Zenker's diverticulostomy with cricopharyngeal myotomy: the endoscopic approach

BACKGROUND

The gold standard for the surgical treatment of Zenker's diverticulum is diverticulectomy and cricopharyngeal myotomy by an external approach. Unfortunately, many of the patients who present with this entity are elderly and have significant comorbidities that increase operative risk. Traditional minimally invasive approaches have not met with widespread success. However, by combining the exposure afforded by the otolaryngologist's newer bivalved operating laryngoscopes with the operative techniques made possible by the general surgeon's laparoscopic instrumentation and staplers, it is possible to achieve reliable and safe endoscopic outpatient management of this disease entity, with resumption of a normal diet on the same day.

METHODS

We reviewed the physiologic basis, instrumentation, and technical considerations for this endoscopic procedure. We also documented our operative experience with 21 patients treated over an 18-month period.

RESULTS

Successful minimally invasive management of Zenker's diverticulum was possible in 18 of 21 patients. In two patients, anatomic limitations of mouth and neck anatomy precluded exposure of the diverticulum; in another patient, the diverticulum was too small. Small operative perforations of the apex of the diverticulum occurred in three cases. Two of these perforations were repaired primarily with minimally invasive techniques; in the other case, treatment consisted of observation alone. In all but this last patient, oral diet was resumed on the day of the operation. Eleven of the patients were discharged from the hospital on the same day; the remaining patients went home the following morning.

CONCLUSIONS

With proper patient selection, minimally invasive management of Zenker's diverticulum is a safe and effective surgical technique that allows for outpatient management of the majority of patients who present with this disease.

A minimum data set and empirical model for population health status assessment

BACKGROUND

The need to assess the health status of American communities in a comprehensive and systematic manner has been widely acknowledged. This study attempts to empirically derive a minimum core data set of indicators, in order to produce a uniform parsimonious model for population health status monitoring.

METHODS

Five years of secondary data (1992-1996) for 113 indicators of community health for each of Florida's 67 counties were organized into 11 conceptual groups. Principal component analysis with orthogonal rotation was conducted separately on each group of indicators for each year. The component scores were converted to standard scores to further study the relationships among the conceptual groups measuring community health. A causal model was hypothesized and tested using ordinary least-squares path analysis.

RESULTS

Nineteen principal components composed of 78 indicators were identified. The model demonstrated a large difference in the ability to explain variance in adult mortality (56%) compared with variance associated with adverse birth outcomes (13%). Both demographic and socioenvironmental factors have a direct effect on adult mortality. Socioeconomic factors, on the other hand, influence adult mortality indirectly through adequacy of primary care and other available resources.

CONCLUSIONS

Minimum core data sets of indicators drawn from extant databases can be used to uniformly describe and explain variation in adult mortality. This research suggests caution in regard to the creation of integrated indices that combine mortality, morbidity, and other concepts such as quality of life into a single measure of community health. Further validation research employing a national sample of counties is recommended.

Natural killer-cell lymphocytosis and strongyloides infection

We report a case of strongyloides infection in a 72-year-old man presenting with acute angio-oedema and urticaria. He was also found to have natural killer cell (NK) large granular lymphocytosis (LGL). We discuss the possible relationship between the strongyloides infection and the NK-LGL lymphocytosis.

An investigation of male-mediated F1 effects in mice treated acutely and sub-chronically with urethane

In order to investigate the alleged potential of paternally administered urethane to cause foetal abnormalities and heritable tumours, male CD-1 mice were treated with urethane, either acutely by intraperitoneal injection at doses of 1.25 and 1.75 g/kg bodyweight (bwt) or sub-chronically in the drinking water at 1.25 for 10 weeks, and 3.75 mg/ml for 9 weeks or vehicle for the control groups. They were mated to untreated females 1 week later. Uterine contents of half the pregnant females were examined just before full term, while the remaining females were allowed to deliver their litters. The resulting F1 offspring were observed for approximately 18 months and 12 months for acute and sub-chronic exposures respectively and subjected to necropsy examination. Some of the mice treated acutely with 1.75 g/kg bwt exhibited partial infertility but none of those treated with 1.25 g/kg bwt had an adverse effect on their reproductive ability. There was no genetic effect of acute urethane treatment on male germ cells as indicated by dominant lethality. After birth, there was an increase (P < 0.05) in post-implantation deaths possibly due to perinatal mortality. There was an increased incidence and earlier onset of liver tumours induced in F1 male offspring from F0 males treated with 1.75 g/kg bwt, (20.7% vs. 10.1%, P = 0.026) but not in the female offspring. F1 males from both treatment groups had mean bodyweights significantly higher than controls (P < 0.01). Some males from each dose group of the acute study were examined using the restriction site mutation assay involving analysis of exon sequences. No mutations were identified in testes, liver or spleen of DNA isolated from the urethane-treated animals. No reproductive or genetic effects were seen with sub-chronic treatment at either 1.25 or 3.75 mg/ml urethane nor was there any predisposition of F1 animals to tumours although observation times were shorter.

