Pathophysiological changes after traumatic brain injury: comparison of two experimental animal models by means of MRI.

In an experimental study MRI was used to compare the pathophysiological changes of brain tissue after lateral fluid percussion injury (FPI) versus cold injury (CI) as models of traumatic brain injury (TBI). Two groups of Sprague-Dawley rats (n=23) were subjected to mild FPI, respectively, CI localized over the right parietal cortex. MRI was performed at different time points including T1w, T2w and T1w-CE (Gd-DTPA 0.2 mmol/kg BW) sequences as well as perfusion-weighted imaging with calculation of regional cerebral blood volume (rCBV) and regional cerebral blood flow (rCBF). T2w and T1w-CE images showed hyperintense areas in the traumatised cortex demonstrating brain edema and blood-brain barrier (BBB)-breakdown increasing up to 12 h. Perfusion-weighted imaging demonstrated a significant decrease of rCBV and rCBF in the ipsilateral cortex of CI animals compared with the contralateral hemisphere. In contrast, rats of the FPI group showed only slight differences in rCBF and rCBV comparing the left and right cortex. The results of our study confirm that both mild FPI and CI produced focal brain edema with concomitant breakdown of the BBB as a model of TBI. Since differences regarding perfusion are much more pronounced in CI our results suggest that, this model more likely seems to reflect pathophysiological changes of brain ischemia, whereas FPI seems to be better suited to model the pathophysiological characteristics of TBI.

Long-term follow-up of cartilaginous tumors of the larynx.

BACKGROUND: Cartilaginous tumors of the larynx are uncommon. A literature review disclosed approximately 250 cases since 1816; the cricoid cartilage is the most common site. The rarity of these tumors has made for limited experience and, as a consequence, our knowledge is incomplete. OBJECTIVE: To report surgical results as well as long-term follow-up on 6 patients with cartilaginous tumors of the larynx. DESIGN: A 28-year retrospective study with the patients followed-up from 6 to 28 years (average, 17.8 years). METHODS: Six adult white male patients with cartilaginous tumors of the larynx: 4 low-grade chondrosarcoma (1 of the thyroid and 3 of the cricoid) and 2 chondroma of the cricoid. Surgical treatment included total laryngectomy of the thyroid and 1 of the cricoid chondrosarcoma, and conservation surgery of the other 4 cricoid tumors: the 2 patients with chondrosarcoma had total resection of the cricoid cartilage with thyrotracheal anastomosis, and the 2 patients with chondroma had local tumor resection using a laryngofissure approach. RESULTS: The margins of the specimen were negative for tumor in the 6 patients. On follow-up, none of the patients had regional or distant metastasis or tumor-related death. One of the patients with cricoid chondrosarcoma developed recurrence 8 years after conservation surgery, and required a total laryngectomy for salvage. Survival rate tumor-free at 5 years was 100% and at 10 years 67%, co-morbidity being responsible for the decrease in survival rate. CONCLUSIONS: Based on this small series of patients, the long-term follow-up of benign and low-grade malignant tumors suggests that the surgical approach and prognosis does not depend on histologic distinction and, importantly, underdiagnosed malignancy on tumor sampling and recurrent chondrosarcoma, managed with salvage surgery, have no adverse impact on patient survival. Total resection of the cricoid cartilage with thyrotracheal anastomosis over a stent proved an alternative surgical technique in chondrosarcoma who otherwise would have been treated by total laryngectomy.

Changes in regional energy metabolism after closed head injury in the rat.

We examined in the present investigation regional ATP, glucose, and lactate content in the cortical and subcortical structures, in a rat model of closed head injury (CHI). In serial tissue sections bioluminescence imaging of ATP, glucose, and lactate was performed at 4 h, 12 h and 24 h (n = 4/5 per time point with) after the induction of CHI or sham surgery. Bioluminescence images were analyzed by computer-assisted densitometry, at the lesion site, in remote cortical areas, and in the subcortical structures (thalamus and caudate nucleus). ATP content was significantly decreased at the lesion site after 4 h and in the remote cortex at 12 h post-injury. At 12 h, the ATP content reached baseline levels on the ipsilateral side and at 24 h also at remote lateral parietal sites. In the contralateral cortex, ATP increased transiently above the baseline at 12 h. No significant changes in ATP were found in the thalamus and caudate nucleus. Cortical glucose and lactate contents could not be discerned over time. Following CHI there is an acute and progressive, yet transient, ischemic cortical profile, which is not reflected in subcortical areas.

Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis.

OBJECTIVE: To present our experience with endoscopic ligature of the sphenopalatine artery in the treatment of severe posterior epistaxis of patients who had previously undergone conservative procedures. METHODS: Eleven patients with severe posterior epistaxis were treated during a 25-month period with an endoscopic ligature of the sphenopalatine artery. The basic principle of the surgical technique is to identify the branches of the sphenopalatine artery through an endoscopic endonasal approach and to apply a titanium clip under direct vision. RESULTS: The endoscopic ligature of the sphenopalatine artery was performed unilaterally in 10 patients and bilaterally in 1 patient, with a total of 12 ligatures. It was possible to identify the sphenopalatine artery in all cases with a successful outcome using this surgical technique alone. CONCLUSION: Endonasal endoscopic ligature of the sphenopalatine artery has been an effective surgical technique for treating severe posterior epistaxis.

The use of buccal mucosa graft at posterior cricoid splitting for subglottic stenosis repair.

BACKGROUND: Since 1955, when Réthi established the posterior cricoid split augmentation (PCSA) method, several authors have published supporting reports of the validity and proven efficacy of its basic principles. A 27-year prospective, retrospective study. OBJECTIVES: To report on experience in performing the PCSA method for subglottic and/or posterior-glottic stenosis repair using buccal mucosa interposition grafting at posterior cricoid split and stenting for 8 weeks, and to assess the impact on vocal function. METHODS: From 1972 on, 60 patients (45 adults, 15 children, aged 8 mo to 72 y) with subglottic and/or posterior-glottic stenosis were operated on using a modified PCSA method. The surgical technique consisted of posterior cricoid splitting, including or not the interarytenoid muscle; wide lateral retraction of the posterior cricoid halves; buccal mucosa interposition grafting and stenting for 8 weeks. The factors evaluated included the subglottic remodeling rate, donor and recipient sites morbidity, time to decannulation, rate of graft take, and phonatory function tests. RESULTS: The modified PCSA procedure resulted in a decannulation rate of 90%, 18 (30%) of which had further procedure to achieve decannulation, and 6 adult patients (10%) were considered failures because of restenosis. The rate of take of the mucosa graft was 100% in both children and adults, with complete epithelialization of the grafted area, the mucosa not becoming dry and crusty. No interarytenoid muscle division resulted in near-normal to normal glottic voicing. Interarytenoid muscle division determined supraglottic voicing with inspiratory noise and pneumophonic incoordination, breathy and hoarse voice, low fundamental frequency, limited dynamic range, and shortened phonation time. CONCLUSION: The PCSA procedure with buccal mucosa graft is reliable, safe, and highly successful with respect to the graft incorporation and subglottic remodeling. The division or not of the interarytenoid muscle is the most important factor influencing the postoperative vocal function.

Bilateral ethmoidal mucocele in cystic fibrosis: report of a case.

The purpose of this study is to report a rare and interesting case of a 10-month-old boy who presented a bilateral ethmoidal mucocele associated with cystic fibrosis and to discuss, according to the literature, the sinonasal involvement in this disease. Only nine pediatric patients with both disorders have been reported previously in literature, and all of these cases were older than 1 year 4 months and presented with a unilateral mucocele.

Lateral thyrotomy approach on the paraglottic space for laryngocele resection.

OBJECTIVE: To report on the results of using a lateral thyrotomy approach on the paraglottic space to gain greater access for laryngocele resection under direct vision. STUDY DESIGN: A 26-year prospective and retrospective study. The study was conducted on 10 adult patients (5 men and 5 women) who had laryngocele of varying size on the paraglottic space. Six of the patients had internal laryngocele and four had exteriorized laryngocele. Five laryngoceles were left-sided, three were right-sided, and two were bilateral. METHODS: A V-shaped, full-thickness thyroid lamina resection with the triangle base at the superior border and the apex at a point midway of the thyroid lamina vertical extent was performed. RESULTS: A V-shaped lateral thyrotomy made exposure to the paraglottic space possible for direct submucosal laryngocele dissection. This approach has presented no complications to date. Postoperative minor edema or hematoma was found in the aryepiglottic and ventricular folds, but this disappeared within a few days. There was no recurrence; the minimum follow-up was 1 year. CONCLUSION: The triangular lateral thyrotomy approach provided access to the paraglottic space and superb visibility for resection of laryngocele of any size under direct vision, thus avoiding recurrence, morbidity, and complications.

