Ultrasound imaging in the preoperative estimation of the size of tracheostomy tube required in specialised operations in children

BACKGROUND

Some children are dependent on a tracheostomy for many years. As they grow, larger tracheostomy tubes may be required. Although tables of sizes of tracheas exist for different age groups, they are estimations of normal and may not be accurate for atypical cases. Chest radiographs and computed tomograms (CT) have been used experimentally to estimate tracheal sizes, but are not in regular use.

METHOD

High-resolution diagnostic ultrasound imaging was used to estimate the internal and external transverse tracheal diameter, and the depth of the trachea from the skin surface. This allowed selection of the correct standard pattern tracheostomy tube, or the construction of a custom-made tube preoperatively.

RESULTS

Four children with various abnormalities who were being considered for replacement tracheostomies were scanned. In one, diagnostic ultrasound confirmed that a new larger fenestrated tube could be placed, which subsequently improved vocalisation and respiration. In the other three, the scan showed there was no space to allow a larger tube to be placed. The standard tables were not suitable for any of these patients.

CONCLUSION

High-resolution ultrasound has a role in the non-invasive measurement of the size of the tube needed for specialised operations in children.

A new approach using intraoperative ultrasound imaging for the localization and removal of multiple foreign bodies in the neck

An innovative method of using ultrasound imaging intraoperatively is reported. Multiple radiopaque and radiolucent foreign bodies within soft tissues were localized in theatre using high resolution ultrasonography. Depth of injury and vessel status were also ultrasonically assessed. Surgical removal of all foreign bodies was aided by intraoperative ultrasound guidance. In addition, this new approach of using intraoperative ultrasonography was pivotal in confirming the removal of all foreign bodies from the wound at the time of the operation.

Decreased access to health care and social isolation among young adults with cerebral palsy after leaving school

OBJECTIVE

To examine if leaving special schools has a negative impact on the health care and social isolation of young adults with cerebral palsy.

METHODS

Young adults with cerebral palsy, aged between 15 and 22 years, were divided into 2 cohorts: current students, who were still receiving services from special schools, and school-leavers, who had since been discharged from care. A questionnaire and physical examination were administered to assess the extent of disability, health care received by, and social isolation of these young adults.

RESULTS

School-leavers had a greater degree of dissability than did students, although the results were not statistically significant. Health care exposure to specialists, general practitioners, therapists physiotherapists, occupational therapists, and/or speech therapists), and medical social workers decreased after leaving school; with the exception of contact with general practitioners, these results were significant (p<0.05). The entire cohort was more socially isolated than a control cohort. School-leavers participated in fewer activities outside their homes, but showed less concern about their disability than did current students.

CONCLUSIONS

Young adults with cerebral palsy continue to have health care and lifestyle needs after leaving school, which are currently not being adequately met.

Interpretation of skull radiographs for facial fractures by medical staff working in UK emergency departments: a pilot study

OBJECTIVES

This was a pilot study to determine the ability of hospital doctors (1) to assess the technical quality of occipitomental (OM) radiographs and (2) to identify facial fractures.

METHOD

Twenty-two doctors from four UK Accident and Emergency (A&E) departments participated in a two part study: Part A was a postal questionnaire containing questions on demographic data, educational background, selection criteria, assessing radiographs and radiation protection; and Part B was a clinical viewing session to interpret 20 randomized OM radiographs divided into four groups; technically good and poor without fractures, and technically good and poor with fractures.

RESULTS

Study participants ranged from junior house officers to senior consultants. There was considerable variation in educational background and radiographic interpretation instruction at undergraduate and postgraduate level. OM radiographs constituted 10% of all skull radiographs examined per week, yet only 40% of the doctors felt confident when assessing technical quality. The majority of participants had only a limited knowledge of radiation protection legislation. During the viewing session, only 50% of the participants correctly identified those radiographs with fractures and those with technique errors. There was no significant difference between house officers and other grades of staff. A higher level of seniority did not equate with greater interpretative ability. Subjective confidence in assessing film quality did not correlate with the actual film viewing.

