-36 is more susceptible to floor and ceiling effects. Both instruments are unsuitable for mildly symptomatic patients based on Rasch model analysis. Each questionnaire assesses a distinct and significant portion of the total HRQL of persistent AR. CONCLUSION: The SF-36 and RQLQ are good for discriminating rhinitis patients from controls, but the former is poor for detecting changes in QOL. Both are inappropriate for mildly symptomatic patients. Each instrument measures non-overlapping halves of the measurable HRQL. For an assessment of the HRQL in persistent AR that is complete and responsive both instruments should be employed together.

Full-motion pulse inversion power Doppler contrast echocardiography differentiates stunning from necrosis and predicts recovery of left ventricular function after acute myocardial infarction.

OBJECTIVES: The goal of this study was to determine, in patients with a recent myocardial infarction (MI) and residual wall motion abnormalities within the distribution of the infarct-related artery, whether normal perfusion by myocardial contrast echocardiography (MCE) would accurately predict recovery of segmental left ventricular (LV) function. BACKGROUND: Left ventricular dysfunction after acute MI may be secondary to myocardial stunning or necrosis. Recent technical innovations in contrast echocardiography, including pulse inversion imaging and power Doppler, now allow full-motion echocardiographic perfusion assessment from a venous injection of fluorocarbon-based contrast agent. METHODS: Thirty-four patients with recent MI underwent baseline wall motion assessment and MCE two days after admission and follow-up echocardiography a mean of 55 days later. RESULTS: Perfusion by MCE predicted recovery of segmental function with a sensitivity of 77%, specificity of 83%, positive predictive value of 90% and overall accuracy of 79%. The mean wall motion score at follow-up was significantly better in perfused, compared with nonperfused, segments (1.4 vs. 2.2, p < 0.0001). Additionally, 90% of perfused segments improved, while the majority of nonperfused segments remained unchanged. CONCLUSIONS: Full-motion MCE utilizing an intravenous fluorocarbon-based agent and pulse inversion power Doppler techniques, identifies stunned myocardium, and accurately predicts recovery of segmental LV function in patients with recent MI.

Squamous cell carcinoma of the temporal bone: a radiographic-pathologic correlation.

OBJECTIVE: To assess the utility of a previously proposed staging system for patients with primary squamous cell carcinoma of the temporal bone. METHODS: Retrospective chart review of 15 patients treated for squamous cell carcinoma of the temporal bone over a 13-year period at an academic tertiary referral center. A review of the medical and surgical records, radiographic studies, and surgical pathology reports allowed for an evaluation of the University of Pittsburgh staging system. Outcome analysis was performed on 13 patients with more than 24 months of follow-up. RESULTS: Radiographic and surgical pathology staging according to the University of Pittsburgh staging system correlated in 11 (73%) of 15 cases. The radiographic staging system was more accurate for larger (T3/T4) tumors than for smaller (T1/T2) tumors (83% vs 67%). When compared with patients with no evidence of disease, nonsurvivors were more likely to present with otalgia (67% vs 43%), facial nerve paralysis (33% vs 0%), and T3/T4 tumors (100% vs 14%). CONCLUSIONS: Pathologic staging by the University of Pittsburgh staging system closely correlates with patient outcome and is more sensitive than preoperative radiographic staging. Prognosis in squamous cell carcinoma of the temporal bone is largely determined by the extent of local disease at the time of presentation.

The value of pre-operative high resolution CT scans in cholesteatoma surgery.

INTRODUCTION: Cholesteatoma is traditionally diagnosed by otoscopic examination and treated by explorative surgery. The need for imaging in an uncomplicated case is contentious. This study assesses the usefulness of a pre-operative high-resolution CT scan in depicting the status of the middle ear structures in the presence of cholesteatoma. MATERIALS AND METHODS: The surgical findings of 36 ears with cholesteatoma operated on by the first author were retrospectively compared with the CT findings reported on by the second author. The following were analysed: diagnostic features of cholesteatoma on CT, status of the middle ear structures (ossicles, facial nerve canal, semicircular canals and tegmen tympani), and presence of any anatomical variations and disease complications. RESULTS: All cases had at least 1, and 30 cases (83.3%) had all, of the following radiological features: (a) a non-dependent tissue mass, (b) a location typical for cholesteatoma and (c) bony erosion. The radiosurgical agreement was excellent for the malleus (kappa statistics, k=0.83), stapes (0.94) and semicircular canals (0.8), good for the incus (0.62) and tegmen (0.65), but poor for the facial nerve canal (0.3). Potential surgical hazards detected by the scans included: low lying dura, high jugular bulb, anterior lying sigmoid sinus, facial nerve dehiscence and other situations brought about by the destructive nature of the lesion. CONCLUSION: There is good to excellent radiosurgical correlation in cholesteatoma for most middle ear structures except for the integrity of the facial canal. The scan alerts the surgeon to potential surgical dangers and complications of disease. High-resolution CT scan is an important investigative tool prior to cholesteatoma surgery.

