Preoperative MRI for oral tongue squamous cell carcinoma: timing and correlation to histopathology.

Magnetic resonance imaging (MRI) is an integral part of the evaluation of local and regional disease in tongue squamous cell carcinoma prior to surgery. The aim of this study was to evaluate the accuracy of MRI in assessing tumour dimensions, as well as the impact of the time-lag from diagnostic biopsy on the accuracy of MRI. The medical records of 64 patients with tongue carcinoma were reviewed retrospectively. Tumour maximum diameter and tumour depth of invasion were compared between pathology and MRI (T1- and T2-weighted). MRI-derived maximum tumour diameter and depth of invasion correlated strongly with histopathology: T1-weighted (r = 0.700 and r = 0.813, respectively) and T2-weighted (r = 0.734 and r = 0.834, respectively). A significant correlation was found between measurements on T1 and T2 MRI for both parameters (P = 0.955 and P = 0.984, respectively). The accuracy rate of MRI for T-staging of early tumours was low: 10% for T1 tumours; 39.3% for T2 tumours. A time-lag of less than 2 weeks between the diagnostic biopsy and MRI adversely affected the correlation of tumour dimensions. MRI is a reliable tool for evaluating tongue carcinoma; however, it overestimates early tumours. A 2-week delay after diagnostic biopsy is desired before completing an MRI. Alternatively, if logistics allow, a pre-biopsy MRI is preferred, especially for T1-T2 tumours.

Repair of frontal sinus fractures: clinical and radiological long-term outcomes.

OBJECTIVE: The long-term clinical and radiological outcomes of patients surgically treated for frontal sinus fracture were assessed. METHODS: A retrospective, single-centre analysis was conducted of patients treated for frontal sinus fracture in a tertiary trauma centre between 2000 and 2017. Patients who underwent surgical repair for frontal sinus fracture followed by clinical and radiographical evaluation for at least six months were included. RESULTS: Of 338 patients admitted with frontal sinus fracture, 77 were treated surgically. Thirty patients met the inclusion criteria for long-term follow-up. The average follow-up duration was 37 months (range, 6-132 months). Reconstruction, obliteration and cranialisation of the frontal sinus fracture were performed in 14, 9 and 7 patients, respectively. Two patients with a reconstructed frontal sinus and one with an obliterated frontal sinus developed mucoceles. One patient developed forehead disfigurement following obliteration. CONCLUSION: Long-term complications of frontal sinus repair using the chosen repair techniques are rare, but patients need to be made aware of these potential complications.

Closed-suction compared with Penrose drainage after free flap reconstruction in the head and neck.

Microsurgical free flaps are common in head and neck reconstruction, and their techniques and outcomes have continuously improved during the past decades. However, there are variations in practice among surgeons between the use of closed-suction drainage systems and Penrose drains. The proponents of Penrose drains propose that the negative pressure generated by the closed-suction drainage system may harm the microvascular anastomosis. We know of no previous studies that have compared the two drains for microvascular free flap reconstruction, so our aim was to compare them in a single-centre, retrospective review of all patients who had microvascular free flap reconstruction of the head and neck region in our department between 1 November 2010 and 1 September 2017. During this period 84 patients had 87 free flap reconstructions in the head and neck, 43 of which had Penrose, and 44 closed-suction, drainage. We compared the number of complications between the groups including haematomas, seromas, wound infections, anastomostic thrombosis, anastomotic revision, and need for re-exploration. There were no significant differences between the groups, despite a trend toward fewer negative explorations in the closed-suction group. There were no differences in complications between suction and passive drainage systems after microvascular free flaps, which suggests that closed suction drainage could be safely used after free flap reconstruction in the head and neck.

The use of fluorescence lifetime technology in benign and malignant thyroid tissues.

OBJECTIVE: To explore the use of fluorescence lifetime imaging microscopy in thyroid tissues, and to investigate how different thyroid lesions affect fluorescence lifetime. METHOD: Fluorescence lifetime measurements were taken of fresh frozen thyroid surgical specimens stained with fluorescein isothiocyanate tagged anti-thyroglobulin monoclonal antibodies. RESULTS: The mean fluorescence lifetime measurements in 12 patients - 3 with multinodular goitre, 4 with follicular adenoma, 4 with papillary thyroid carcinoma and 1 with follicular carcinoma - were 3.16 ns (range, 2.66-3.52 ns), 3.75 ns (range, 2.99-4.57 ns), 2.97 ns (range, 2.57-3.21 ns) and 3.61 ns, respectively. The fluorescence lifetime of follicular adenoma patients was higher than that of papillary thyroid carcinoma patients by 26 per cent (p = 0.058). The fluorescence lifetime in the follicular carcinoma patient was similar to the follicular adenoma group, but higher than in the papillary thyroid carcinoma group by 22 per cent (p = 0.01). CONCLUSION: Fluorescence lifetime measurements varied in different thyroid pathologies, possibly because of tissue-scale structural influences.

