Pediatric maxillary expansion has a positive impact on hearing? A systematic review and meta-analysis.

OBJECTIVE: Hearing loss is a highly prevalent condition in the pediatric population. Pediatric maxillary expansion is a widespread treatment to address transverse maxillary deficiency. First reports describing an association between improvements for patients with HL and PME initiated in the 1960s. In this systematic review and meta-analysis we aim to review the role of maxillary expansion in reducing conductive hearing loss in pediatric population. REVIEW METHODS: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked. Main outcome was expressed as the difference between air-bone gap, compliance, ear volume and conductive hearing thresholds before and after treatment and the 95% confidence interval. RESULTS: A total of 10 studies (218 patients) met inclusion criteria. The pooled data in the meta-analysis under a random effects model shows a statistically significant difference of 10.57dB mean reduction after palatal expansion. The air-bone gap was significantly reduced by 5.39dB (CI 95% 3.68, 7.10). Compliance and volume were assessed in three studies, with a non-significant positive difference in the compliance (0.14) and a statistically significant difference for volume (0.80) after palatal expansion. CONCLUSION: This systematic review and meta-analysis found a positive effect of pediatric maxillary expansion in conductive hearing loss in well-select children. However, results cannot be extrapolated for children with conductive hearing loss without an accompanying orthodontic indication (maxillary constriction). It showed that the existing prospective studies exhibited qualitative pitfalls, limiting the ability to obtain conclusive evidence about the role of pediatric maxillary expansion on conductive hearing loss in children.

[Ketamine administration in case of severe, therapy resistant depressed patient, case report]. / Ketamin alkalmazása súlyos, terápiarezisztens depressziós beteg esetében.

Objective - In our case report we present the treatment of a female patient suffering from therapy resistant depression. This procedure is not in practice in Hungary at present, the aim of our work to reproduce the findigs of international studies in domestic circumstances. Matter - Major depression is a common, chronic and severe mental disorder, with 16.2% lifetime prevalence. Many international randomized, placebo controlled trials found administration of ketamine infusion effective in depressed patients. Methods - Since ketamine is an anesthetic agent, its administration was performed in the post-operative monitoring room of our hospital operating-room, supervised by an anesthesiologist. According to formerly published data, a dose of 0.5 mg/kg of body weight was administered intravenously in 40 minutes by perfusor. The drug was administered in a same manner fifteen days later. Subject - The patient was admitted to our inpatient ward with severe depression. During two months of combined antidepressant therapy her condition has not improved significantly. Approval for off label drug indication was granted with urgency by the National Institute of Quality and Organizational Development in Healthcare and Medicines. Results - During the two treatments the Hamilton Depression Rating Scale 21 items rating scale score was reduced to 8 from the baseline 28, the Hamilton Anxiety Rating Scale score was reduced to 6 from 25, Beck Depression Inventory was reduced to 9 from 20. Upon administration of the drug no severe adverse event was detected, the mild dissociative state related to ketamine was ceased in a short period of time. Discussion - With administration of 0.5 mg/kg ketamine the authors managed to achieve rapid improvement in a therapy resistant depressed patient, without permanent side effects. Our future plan is to repeat the use of the drug within a double-blind, placebo controlled trial in order to prove its efficacy in hospital settings.

Prognostic factors in laryngotracheal injury following intubation and/or tracheotomy in ICU patients.

The aim of this study was to determine the incidence of laryngotracheal injuries following intubation and/or tracheotomy in intensive care unit (ICU) patients and to analyze their prognostic factors. This prospective study includes the clinical data and endoscopic exploration of 654 ICU patients who underwent oro-tracheal intubation between September 1992 and February 1999. The prognostic factors for upper airway injuries were analyzed using a multivariate statistical study. Endoscopic exploration of the upper airway 6 to 12 months after extubation revealed laryngotracheal injuries in 30 of the 280 patients examined (11%). The most important factors influencing the development of laryngotracheal lesions were the duration of the oro-tracheal intubation and the length of time in the ICU. Patients at high risk of developing injuries were those with pathological background, a non-neurological or non-surgical (medical) admission or upper-airway injuries at an early stage. The length of oro-tracheal intubation is the most important factor in the development of laryngotracheal injuries. Consequently, it is essential to establish a time limit to perform tracheotomy in ICU patients. Such timing should be adapted to each patient and pathology.