CONCLUSION

Only half of the A&E doctors taking part in the study were able to correctly assess film quality and identify facial fractures on OM radiographs. If the pilot sample is representative, then the findings are of considerable concern.

Development and applications of injectable poly(ortho esters) for pain control and periodontal treatment

Poly(ortho esters) with a low glass transition temperature are semi-solid materials so that therapeutic agents can be incorporated at room temperature, without the use of solvents, by a simple mixing procedure. When molecular weights are limited to < 5 kDa, such materials are directly injectable using a needle size no larger than 22 gauge. Somewhat hydrophilic polymers can be produced by using the diketene acetal 3,9-diethylidene-2,4,8,10-tetraoxaspiro[5.5]undecane and triethylene glycol (TEG), while hydrophobic materials can be produced by using the diketene acetal and 1,10-decanediol. Molecular weight can be reproducibly controlled by using an excess of the diol, or by use of an alcohol that acts as a chain-stopper. Erosion rates can be controlled by varying the amount of latent acid incorporated into the polymer backbone. Toxicology studies using the TEG polymer have been completed and have shown that the polymer is non-toxic. Toxicology studies using the decanediol polymer are underway. Development studies using the TEG polymer aimed at providing a sustained delivery of an analgesic agent to control post-surgical pain are under development and human clinical trials using the decanediol polymer for the treatment of periodontitis are also underway.

A retrospective survey of attitudes toward acceptance of peritoneal dialysis in Chinese end-stage renal failure patients in Hong Kong--from a cultural point of view

OBJECTIVE

We undertook to study the attitudes toward dialysis of patients approaching end-stage renal failure and to analyze those attitudes from a cultural perspective.

SETTING

The study was performed in the pre-dialysis clinic of a tertiary referral renal center.

PATIENTS

All patients of Chinese ethnic origin seen in the pre-dialysis clinic from 1995 to 2000 for assessment of dialysis therapy were included.

METHOD

We performed a retrospective analysis of patient records with regard to attitudes of the patients toward dialysis, reasons for those attitudes, and factors that could lead to a subsequent change in attitude.

RESULTS

We assessed 462 patients over the 6-year period. Their mean age was 65.5 +/- 13.3 years, and 43.9% of the patients had diabetes. Peritoneal dialysis (PD) was offered to 74% of the patients, and hemodialysis (HD) to 3.9%. Among the patients offered PD, only 44% accepted dialysis. After counselling, 54% of the patients who originally declined PD ultimately accepted it. The major reasons for refusing PD were the ideas of "having lived long enough" and "lack of family support." Most other reasons could be overcome by counselling. Only a minority of patients demanded hemodialysis.

CONCLUSIONS

Declining an offer of dialysis was common. Counselling helped patients to accept PD. Certain cultural elements that hindered acceptance of dialysis were involved in the ideas of "having lived long enough" and "lack of family support." Those cultural elements should be tackled more specifically during counselling.

Intraoperative ultrasound imaging to aid abscess drainage--a technical note

Diagnostic ultrasound is used widely to identify the presence of fluid collections preoperatively. Although its role in other parts of the body is well established, this report describes the technique of using diagnostic ultrasound intraoperatively to aid drainage of a large fascial space abscess in the head and neck. Following previously inadequate drainage of a large superficial abscess from a blindly placed drain, a second procedure was carried out, using ultrasound imaging to locate the persisting abscess. Furthermore, ultrasound demonstrated the adequacy of drainage and helped the surgeon to position the drain in the correct tissue space. We consider that intraoperative use of ultrasound has a role as a guidance tool to drain superficial fascial space abscesses in the head and neck region.