Prognostic value of lymph node ratio in metastatic papillary thyroid carcinoma.

OBJECTIVE: Cervical metastases in papillary thyroid carcinoma are associated with increased recurrence. However, their effect on survival remains controversial. This study evaluated literature on the prognostic value of lymph node ratio for loco-regional recurrence and survival in metastatic papillary thyroid carcinoma. METHODS: The PubMed database was systematically searched using the terms 'papillary thyroid carcinoma' and 'lymph node ratio'. Articles addressing the association between lymph node ratio and loco-regional recurrence or survival were identified. RESULTS: Nine retrospective studies were included, comprising 12 400 post-thyroidectomy and neck dissection papillary thyroid carcinoma patients (median age, 48.6 years; 76 per cent females). Lymph node ratio was associated with worse recurrence-free survival in 60 and 75 per cent of studies investigating the effect of central compartment metastases and both central and lateral compartment metastases on recurrence-free survival, respectively. One large population-based study showed an association between lymph node ratio and disease-specific mortality in N1 nodal disease, but failed to maintain the same association when N1b patients were excluded. CONCLUSION: Regional lymph node ratio is an independent predictor for loco-regional recurrence in pathologically staged N1 patients with papillary thyroid carcinoma. Patients with a high lymph node ratio should be closely followed up.

The significance of Computed Tomography in invasive paranasal mucormycosis.

INTRODUCTION: Early diagnosis of acute invasive fungal rhinosinusitis (AIFR) is crucial for patients prognosis and may reduce the extent of surgical debridement. Initial evaluation usually includes paranasal Computed Tomography (CT), with an emphasis on bony erosion which is considered a specific but insensitive radiologic sign. Most studies made no distinction between Aspergillus and Mucor species while addressing CT findings. In this study, we seek to evaluate whether bony erosion on paranasal CT is a significant and reliable finding in the initial evaluation of invasive paranasal mucormycosis. METHODS: A retrospective review of pre-operative non-contrast craniofacial CT scans of patients diagnosed with acute invasive fungal rhinosinusitis (AIFR) caused by Mucor species for the presence of bony erosion. RESULTS: A total of 13 patients (9 males, 4 females) were included. Twelve patients were immunosuppressed due to various hematological malignancies. Six patients underwent debridement due to gross intraoperative findings of bony fungal invasion, but only one patient had evidence of bony erosion on the pre operative paranasal CT. CONCLUSION: Bony erosion on paranasal CT is an exceptionally insensitive radiologic sign for establishing or rejecting the diagnosis of Mucor induced AIFR. The mainstay of confirming or rejecting the diagnosis of AIFR is by physical examination, endoscopy and oriented biopsy of suspicious mucosal lesions.

Hearing threshold shifts among military pilots of the Israeli Air Force.

BACKGROUND: Military aviators are potentially at risk for developing noise-induced hearing loss. Whether ambient aircraft noise exposure causes hearing deficit beyond the changes attributed to natural ageing is debated. The aim of this research was to assess changes in hearing thresholds of Israeli Air Force (IAF) pilots over 20 years of military service and identify potential risk factors for hearing loss. METHODS: A retrospective cohort analysis was conducted of pure-tone air conduction audiograms of pilots, from their recruitment at 18 years of age until the last documented medical check-up. Mean hearing thresholds were analysed in relation to age, total flight hours and aircraft platform. Comparisons were made to the hearing thresholds of air traffic controllers (ATCs) who were not exposed to the noise generated by aircraft while on duty. RESULTS: One hundred and sixty-three pilots were included, with flying platforms ranging from fighter jets (n=54), combat helicopters (n=27), transport helicopters (n=52) and transport aircraft (n=30). These were compared with the results from 17 ATCs. A marked notch in the frequency range of 4-6 kHz was demonstrated in the mean audiograms of all platforms pilots, progressing with ageing. Hearing threshold shifts in relation to measurements at recruitment were first noted at the age of 30 years, particularly at 4 kHz (mean shift of 2.97 dB, p=0.001). There was no statistical association between flying variables and hearing thresholds adjusted for age by logistic regression analysis. CONCLUSIONS: The audiometric profile of IAF pilots has a pattern compatible with noise exposure, as reflected by characteristic noise notch. However, no flight variable was associated with deterioration of hearing thresholds, and no significant difference from non-flying controls (ATCs) was seen.