Intima media thickness of carotid arteries is reduced in heterozygous carriers of the Gly972Arg variant in the insulin receptor substrate-1 gene.

BACKGROUND: The Gly972Arg mutation in the IRS-1 gene has been found to be associated with insulin resistance and type II diabetes. A recently published study described an association between the Arg allele and an increased risk for coronary artery disease. In the present study we asked whether the presence of the codon 972 mutation in the IRS-1 gene is associated with higher IMT values of the carotid arteries. MATERIALS AND METHODS: To address this question, genotypes of the codon 972 polymorphism were determined in 1018 healthy unrelated individuals aged 40-65 years. Three homozygous carriers of the mutation were excluded for statistical analysis. In all subjects, intima media thickness (IMT) and B-scores of carotid arteries as well as a large number of metabolic parameters were determined. RESULTS: Heterozygous carriers of the Arg972 allele exhibited significantly lower IMT and B-score values than noncarriers. Total cholesterol, LDL-cholesterol and serum levels of apolipoprotein B were significantly lower in the carriers. Furthermore, a significant interaction between Gly972Arg-carrier status and mean daytime 24-h systolic blood pressure with regard to IMT could be observed; carriers with a systolic blood pressure above the median had lower IMT values than carriers with a systolic blood pressure equal or below the median. All these effects were more pronounced in females and remained significant after adjustment for sex, age, BMI, systolic blood pressure and serum apolipoprotein B levels. No significant differences between the carriers and the noncarriers could be found for BMI, insulin sensitivity or frequency of type II diabetes. CONCLUSIONS: The results of our study demonstrate that the presence of the Arg972 allele is associated with lower IMT values of the carotid arteries. This finding is partly explained by lower serum levels of apolipoprotein B in carriers. The protective effect of the Gly972 Arg mutation seems to be stronger in the presence of a higher systolic blood pressure. Our data contradict previous findings suggesting an increased risk for insulin resistance, type II diabetes and atherosclerotic vascular disease in carriers of the mutation.

Activation of the MAP kinase pathway induces chicken ovalbumin upstream promoter-transcription factor II (COUP-TFII) expression in human breast cancer cell lines.

Growth factors are essential for cellular growth and differentiation in both normal and malignant human breast epithelial cells. In the present study we investigated the effect of epidermal growth factor (EGF), transforming growth factor alpha (TGFalpha) and phorbol myristate acetate (PMA) on chicken ovalbumin upstream promoter-transcription factor (COUP-TF) expression in human breast cancer cells. The orphan receptors COUP-TFI and COUP-TFII are members of the nuclear receptor superfamily. The high degree of evolutionary conservation of these proteins strongly argues for an important biological function. COUP-TF expression was highest in SK-BR3 cells (approximately 130 amol/ micro g total RNA), while the lowest COUP-TF expression was observed in MCF-7 cells (3.5 amol/ micro g total RNA). While treatment of EGF, TGFalpha and PMA induced expression of COUP-TFII, COUP-TFI did not respond to these agents. Oncostatin M (OSM) is known to exert an antiproliferative effect in breast cancer cells. Treatment of MCF-7 cells with OSM resulted in an approximately 90% reduction of COUP-TFII mRNA expression. In SK-BR3 cells, treatment with the MEK inhibitor UO126 resulted in a profound suppression of endogenous COUP-TFII expression. Furthermore, cotreatment with UO126 prevented induction of COUP-TFII expression by EGF in MCF-7 cells. In conclusion, our data provide evidence, for the first time, that mitogenic substances which activate the MAP kinase pathway, can induce COUP-TFII expression. Our results strongly suggest that an active MAP kinase pathway is essential for COUP-TFII expression in human breast cancer cells.