Posterior cricoidotomy lumen augmentation for treatment of subglottic stenosis in children.

OBJECTIVES: To determine the results of posterior cricoidotomy lumen augmentation in the treatment of moderate and severe subglottic stenosis in children, and to assess the effect of this surgery on the growth of the larynx in young children. DESIGN: A 17-year retrospective study. PATIENTS AND METHODS: Thirteen children with moderate and severe subglottic stenosis who underwent posterior cricoidotomy lumen augmentation from 1980 to 1996. Eight children (62%) were male and 5 (38%) were female. The average age was 4.7 years (age range, 8 months to 15 years). Six (46%) of the 13 children were younger than 3 years. Nine children (69%) had acquired subglottic stenosis, 3 of whom had a combined subglottic-posterior glottic stenosis, and 4 (31%) had congenital subglottic stenosis. All the children already had a tracheotomy tube placed and had undergone treatment at our clinic or at other institutions. The surgical procedure we used included a cricoid lamina split with grafting (2 children with costal cartilage graft and 11 with buccal mucosal graft) and stenting. RESULTS: Twelve (92%) of the 13 children underwent decannulation, and 1 (8%) is still undergoing treatment: decannulation is expected to be carried out in the near future. Of the 12 children who underwent decannulation, 9 demonstrated good postoperative voice quality and 3, who had combined subglottic-posterior glottic stenosis, developed impaired voice function. Following stent removal, all children experienced some degree of difficulty in swallowing saliva and liquids, which was soon overcome. No evidence of surgery-induced laryngeal growth impairment in younger children was observed. CONCLUSIONS: The posterior cricoidotomy lumen augmentation is a safe and effective technique for the treatment of moderate and severe subglottic stenosis in children of any age. This study lends further support to the assertion that external surgery does not affect the growth of the larynx in younger children.

Consensus guidelines for the promotion and management of continence by primary health care teams: development, implementation and evaluation. NHS Executive Nursing Directorate.

A project was undertaken as part of the NHS Executive Strategy for Major Clinical Guidelines, involving the development of national clinical guidelines for the promotion and management of continence by primary health care teams, through the process of managed consensus based on scientific review. The guidelines were then implemented at one urban general practice. This article outlines the development and implementation of the guidelines and describes the study undertaken to evaluate the impact of implementation on clinical outcomes. The study involved a pre-and post-implementation postal survey of a random sample of 17% of patients aged 18 years and over from the practice (n = 1503). The pre-implementation survey determined the period prevalence of incontinence, related biological data and data on the pre-implementation management of incontinence. Incontinence sufferers were invited to have their condition assessed or reviewed. All sufferers who agreed to be followed-up were sent the post-implementation survey, which identified those patients who had sought help, and ascertained reasons for not seeking help. Data on the management of incontinence post-implementation were also obtained. Clinical outcomes measured pre- and post-implementation were a validated severity index for urinary incontinence, (also adapted for faecal incontinence) and perception of the incontinence as a problem. A 3-month period was allowed between pre- and post-implementation surveys. The study confirmed previous research which showed that few incontinence sufferers respond to invitations to seek help, and that help-seeking behaviour was significantly related to severity of incontinence. The guidelines did not have any positive impact on the clinical outcomes measured, although slight improvements in approaches taken by the primary health care team to the promotion and management of continence were recorded. However, the study was limited by the small sample size and short time scale. Further evaluation of the impact of the guidelines on these outcomes is therefore recommended.

Antiinflammatory 2-benzyl-4-sulfonyl-4H-isoquinoline-1,3-diones: novel inhibitors of COX-2.

A series of 2-benzyl-4-sulfonyl-4H-isoquinoline-1,3-diones was prepared. Members of this series are potent and selective inhibitors of cyclooxygenase-2 (COX-2) in both microsomal and cellular assays. Two representatives demonstrated activity in the carrageenan-induced paw edema model in rats upon oral administration.