Tracheoesophageal puncture outcomes and predictors of success in laryngectomised patients.

INTRODUCTION: Prosthetic voice restoration has been widely used for vocal rehabilitation in laryngectomised patients. The objectives of this study were to examine success rates, predictors of success and complications for our patients who had undergone tracheoesophageal punctures (TEPs) and voice prosthesis placement after laryngectomy. To our knowledge, this is the first analysis of the use and complications of TEPs in Singapore. PATIENTS AND METHODS: Thirty-eight patients seen in our centre were analysed in this retrospective case review. Factors analysed included voice quality with age, timing of insertion, type of closure, use of radiotherapy, regular maintenance and attendance at our clinic. Twenty-eight had undergone primary TEP surgery and 10 had undergone secondary TEP surgery for voice restoration after laryngectomy for cancer. Thirty-five patients had primary closure of the pharynx with 13 vertical, 19 horizontal and 3 T-shaped closures. The other 3 patients required reconstructive surgery. Thirty-five patients had radiotherapy. A numerical assessment of voice production was made of patients immediately and at 6 months post-insertion. A review of the complications was also done. RESULTS: TEPs provided a fair to good voice in 74% of our laryngectomees. Patients who attended the voice restoration clinics and who regularly cleaned their prostheses were found to have statistically better voices (P = 0.044 and P = 0.002, respectively). Patients less than 60 years old had better results, as did patients with horizontal or T-shaped closures; however, these were not statistically significant. Secondary TEPs provided fair/good voices in 90% of cases compared to 68% of primary TEPs. Voice quality during radiotherapy was diminished but recovered at 6 months postradiotherapy. The commonest complications noted included crusting (seen in 40% of cohort), candida infections and leaks which were seen in 16% of our patients. There was no mortality attributable to the use of TEPs in our study.

Cost-effectiveness of stress echocardiography and nuclear perfusion imaging.

Cost-effectiveness analysis is a method of comparing societal economic value of 2 different strategies. Ideally, it defines accurate test-related (direct and downstream) costs and appropriately converts differential patient outcomes into a dollar value. The likelihood that cost-effectiveness analysis translated into a policy-making tool will enhance health care and/or control costs is dependent on the validity of numerous assumptions about relative costs, patient outcomes, and generalizability of the literature to regional capabilities. The purpose of this report is to review the concept of cost-effectiveness analysis as it applies to stress echocardiography and stress myocardial perfusion imaging for selected patient subsets.

Rhizosphere bacteria enhance the accumulation of selenium and mercury in wetland plants.

The role of rhizosphere bacteria in facilitating Se and Hg accumulation in two wetland plants, saltmarsh bulrush (Scirpus robustus Pursh) and rabbitfoot grass (Polypogon monspeliensis (L.) Desf.), was studied. Ampicillin-amended plants (i.e., with inhibited rhizosphere bacteria) supplied with Na(2)SeO(4) or HgCl(2) had significantly lower concentrations of Se and Hg, respectively, in roots than plants without ampicillin. These results were confirmed by inoculating axenic saltmarsh bulrush plants with bacteria isolated from the rhizosphere of plants collected from the field; these plants accumulated significantly more Se and Hg compared to axenic controls. Therefore, rhizosphere bacteria can increase the efficiency of Se and Hg phytoremediation by promoting the accumulation of Se and Hg in tissues of wetland plants.

Pharyngocutaneous fistula after laryngectomy--incidence, predisposing factors and outcome.

