Revision stapes surgery for recurrent transmissional hearing loss after stapedectomy and stapedotomy for otosclerosis.

A total of 20 stapedotomy and 24 stapedectomy cases were retrospectively reviewed to establish the causes of failure, and to evaluate hearing results after revision surgery. Our series included 23 male and 21 female patients. Mean age at revision time was 42 years, and the mean interval from primary surgery and revision stapes surgery was 27 months. The retrospective review of our data, revealed that the most common cause for revision surgery was a displaced prosthesis (47.7%). After revision surgery, the mean post-operative air-bone gap was 14.78 dB. A mean post-operative air-bone gap within 10 dB occurred in 24 patients (54.5%), in 14 patients (31.5%) this was between 11 and 20 dB, in 5 patients (11.5%) between 21 and 30 dB, and in one patient (2.5%) > 30 dB. There were no "dead ears" in this series. Our results compare to other reported series, and confirm that after revision stape surgery, an air-bone gap closure within 10 dB is difficult to obtain. In the present series, the use of the total ossicular replacement prosthesis resulted in the poorest functional hearing results.

Negative pressure ventilation versus conventional mechanical ventilation in the treatment of acute respiratory failure in COPD patients.

This case-control study was aimed to evaluate the effectiveness of negative pressure ventilation (NPV) versus conventional mechanical ventilation (CMV) for the treatment of acute respiratory failure (ARF) in patients with chronic obstructive pulmonary disease (COPD) admitted to a respiratory intermediate intensive care unit (RIICU) and four general intensive care units (ICU). Twenty-six COPD patients in ARF admitted in 1994-95 to RIICU and treated with NPV (cases) were matched according to age (+/-5 yrs), sex, causes triggering ARF, Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/- 5 points), pH (+/-0.05) and arterial carbon dioxide tension (Pa,CO2) on admission with 26 patients admitted to ICU and treated with CMV (controls). The primary end points of the study were inhospital death for both groups and the need for endotracheal intubation for cases. The secondary endpoints were length and complications of mechanical ventilation and length of hospital stay. The effectiveness of matching was 91%. Mortality rate was 23% for cases and 27% for controls (NS), five cases needed endotracheal intubation, four of whom subsequently died. The duration of ventilation in survivors was significantly lower in cases than in controls, with a median of 16 h (range 2-111) versus 96 h (range 12-336) (P<0.02), whereas the length of hospital stay was similar in the two groups, with a median of 12 days (range 2-47) for cases vs 12 days (range 3-43) (NS) for controls. No complications were observed in cases, whereas three controls developed infective complications. These results suggest that negative pressure ventilation is as efficacious as conventional mechanical ventilation for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease and that it is associated with a shorter duration of ventilation and a similar length of hospital stay compared with conventional mechanical ventilation.

Continuous infusion of vancomycin in methicillin-resistant staphylococcus infection.

OBJECTIVE: The aim of the study was to verify the therapeutic response of vancomycin in methicillin-resistant staphylococcus infection (MRSA/ MRCNS) administered according to two different methods (intermittent infusion vs. continuous infusion). METHOD: Experimental plan: retrospective study; study environment: university hospital, two intensive care units. Twenty-five critically ill patients submitted to antibiotic treatment with vancomycin for infection from MRSA/MRCNS were studied. The patients, who were classified according to SAPS II scores, were divided into two groups: group A (n = 14): dose of vancomycin of 0.5 g x 4/day and group B (n = 11): dose of 2 g/day of vancomycin administered in a continuous infusion. Before the antibiotic therapy was started (T1) and prior to its end (T2), the following parameters were evaluated: degree of impairment of the main organs and systems by means of sepsis-related organ failure assessment score (SOFA) and count of the white blood cells (WBC). The length of the hospital stay during intensive care was calculated for both groups (statistics: Student t test). RESULTS: No significant differences were found in the SAPS II scores and in the length of the hospital stay. In a comparison of the T1 and T2 results, we noted that patients of group A had no variations in the SOFA scores (4.84 +/- 2.48 vs. 4 +/- 3.9) and in the WBC mean values (12,415 +/- 5,099 vs. 12,841 +/- 6,864 cells/mm3). In contrast, in the patients of group B, we noted significant variations (p < 0.05) in the mean values of the SOFA scores (6.62 +/- 2.2 vs. 4.37 +/- 3.5) and in the mean values relative to the WBC count (17,242 +/- 12,842 vs. 10,757 +/- 3,610 cells/mm3). CONCLUSIONS: In critically ill patients suffering from MRSA/MRCNS infection, vancomycin administration in continuous infusions improved organ function and leukocyte response, but did not seem to modify the overall evolution of the disease.