Immune mediated chorea encephalopathy syndrome in childhood

We report four previously healthy female children, aged between 3 and 8 years, who presented with encephalopathy and an extrapyramidal movement disorder (chorea n=4, rigidity n=2, oculogyric crisis n=2). In addition, an acute behavioural disturbance occurred in two patients and mutism in two others. Seizures heralded the onset of the illness in three patients. Acute MRI was either normal or initially normal with later generalized cerebral atrophy. All infective (including streptococcus), biochemical, and metabolic investigations were normal, although all four patients had oligoclonal bands in the (CSF) but not the serum, indicating intrathecal immunoglobulin synthesis. All four children made an apparently full recovery within four months of the onset. We suggest that these patients represent an immune-mediated movement disorder and encephalopathy syndrome.

Intraoperative ultrasound-guided retrieval of an airgun pellet from the tongue: a case report

Real-time intraoperative ultrasonography was used to detect and facilitate removal of an airgun pellet from the tongue of a 14-year-old boy. Diagnostic ultrasound was crucial in clarifying the positional relation between the foreign body and the instrument used, enabling safe, precise and rapid retrieval during a potentially hazardous surgical operation.

Ultrasound features of osteosarcoma of the mandible--a first report

Ultrasound imaging is becoming widely used in the head and neck region as a first-line investigation to assess soft tissue swellings. Clinicians should be aware of the potential of diagnostic ultrasound to identify important signs of malignant disease involving bone. Involvement of the mandible by osteosarcoma is uncommon. A young adult patient presented with facial swelling and an apparently infected lower third molar extraction socket. Subtle signs were missed on dental radiographs. Diagnostic ultrasound investigation was pivotal in identifying sinister signs: namely, soft tissue mass associated with bone thinning, erosion, expansion, and the "sunray" appearance of the buccal cortex, which were suggestive of osteosarcoma. These findings enabled priority to be given to subsequent investigations using other modalities. We present a first report of the ultrasound features of osteosarcoma of the mandible and consider this to be a useful modality in an initial investigation.

Metachronous bilateral primary adenocarcinoma of the submandibular glands

A young woman developed an unusual adenocarcinoma in each submandibular salivary gland at an interval of 30 months. This presentation has not been described previously. The possible etiology for this and treatment options are discussed. The choice of diagnostic imaging (ultrasound versus magnetic resonance imaging) is highlighted. As a result of regular follow-ups using diagnostic ultrasound, a second tumor was observed to reach a dimension of 8 mm in less than 6 months. This is probably the first report documenting the extent of initial growth of this rare tumor.

Release of BSA from poly(ortho ester) extruded thin strands

A solventless procedure was used where powdered polymer and micronized protein were intimately mixed and then extruded into 1 mm strands that were cut to the desired length. The polymers used were poly(ortho esters) specifically designed to allow extrusion in the neighborhood of 70 degrees C. At these temperatures many proteins maintain activity in the dry state. In vitro erosion and BSA release results indicate that after a fairly long lag-time, BSA release and polymer erosion occur concomitantly indicating an erosion-controlled process. The lag-time could be eliminated by the addition to the mixture prior to extrusion between 1 and 5 wt% poly(ethylene glycol) or its methoxy derivatives. The lag-time could also be eliminated by using an AB-block copolymer where A is poly(ortho ester) and B is poly(ethylene glycol).

Ultrasound-guided retrieval of labial minor salivary gland sialoliths

We report a case of minor salivary gland sialolithiasis presenting as acute, painful swelling of the upper lip. Conventional, unguided, incision and drainage removed three of the sialoliths. Diagnostic ultrasound identified two further sialoliths which were successfully removed with real-time, ultrasound-guided, needle localization. This technique of sialolith retrieval has not been previously reported.