[Factors helping in the decision to change intubation for tracheotomy in critical patients]. / Estudio de los factores que ayudan a la decisión del paso de intubación a traqueotomía en pacientes críticos.

We carry out a prospective study in order to determine the prognostic factors in the development of injuries of upper airways, and their influence in the decision to perform a tracheotomy. The time to tracheotomy was previously stated, according to the type of patient (neurological or non-neurological). This study includes the clinical data and the upper airways endoscopic exploration of 654 patients with oro-tracheal intubation and mechanical ventilation for more than 48 hours in a 6 year period. Three endoscopic explorations were carried out in the first month (early exploration), with two additional explorations at six and twelve months (late exploration). Using a multivariable statistical study we have analysed the prognostic factors and the risk groups for the development of later injuries of the upper airway of these patients. The later endoscopic exploration of the upper airways has shown injuries in 30 of 280 cases (11%). In this study, the main factor that determines the development of injuries of the upper airway was the time of intubation. The risk groups to develop later lesions of the upper airways include: patients with pathological background, patients with medical admissions, non-neurological patients and patients with serious lesions in the earlier endoscopic exploration. We conclude that it is necessary to state the time to perform a tracheotomy in patients with oro-tracheal intubation. It must be based on the own experience, the patient's clinical condition and the disease that caused hospital admission.

Estudio de los factores que ayudan a la decisión del paso de intubación a traqueotomía en pacientes críticos / Study of the factors that help in the decision making to pass from intubation to tracheotomy in critical patients

Se realiza un análisis prospectivo para determinar los factores favorecedores del desarrollo de lesiones de la vía aérea y su influencia para llevar a cabo una traqueotomía en pacientes críticos. Se definen los tiempos de paso a traqueotomía en función del tipo de paciente (neurológico o no neurológico). Se recogen 654 pacientes consecutivos sometidos durante más de 48 horas a ventilación mecánica a lo largo de un periodo de 6 años. Se establecieron 3 controles endoscópicos durante el primer mes (exploración precoz) y dos posteriores, a los 6 y 12 meses (exploración tardía).Mediante un estudio estadístico multivariado se analizan los factores pronósticos y grupos de riesgo para el desarrollo de lesiones tardías. En la exploración tardía se observaron lesiones en 30/280 casos (11 por ciento). El principal factor influyente en el desarrollo de lesiones fue el tiempo de intubación. El grupo de riesgo de presentar lesiones tardías incluye: presencia de antecedentes patológicos, ingresos médicos, paciente no neurológico y presencia de lesiones graves en el período precoz. Se concluye que es preciso un calendario que defina el momento de pasar a traqueotomía. Este calendario ha de basarse en la propia experiencia, en las condiciones clínicas del paciente y en el tipo de enfermedad que motivó el ingreso. (AU)

We carry out a prospective study in order to determine the prognostic factors in the development of injuries of upper airways, and their influence in the decision to perform a tracheotomy. The time to tracheotomy was previously stated, according to the type of patient (neurological or non-neurological). This study includes the clinical data and the upper airways endoscopic exploration of 654 patients with oro-tracheal intubation and mechanical ventilation for more than 48 hours in a 6 year period. Three endoscopic explorations were carried out in the first month (early exploration), with two additional explorations at six and twelve months (late exploration). Using a multivariable statistical study we have analysed the prognostic factors and the risk groups for the development of later injuries of the upper airway of these patients. The later endoscopic exploration of the upper airways has shown injuries in 30 of 280 cases (11%). In this study, the main factor that determines the development of injuries of the upper airway was the time of intubation. The risk groups to develop later lesions of the upper airways include: patients with pathological background, patients with medical admissions, non-neurological patients and patients with serious lesions in the earlier endoscopic exploration. We conclude that it is necessary to state the time to perform a tracheotomy in patients with oro-tracheal intubation. It must be based on the own experience, the patient's clinical condition and the disease that caused hospital admission (AU)

Co-expression of tenascin-C and vimentin in human breast cancer cells indicates phenotypic transdifferentiation during tumour progression: correlation with histopathological parameters, hormone receptors, and oncoproteins.