AIMS: The occurrence of pharyngocutaneous fistula in a totally laryngectomised patient is a serious complication as it increases patient morbidity and mortality. This paper aims to determine the incidence of the problem in our patients, to identify factors which may contribute to fistula formation and to analyse our results in managing this complication. METHODS: The case records of 69 patients who underwent total laryngectomy between April 1990 and July 1997 were assessed. RESULTS: There were 11 cases of pharyngocutaneous fistula out of 69 patients with total laryngectomy, giving an incidence of 15.9%. Our findings showed that fistula formation was significantly more common in patients who had received pre-operative radiotherapy (p = 0.001) or who had tumour involved surgical resection margins (p = 0.018). The development of fistula delayed hospital discharge, and in 1 patient, contributed to sepsis and death. Of the 11 patients with fistula, 4 required surgical intervention for closure. There was a trend towards surgical repair when the size of the fistula was large (> 2 cm). CONCLUSION: This paper identifies the patients at high risks for developing pharyngocutaneous fistula and also discusses our experience with managing this complication.

Vocal cord paresis in acute ischemic stroke.

We prospectively determined the frequency of vocal cord paresis (VCP) among first-ever acute ischemic stroke patients. Vocal cords were examined endoscopically within 48 h of stroke onset, at 1 week and 1 month. Of the 54 study patients, 64.8% had lacunar (group 1), 22.2% cortical/large subcortical (group 2), 9.3% lateral medulla (group 3) and 3.7% other brainstem (group 4) infarcts. VCP was found in 11 (20.4%): 11.4% of group 1, 16.4% of group 2, 100% of group 3 and 0% of group 4. VCP was contralateral to the brain lesion in groups 1 and 2, and ipsilateral in 80% of group 3. VCP was strongly correlated with dysphonia (p < 0.0001) and resolved in 2/11 patients after 1 week and in 5/11 after 1 month. Our finding of VCP among acute ischemic stroke patients questions the belief that the nucleus ambiguous is invariably bilaterally innervated by supranuclear centers.

Quality of life of patients with perennial allergic rhinitis: preliminary validation of the Rhinoconjunctivitis Quality of Life Questionnaire in Singapore.

Though sufferers of perennial allergic rhinitis do not die from their ailment, they endure years of chronic nose disease that Interferes with many important aspects of their lives. A rhinitis-specific instrument to gauge the quality of life of patients with this disease was published in 1991. Here, we validated the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) for use in English-speaking patients with perennial allergic rhinitis. We established that the RQLQ distinguishes between patients and control, demonstrates internal consistency and is sensitive to change. This study suggests that the RQLQ can be used to assess the quality of life of patients with perennial allergic rhinitis in Singapore.

Clinical audit on tonsils and adenoid surgery. Is day surgery a reasonable option?

Four hundred and five patients who underwent tonsillectomy and/or adenoidectomy over a 27-month period were reviewed retrospectively to determine local patient characteristics and complication rates. The predominance of adult patients (mean age of 23.8 years), male subjects (male to female ratio of 2:1), and tonsillectomy cases (85.4%) were in contrast to studies reported in Western countries. Chronic tonsillitis or adenoiditis was the most common indication for surgery and the most frequent complications encountered were fever (20.0%) and haemorrhage (5.2%). Three patients (0.7%) had significant haemorrhage requiring a return to the operating theatre for haemostasis. Bleeding occurred within 6 hours in 2 patients and on the third postoperative day in 1 patient. The rate of haemorrhage was significantly higher in male patients (P = 0.038). The average duration of hospitalisation was 3.6 days. The main reasons for delayed discharge from hospital were retention for observation of pain and fever or for social or administrative purposes. Based on the results of the survey, day surgery for tonsillectomy and adenoidectomy would be feasible in Singapore provided patients are carefully selected and actively monitored for at least 6 hours after the operation.

Metabolic heterogeneity in rabbit brain glycogen.

Glycogen has been carefully isolated from rabbit brain tissue and found to be of significantly greater molecular size (up to approx. 100 MDa) and heterogeneity than previously reported. The incorporation of radioisotope from glucose, pyruvate or acetate precursor has been shown to be non-uniform, being similar to the metabolic inhomogeneity observed in other tissues. Physicochemical studies have shown the gross hydrodynamic structure of the glycogen to be inhomogeneous and to differ significantly from that of liver glycogen.