Poly(ortho esters) - their development and some recent applications

Poly(ortho esters) have been under development since the early 1970s and four families of such polymers have been described. Of most interest are poly(ortho ester) III and poly(ortho ester) IV. Poly(ortho ester) III is a semisolid material that has been shown to be highly biocompatible and is currently being investigated as an adjunct to glaucoma filtering surgery and other ocular applications. However, the polymerization is difficult to control and is not readily scaled up. Poly(ortho ester) IV can be easily prepared in a highly reproducible manner, is very stable provided moisture is rigorously excluded and has also been shown to be highly biocompatible. It is currently under development for a variety of applications, such as ocular delivery, protein release, post-operative pain treatment and post-operative cancer treatment.

Extensive temporal bone pneumatization: incidental finding in a patient with TMJ dysfunction

An 18-year-old male presented with symptoms of temporomandibular joint dysfunction. A panoramic radiograph revealed slight erosion of the condylar heads, and an incidental finding of multilocular radiolucencies in the zygomatic processes of the right and left temporal bones. CT scans were undertaken to exclude any sinister cause. The radiolucencies were shown to be extensive bilateral pneumatization of the temporal bones. Conservative management relieved the symptoms of TMJ dysfunction.

Development of a poly(ortho ester) prototype with a latent acid in the polymer backbone for 5-fluorouracil delivery

A study has been carried out to determine whether the latest family of poly(ortho esters) can be converted into a practical delivery system. This polymer differs from the previously described polymers in that it incorporates a short segment of a latent acid in the polymer backbone. The following issues were specifically addressed: (a) can the erosion and drug release be reproducibly controlled to yield the desired drug release kinetics and erosion rates? (b) Is the polymer stable during radiation sterilization, on storage and on fabrication? (c) Can the polymer be prepared reproducibly at the desired molecular weights and molecular weight distribution? (d) Is the polymer safe for its intended application and does the in vivo erosion proceed to completion? (e) Can the polymer be easily fabricated into desired configurations? Studies have shown that if the synthesis is carefully controlled, the desired molecular weights can be reproducibly prepared, that the polymer is reasonably stable after irradiation at 24 kGy and during storage at room temperature under anhydrous conditions, and that it can be safely thermally fabricated at temperatures in the neighborhood of 120 degrees C. When polymer devices were implanted intraperitoneally in rats the polymer eroded to completion without any overt toxicity as determined by the measured parameters.

Hair calcium and magnesium levels in patients with fibromyalgia: a case center study

BACKGROUND

Fibromyalgia is not an uncommon condition. Because its cause has yet to be identified. treatment of the condition has been empirical; frequently, outcomes are unsatisfactory. Some patients with fibromyalgia were observed to have high hair calcium and magnesium levels compared with healthy subjects. Because of this and because supplementing calcium with magnesium to fibromyalgia subjects reduced the number of tender points detected by digital palpation, it is worth investigating if patients with fibromyalgia have significantly higher hair calcium and magnesium levels than their healthy counterparts.

OBJECTIVES

To determine the degree of difference between the hair calcium and magnesium levels in patients with fibromyalgia and in healthy subjects.

METHODS

The study was retrospective and of paired design. Twelve patients who had hair analysis performed and met the criteria of fibromyalgia defined by American College of Rheumatology (1990) were selected consecutively from clinical files. These patients were then matched by age and sex to 12 healthy subjects selected consecutively from the same patient files who had hair analysis performed for checkup purposes. Nonparametric Wilcoxon rank sum tests were used to determine if the hair calcium and magnesium levels in patients with fibromyalgia were significantly higher than that of the control subjects.

RESULTS

Wilcoxon rank sum tests showed that patients with fibromyalgia had significantly higher calcium and magnesium levels than the control subjects at alpha = .025 and .05, respectively.

CONCLUSION

In the presence of high hair calcium and magnesium levels, calcium and magnesium supplements may be indicated as an adjunctive treatment of fibromyalgia.