Loss of epithelial morphology and the acquisition of mesenchymal characteristics are typical for carcinoma cells in tumour progression. In human breast carcinomas, up-regulation of tenascin-C (TN-C) and vimentin (Vim) is frequently observed in cancer cells and correlates with increased malignancy. Thus, it is possible that TN-C is co-expressed with Vim, representing cancer cells that have undergone epithelial-mesenchymal transition (EMT). This study examined 128 breast carcinomas using immunohistochemical techniques to demonstrate that mammary cancer cells are a prominent source of both TN-C and Vim. Statistical analysis revealed a significant association between TN-C and Vim expression in cancer cells. TN-C expression also correlated positively with overexpression of c-erbB-2 oncoprotein and down-regulation of oestrogen receptors (ERs). Eleven human mammary cancer cell lines and two 'normal' cell lines were examined by western blotting and immunohistochemistry. Co-expression of TN-C and Vim was detected in the carcinosarcoma cell line HS 578T, SK-BR-3 (B), fibroblast-like MDA-MB-231 cells, and the myoepithelial cell line HBL 100. These findings suggest that TN-C and Vim, when co-expressed in mammary carcinoma cells, represent regulator genes likely to be involved in EMT during mammary carcinogenesis.

American women physicians in 2000: a history in progress.

This article surveys major trends in the history of women physicians in American medicine during the 20th century, noting especially factors that have elicited renewed and increasingly public attention during the past two decades. These include the challenges of achieving greater professional visibility while also balancing family and career, of sustaining women physicians' legacy of commitment to women's health and primary care medicine without reinforcing the traditional stereotype that these are the specialties "best suited" to women doctors, and of addressing the need for more ethnic and racial diversity in the medical profession. Other recent developments include the leveling off of the number of women entering medical school and the increasing tendency of both men and women physicians to practice as employees.

[Airway management in ICU patients with mechanical ventilation]. / Mantenimiento de la vía aérea en pacientes de UCI bajo ventilación mecánica.

A prospective protocol for the management of the airway was applied to patients in the ICU. Acute complications due to intubation and tracheotomy as well as laryngo-tracheal lesions were studied in 125 consecutive patients during one year from the moment of extubation. Thirty four cases (27%) needed reintubation, and 58 tracheotomies were performed (46%). The average length of intubation was of 10 +/- 7 days. Sixty five patients (53%) had acute complications due to intubation and 30 (52%) had acute complications due to the traccotomy. The high incidence of laryngo-tracheal lesions in the 85 patients who underwent early exploration (76 cases [90%]) was reduced in those who underwent late exploration (11 cases [20%]). Analysis of possible prognostic factors in the development of late lesions allows us to affirm that a reduction in the length of intubation diminishes the presence of late lesions. We recommend the avoidance of oro-tracheal intubation prolonged for more than 10 days by the early carrying out of tracheotomy.

[Post-mortem study of laryngotracheal lesions produced by prolonged intubation and/or tracheotomy]. / Estudio necrópsico de las lesiones laringotraqueales por intubación prolongada y/o traqueotomía.

Injuries of the laryngotracheal axis caused by prolonged intubation in critically ill patients raise the issue of the timing of tracheotomy in intubated patients. In 1992 a prospective study was begun in intensive care patients with intubation lasting more than 48 hours. Eight months later, post-mortem data on the laryngotracheal axis of deceased patients was added to our prospective study protocol. The study was closed with 125 cases (52 deceased). The clinical data of 73 surviving patients was compared with that of 18 post-mortem cases. The macroscopic results of the post-mortem study are summarized by grading the lesions according to a personal modification of the Lindholm classification. All cases had laryngotracheal injuries. Only 15% of the lesions were located in the tracheal region. Five cases were classified as grade 2, with an average orotracheal intubation of 9 days, 9 cases as grade 3 with 15 days intubation, and 4 cases as grade 4 with 21 days intubation. We concluded that the severity of laryngotracheal injuries in the early post-mortem exploration was related with the duration of intubation.