Predicting outcome in tracheal and cricotracheal segmental resection.

The aim of this study was to analyze prognostic factors of successful tracheal and cricotracheal segmental resection (TR/CTR), the type of revisions performed in cases of failure, and the outcome of revisions. The study is designed as case series with chart review. Between 1995 and 2011, 122 adult patients underwent TR/CTR. Forty-six patients (38 %) had concomitant airway pathologies and 59 patients (48 %) failed previous interventions. Forty-six patients (38 %) were aphonic with a complete obstruction. Cricotracheal, tracheotracheal, and thyrotracheal anastomosis was performed in 78 (64 %), 24 (20 %) and 20 (16 %) patients, respectively. Subglottic involvement, higher grade of obstruction, preoperative tracheostomy, presence of any concomitant airway pathology and impaired vocal cord movement were all associated with poorer outcome. Initially, 85 patients (68 %) achieved primary goal with no need for further intervention. Thirty-six patients underwent one or more revision surgeries (laser, dilatation, tracheostomy, stent or T-tube, laryngoplasty, segmental resection, posterior cordotomy) with a success rate of 69 %. Overall success rate, after revisions, was 88.5 %. Segmental tracheal resection for tracheal stenosis is highly successful in non-tracheotomized, cricoid sparing incomplete tracheal stenosis patients, without secondary airway pathologies. Initial failures of TR/CTR can be managed with revision surgery.

Are young adults with special needs ready for the physical work demands?

Youth and Adolescents with Special Needs (YASN) face many challenges during transition into employment. Although most of their physical challenges are secondary, yet they call for attention since most of them are hired for blue collar jobs. Functional Capacity Evaluation (FCE) should be adapted to prepare them addressing the physical job-demands, and maintain their jobs effectively and safely. The current pilot study aims to demonstrate the use of standard (FCE) in order to assess performance of basic generic physical activities conducted by YASN, as part of transition to work program. Specifically, it compared subtests of the Physical Work Performance Evaluation of YASN (N = 13) with matched control group (YA) (N = 13). Results revealed slower and reduced performance among YASNs than YA, in basic job demands, like dynamic strength, hand strength, and fine motor skills. Implications and recommendations for research and transition to work practice in the educational setting are discussed.

[Controlled release hydromorphone for visceral, somatic and neuropathic pain]. / Retardiertes Hydromorphon bei viszeralen, somatischen und neuropathischen Schmerzen.

The aim of this multicentre, longitudinal investigation was to document the efficacy and tolerability profiles of controlled release hydromorphone in patients with heavy visceral, somatic or neuropathic pain under practical conditions. To this end, a prospective observational study was conducted in 57 centres in Switzerland, on a total of 196 patients. After an average of 43 days of treatment with controlled release hydromorphone, the intensity of momentary pain dropped by 46.5% and that of maximum pain dropped by 41.3%, with the efficacy of the treatment being most pronounced with visceral and somatic pain. At the same time, the prevalence of sleep disorders as a result of pain decreased from initially 86.7% to 21.0%. Controlled release hydromorphone was excellently tolerated in this group of elderly (average age 70.6 years), multimorbid pain patients receiving various medical treatments (average of 2.4 drugs in addition to pain medication), even in the voluntary long-term extension study of up to 96 days. No medical interactions were reported. Six and thirteen weeks after introducing the treatment, 89.8% and 85.2%, respectively, were still taking controlled release hydromorphone. Controlled release hydromorphone is a recommendable option for practical treatment of heavy and extremely heavy pain of various genesis.

Post-operative epidural versus intravenous patient-controlled analgesia.

Patient-controlled analgesia techniques have opened a new dimension to individualize patient's need for analgesia, in the treatment of acute post-operative pain. These techniques can be used intravenously, in the epidural space, and into peripheral nerve sheets. There is a common consensus that intravenous patient-controlled analgesia should not have a continuous infusion while epidural patient-controlled analgesia (PCEA) should be programmed with a continuous infusion. The drugs used for epidural analgesia are: opioids, local anaesthetics or the combination of both. The combinations seem to provide better pain relief and less side effects. The continuous epidural infusion of opioids has the advantages of fewer fluctuations in cerebrospinal fluid concentrations of drug, but it is necessary to administer a loading bolus, to overcome the fact that it takes several hours to provide adequate analgesia. The advantages of epidural versus intravenous patient-controlled analgesia are represented by better analgesia and a reduced opioids requirement, while the advantages when compared to epidural continuous infusion are: increased efficiency, self-adjustment by the patient, higher patient satisfaction, less sedation, and lower opioids dosage. The clinical advantages of PCEA may outweigh the greater cost and invasiveness of this technique.