A case of Castleman's disease mimicking a multicystic ovarian tumour

We report on a case of solitary Castleman's disease that had an unusual presentation. A 29-year-old Filipino woman who had a history of intermittent right lower abdominal pain for several years was admitted to the Princess Margaret Hospital because of a sudden exacerbation of the abdominal pain. Ultrasonography had previously detected a multilocular right ovarian cyst of approximately 6.5 cm in diameter. Intra-operative findings, however, revealed a retroperitoneal presacral cystic tumour of approximately 7 cm in diameter, which was unrelated to the ovaries. The tumour was removed and found to be well defined and measure 7 x 5 x 4 cm. The cut surface revealed homogenous light-brown tissue at the periphery. The central part showed cystic spaces of 1- to 3-cm diameter. Histological examination of the tumour led to the diagnosis of hyaline vascular-type Castleman's disease. Cystic spaces were visible within the infarcted tissue; extensive cystic changes in Castleman's disease are unusual and may have caused the diagnostic difficulty.

In vitro drug release from self-catalyzed poly(ortho ester): case study of 5-fluorouracil

Self-catalyzed poly(ortho esters) are a new variation of linear poly(ortho esters) prepared by the addition of diols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetraoxaspiro[5,5]undecane where dimer segments of lactic acid or glycolic acid are built into the polymer backbone. By varying the concentration of these segments, polymer erosion rate can be controlled. The present investigation describes the in vitro drug release characteristics from these new polymers. Because poly(ortho esters) have potential applications for the delivery of antifibroblastic agents for example after glaucoma-filtering surgery, the in vitro release studies were evaluated using 5-fluorouracil as the active compound. It was shown that a mole ratio of 90/10 or 80/20 diol/diol-lactate incorporated into the polymer lead to a release of 5-fluorouracil by an erosion process. Smaller amounts of diol-lactate lead to a concomitant drug release by diffusion and erosion. It was also shown that the release rate depends on the alkyl chain length of the diol in the polymer backbone but it does not depend on the drug loading.

Pseudomonas exit-site infections in CAPD patients: evolution and outcome of treatment

OBJECTIVE

To examine the natural history of Pseudomonas aeruginosa (PSA) exit-site infections (ESI) in patients treated with antibiotics with or without surgical interventions.

DESIGN

Retrospective record review from May 1994 to April 1997.

SETTING

A single dialysis unit in a district hospital.

PATIENTS

The review included 353 patients who had undergone continuous ambulatory peritoneal dialysis (CAPD).

OUTCOME MEASURES

The prevalence and etiology of ESI, the treatment regimen for PSA ESI, and the outcome of treatment.

RESULTS

The prevalence of ESI was 55%. A total of 131 episodes (range 1-5) of PSA ESI occurred in 78 (40.2%) of the 194 patients who experienced ESI. Among these 78 patients, 4 groups with different outcomes were identified. In group I, 35 patients (44.9%) were treated successfully with antibiotic therapy alone. Among these 35 patients, 4 developed PSA peritonitis at a mean of 5 months (range 2-10 mth) after apparent clinical resolution of PSA ESI. Two of the 4 patients switched to long-term hemodialysis (HD) because of peritoneal failure. In group II, 8 patients (10.3%) responded to a combination of antibiotics and shaving of the external cuff. In group III, 21 patients (26.9%) with recurrent ESI underwent elective Tenckhoff catheter removal and reinsertion. One of the 21 patients had relapse of PSA ESI 14 months after the operation. In group IV, 14 patients (17.9%) had recurrent PSA ESI that failed to respond to multiple courses of antibiotics and shaving of the external cuff. Consent for Tenckhoff catheter removal was not obtained and 4 of these 14 patients subsequently developed PSA peritonitis. One of the 4 patients changed to permanent HD due to peritoneal failure.

CONCLUSIONS

Considering the increased risk and the poor outcome of PSA peritonitis in patients with persistent PSA ESI, early Tenckhoff catheter removal is recommended if the patient fails to respond to antibiotics with or without externalization of the external cuff.