[Grading system for nasosinusal polyposis treated by functional endoscopic surgery]. / Sistema de estadiaje de la poliposis nasosinusal tratada mediante cirugía endoscópica funcional.

A system for grading nasosinusal polyposis treated by functional endoscopic sinus surgery is needed. We propose our CER system, which was designed for easy use and reliable classification of polyposis involvement. Four levels, from zero to four, are added as suffixes to three letters. These levels indicate increasing intensity and are used to categorize the clinical (C), endoscopic (E) and radiological, (R) grade of polyposis. The same system was used for postoperative follow-up and criteria were established for defining the surgical result as good, average, or poor.

Empathy as a hermeneutic practice.

This essay will argue for the centrality of empathy in the doctor-patient relationship-as a core of ethically sound, responsible therapeutics. By "empathy," I intend an explicitly hermeneutic practice, informed by a reflexive understanding of patient and self. After providing an overview of the history of the concept of empathy in clinical medicine, I discuss current definitions and the use of Balint groups in residency training as a way to develop empathic competence in novice physicians.

Medical history in the undergraduate medical curriculum.

History has long played a role in the education of American physicians, but the uses of medicine's past have changed over time. In the late nineteenth century, some physicians taught medical history to their students to supply a sense of continuity with professional traditions in times of rapid and bewildering change. Other physicians believed that instruction in medical history would impart a sense of refinement to medical practitioners. In the late twentieth century, medical history is increasingly viewed as a significant dimension of the professional, intellectual, and humanistic development of medical students. Further, it is one of the principal means by which recent, radical changes in health care can be given needed perspective. The knowledge that medicine and the medical sciences are fundamentally social enterprises is an important lesson for medical students. Through exposure to the history of health care, students also learn that medical knowledge is itself subject to change and is acquired in specific contexts. In the 1990s, medical history is taught in a variety of settings. In some schools, history is integrated into the teaching of medical humanities. Where medical history is institutionally distinct from the humanities, courses in medical history may be either elective or required. In order to reach students at every stage of their medical education, historians and clinicians can join forces to teach history in innovative and flexible programs.

[Lesions of the laryngotracheal axis due to prolonged intubation and/or tracheotomy. Preliminary data of a follow-up guidelines]. / Lesiones del eje laringotraqueal por intubación prolongada y/o traqueotomía. Datos preliminares de un protocolo de seguimiento.

Lesions caused by prolonged intubation and tracheostomy when performed in critically ill patients to keep the airways opened are a permanent topic of discussion between intensive care professionals and otolaryngologists. We present a prospective study of such complications following the guidelines elaborated by the intensive care unit and the otolaryngology department of our hospital. The outcomes obtained in the first-year follow up allow us to verify a high incidence of such lesions in the initial period (87%) and a markedly decreased frequency in the following twelve months (17%). Results also show the relation between prolonged intubation and the appearance of laryngotracheal lesions. We conclude that it is very important to reduce the intubation period by performing an earlier tracheostomy.

[Synchronous carcinomas of the upper aerodigestive tract: a diagnostic and therapeutic problem]. / Carcinomas sincrónicos de vías aerodigestivas superiores: un problema diagnóstico y terapéutico.

Patients with epithelial cancer of the upper aerodigestive tract are at increased risk of a new epithelial cancer developing in the same upper aerodigestive tract, in the oesophagus, or in the lung. We studied the cases seen at our Hospital in the last seven years. The clinical characteristics, the diagnosis and the treatment of 38 patients with synchronic epithelial cancer of the upper aerodigestive tract, oesophagus and lung, were reviewed.