Colon adenocarcinoma metastatic to the larynx.

Secondary neoplasms of the larynx are rare and account for 0.09 to 0.4% of all laryngeal tumors. These tumors can occur by hematogenous or lymphogenous spread and may represent a diagnostic dilemma when the laryngeal localization is the only manifestation of disease. When multiple metastases are present, the appropriate treatment becomes even more controversial. To our knowledge only 148 cases of metastatic laryngeal neoplasms have been reported in the literature, with cutaneous melanomas and carcinomas from the kidney representing the most frequent primary sites of origin. Our research of the available literature has shown that only nine cases of metastases from colon adenocarcinomas have been described. In general, the overall prognosis of patients with a secondary laryngeal tumor is poor, since involvement of the larynx by a distant tumor commonly occurs in the terminal phase of the primary disease process. As such, the aim of treatment frequently is only to improve the quality of life of the patient. We report a case of colon adenocarcinoma metastatic to the larynx and discuss the problems related to its pathogenesis, diagnosis and treatment.

[Evaluation of total and inflated lung volumes by a quantitative study using computerized tomography in patients with acute noncardiogenic pulmonary edema (ARDS)]. / Valutazione dei volumi polmonari totali e aereati mediante lo studio quantitativo con tomografia computerizzata nei pazienti con edema polmonare acuto non cardiogeno (ARDS).

Our study was aimed at developing a method to assess lung volumes and relative percentages of well-inflated lung parenchyma in Adult Respiratory Distress Syndrome (ARDS) patients by processing conventional CT examinations of the lung and at investigating the prognostic value of CT findings. Fourteen patients (5 women and 9 men, age range: 35-79 years) admitted to the intensive care unit January, 1992, to June, 1994, because of severe ARDS, and with lung injury scores exceeding 2.5, were submitted to CT. A homologous group of 14 patients matched for sex and age and with normal lungs was examined as a control group to investigate the accuracy of our method. Two examinations were obtained in 7 of 14 ARDS patients; the trend of lung volumes and of the relative rates of well-inflated parenchyma could thus be calculated. During the examination, we maintained in all ARDS patients the same ventilatory pattern used in the intensive care unit. Consequently, in 18/21 examinations scans and respiratory phases were not correlated. In the control group no statistically significant differences were observed between the scans obtained with (inspiratory apnea) and without coordination with the respiratory phase. As for lung volumes, our results in normal subjects showed a good correlation with normal spirometric data. In ARDS patients lung volumes, although reduced, did not correlate with prognosis. As for the percentage of well-inflated parenchyma in ARDS patients, we observed a good correlation with prognosis in the patients submitted to two examinations and, in all patients, a good correlation with D(A-a)O2 index (p < 0.05), PaO2/FiO2 index (p < 0.005) and with the rate of arteriovenous shunt (p < 0.001). In conclusion, our results show that CT of the lung is a reliable and repeatable method for the functional assessment of the lung in ARDS patients.

[Use of a new type of permanent caval filter in a case of recurrent pulmonary embolism]. / Utilizzazione di un nuovo tipo di filtro cavale definitivo in un caso di embolia polmonare recidivante.

We describe a case of postoperative recurrent pulmonary embolism, treated with a percutaneous caval filter ("Double hooks DF 06-Filcard"), that was useful for stemming the tide of venous thromboembolism starting from right leg deep venous thrombosis. We discuss diagnostic protocols, current indications to caval filtration, and the characteristic of an ideal caval filter.

[A review technique: the interscalene brachial plexus block in orthopedic surgery (author's transl)]. / Una tecnica revisitata: il blocco del plesso brachiale per via interscalenica negli interventi di chirurgia ortopedica.

The paper is dedicated to the description of a technique now new but also not very used, of regional anesthesia, indicated for surgery of upper limbs: the interscalene brachial plexus block. In Author's experience this type of anesthesia has many indications, related especially to orthopedic and traumatologic surgery, in patients with high anesthesiologic danger. This type of regional anesthesia by interscalene technique is, in Author's opinion, much better than the axillar technique, now moore frequently used.