Death-effector filaments: novel cytoplasmic structures that recruit caspases and trigger apoptosis

The death-effector domain (DED) is a critical protein interaction domain that recruits caspases into complexes with members of the TNF-receptor superfamily. Apoptosis can also be induced by expressing certain DED-containing proteins without surface receptor cross-linking. Using Green Fluorescent Protein to examine DED-containing proteins in living cells, we show that these proteins cause apoptosis by forming novel cytoplasmic filaments that recruit and activate pro-caspase zymogens. Formation of these filaments, which we term death-effector filaments, was blocked by coexpression of viral antiapoptotic DED-containing proteins, but not by bcl-2 family proteins. Thus, formation of death-effector filaments allows a regulated intracellular assembly of apoptosis-signaling complexes that can initiate or amplify apoptotic stimuli independently of receptors at the plasma membrane.

Synthesis and characterization of self-catalyzed poly(ortho ester)

Poly(ortho esters) are currently under investigation as a carrier system for an antiproliferative agent in glaucoma filtering surgery. The present investigation illustrates the development of a series of self-catalyzed poly(ortho ester). These polymers contain short dimer segments of alpha-hydroxy acids in their backbone and are prepared by the addition of different polyols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetra-oxaspiro-[5.5]-undecane. The structures were confirmed by NMR- and FT-IR-spectroscopy. The polymers were characterized by determination of the molecular weight, the glass transition temperature and the rheological behavior. The amount of residual solvents was also analyzed. The characteristics of the polymer can be varied by the type of polyol incorporated in its backbone. Since poly(ortho ester) is susceptible to acid-catalyzed degradation, the polymer hydrolysis can be controlled by the amount of incorporated portion of alpha-hydroxy acid. Due to the high hydrophobicity of the polymer structure, the ester bonds are more susceptible to hydrolysis than the ortho ester bonds in the polymer backbone. The hydrolysis proceeds via initial protonation of the exocyclic alkoxy group to yield pentaerythritol dipropionate and the free diol. In a next step, the pentaerythritol dipropionate hydrolysis to pentaerythritol and propionic acid. The molecular weight decrease, weight loss and the pH profile of the polymer in aqueous medium were monitored during the degradation.

Intra-oral ultrasound imaging of a submandibular duct calculus

A case is presented showing the first reported use of a small, digitally-guided, intra-oral ultrasound probe to image a calculus in a submandibular salivary duct. This use of intra-oral ultrasound is discussed in the context of the overall current status of intra-oral and extra-oral ultrasound imaging. It is proposed that using a combination of intra-oral and extra-oral probes, the whole of the salivary apparatus may now be examined sonographically for the presence of calculi.

CD28-costimulation activates cyclic AMP-responsive element-binding protein in T lymphocytes

Cyclic AMP-responsive element binding protein (CREB) mediates gene expression in response to cAMP stimulation. The transcriptional activity of CREB depends on both the phosphorylation of Ser133 and the recruitment of cofactor for assembly of transcriptional complex. Extensive Ser133 phosphorylation of CREB was induced during T cell activation. This phosphorylation event is essential for IL-2 gene expression. However, phosphorylation of CREB at Ser133 was not sufficient for transcriptional activity by CREB. The presence of a second signal from CD28, a potent costimulatory molecule on T cells, stimulated CREB-mediated gene expression. CD28, an effective costimulator of T cell activation and IL-2 gene expression, is shown to induce CREB activation in the presence of anti-CD3 or O-tetradecanoylphorbol 13-acetate. These two signals together stimulated a CRE-dependent reporter gene, the proliferating cell nuclear Ag promoter, and transactivation by the GAL4-CREB fusion protein. Thus optimal induction of CREB, similar to the full activation of T lymphocytes, may be mediated by two distinct signal transductions. Using the specific kinase inhibitor, one of the two pathways appeared to involve mitogen-activated protein kinase kinase but not protein kinase C, protein kinase A, or p70 S6 kinase.