[Operating room management]. / Operationssaal- Management.

The changing health care climate has triggered important changes in the management of high cost components of acute care facilities. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated as one would a manufacturing process. All steps involved in producing the end result can and should be analyzed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide is crucial to the success of this undertaking. The role of the anesthesiologist in the management of the operating room setting (OR) has gained broad acceptance because: a) it contributes to the effort of a larger team process; b) the anesthesiologist ordinarily practices in the OR setting; and c) the anesthesiologist can view the priorities of the OR in an unbiased manner. Many of the successful concepts in managing an OR are just common sense. The single best opportunity for dramatic improvement in effective resource use in Surgical Services lies in the perioperative process. The management strategy must focus on process-measurement using information technology and feedback implementing modern quality management tools. The impact of new treatments, drugs, devices and process changes can be assessed rationally.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996.

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

Measurement of intraocular pressure during laparoscopy and its relationship to central venous pressure.

UNLABELLED: STUDY OBJECTIVE. To determine the effect of different positional degrees on hemodynamics, especially central venous pressure and intraocular pressure, and a possible interrelationship, during laparoscopic surgery. SETTING. University teaching hospital (Canadian Task Force classification II-1). PATIENTS: Seven women undergoing elective gynecologic laparoscopy. INTERVENTIONS: The women were monitored for heart rate, partial pressure of oxygen, end-tidal carbon dioxide, arterial blood pressure, central venous pressure, end-tidal isoflurane concentration, and intraocular pressure in several body positions during general anesthesia. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure depends on body position (r2 = 0.58) related to central venous pressure (r2 = 0.7). Heart rate and arterial blood pressure are also dependent on the body position, but to a lesser degree. CONCLUSION: Continuous monitoring of intraocular pressure may help detect alterations in central venous pressure during general anesthesia for laparoscopic surgery. Undesirable alterations caused by degree of Trendelenburg position may negatively affect patients with high cardiac or ophthalmic risk.

[Opioids in treatment of chronic noncancer pain]. / Opioide zur Behandlung chronischer Nicht-Karzinomschmerzen.

Opioids have been accepted as appropriate analgesic treatment for pain associated with cancer. However, controversy exists about their use for chronic noncancer pain. Reasons for reluctance are concerned about efficacy and potential adverse effects such as respiratory depression, addiction, physical dependence or intolerance. Many physicians worry about liability and legal restrictions. Nevertheless, pain management of chronic severe pain with opioids can be the only help when alternative methods are too risky of fail to be effective. This article briefly reviews the published literature on this topic and discusses some practical guidelines for the use of opioids in the treatment of non-cancer pain.

Tropisetron for treating established postoperative nausea and vomiting: a randomized, double-blind, placebo-controlled study.

UNLABELLED: Tropisetron can prevent postoperative nausea and vomiting (PONV) at doses smaller than those used to control chemotherapy-induced nausea and vomiting. In this placebo-controlled study, the efficacy and tolerability of three different doses of tropisetron were compared for the treatment of established PONV after surgical procedures in general anesthesia. Of 1513 patients who satisfied inclusion criteria, 314 experiencing PONV during the first 2 h after recovery from anesthesia were treated with one of three different doses of tropisetron (0.5, 2, or 5 mg) or placebo, administered i.v. as a single dose. Patients were then observed during 24 h for efficacy and tolerability. All three doses of tropisetron were significantly better than placebo in controlling emetic episodes and in reducing the need for rescue treatment. There were no significant differences among the three doses. However, in the subgroup of patients who had previous PONV, and in those randomized for nausea alone, the 2-mg and 5-mg doses controlled emetic episodes better than the 0.5-mg dose. All studied doses of tropisetron were well tolerated and did not affect vital signs. We conclude that a single i.v. administration of tropiestron significantly reduces the recurrence of emetic episodes in patients with established PONV after elective surgery with general anesthesia. Its optimal dose seems to be 2 mg. IMPLICATIONS: Three hundred-fourteen patients suffering from postoperative nausea and vomiting received different i.v. doses of a new antiemetic drug, tropisetron, to determine the lowest effective dose. We found that a single i.v. administration of tropisetron significantly reduced postoperative nausea and vomiting after elective surgery with general anesthesia.