Relapsing polychondritis and myelodysplasia: a report of two cases and review of the current literature

Relapsing polychondritis (RP) is a rare multisystem disorder. We describe two case reports of patients with RP, one of whom developed myelodysplasia subtype refractory anaemia (RA) and the other, refractory anaemia with ringed sideroblasts (RARS). We also review the literature of association between RP and haematological disorders.

Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure

BACKGROUND

Patients with acute renal failure (ARF) have high morbidity and mortality rates, particularly if they have serious comorbid conditions. Several studies indicate that in rats with ARF caused by ischemia or certain nephrotoxins, insulin-like growth factor-I (IGF-I) enhances the recovery of renal function and suppresses protein catabolism.

METHODS

Our objective was to determine whether injections of recombinant human IGF-I (rhIGF-I) would enhance the recovery of renal function and is safe in patients with ARF. The study was designed as a randomized, double-blind, placebo-controlled trial in intensive care units in 20 teaching hospitals. Seventy-two patients with ARF were randomized to receive rhIGF-I (35 patients) or placebo (37 patients). The most common causes of ARF in the rhIGF-I and placebo groups were, respectively, sepsis (37 and 35% of patients) and hypotension or hemodynamic shock (42 and 27% of patients). At baseline, the mean (+/- SD) APACHE II scores in the rhIGF-I and placebo-treated groups were 24 +/- 5 and 25 +/- 8, respectively. In the rhIGF-I and placebo groups, the mean (median) urine volume and urinary iothalamate clearances (glomerular filtration rate) were 1116 +/- 1037 (887) and 1402 +/- 1183 (1430) ml/24 hr and 6.4 +/- 5.9 (4.3) and 8.7 +/- 7.2 (4.4) ml/min and did not differ between the two groups. Patients were injected subcutaneously every 12 hours with rhIGF-I, 100 microgram/kg desirable body weight, or placebo for up to 14 days. Injections were started within six days of the onset of ARF. The primary end-point was a change in glomerular filtration rate from baseline. Other end points included changes from baseline in urine volume, creatinine clearance and serum urea, creatinine, albumin and transferrin, frequency of hemodialysis or ultrafiltration, and mortality rate.

RESULTS

During the treatment period, which averaged 10.7 +/- 4.1 and 10.6 +/- 4.5 days in the rhIGF-I and placebo groups, there were no differences in the changes from baseline values of the glomerular filtration rate, creatinine clearance, daily urine volume, or serum urea nitrogen, creatinine, albumin or transferrin. In patients who did not receive renal replacement therapy, there was also no significant difference in serum creatinine and urea between the two groups. Twenty patients in the rhIGF-I group and 17 placebo-treated patients underwent dialysis or ultrafiltration. Twelve rhIGF-I-treated patients and 12 placebo-treated patients died during the 28 days after the onset of treatment.

CONCLUSIONS

rhIGF-I does not accelerate the recovery of renal function in ARF patients with substantial comorbidity.

Renal blood flow: measurement in vivo with rapid spiral MR imaging

PURPOSE

To assess the ability of three cine phase-contrast magnetic resonance (MR) imaging techniques to measure normal human renal blood flow (RBF) in vivo.

MATERIALS AND METHODS

Eighteen healthy volunteers were studied with three cine phase-contrast MR imaging techniques: breath-hold, segmented k-space, two-dimensional, Fourier transform technique (ie, time-resolved imaging with automatic data segmentation, or TRIADS); a breath-hold rapid spiral acquisition; and a non-breath-hold rapid spiral acquisition that allowed resolution of both cardiac and respiratory cycles. In each case, total arterial RBF and blood flow per unit of renal volume were calculated. For each subject, RBF was measured with a standard technique of p-aminohippuric acid (PAH)-clearance hematocrit on the same day as the MR imaging examination was performed.

RESULTS

The range of agreement (2 standard deviations, or 95% confidence interval) between RBF measurements obtained with the PAH-clearance hematocrit technique and the various cine phase-contrast techniques varied from +/- 17.6% to +/- 26.5%. The best agreement was obtained with non-breath-hold rapid spiral data, by using data from the end-expiratory phase of respiration.

CONCLUSION

Findings with cine phase-contrast MR imaging employing rapid spiral acquisition are in good agreement with measurements made with PAH-clearance hematocrit and give the promise of clinical measurements of RBF.

Parvovirus-induced pancytopenia in a child with acquired haemolytic anaemia

A 14-year-old boy, with acquired haemolytic anaemia secondary to paravalvular leak from a prosthetic aortic valve, presented with severe pancytopenia. Subsequent investigation showed serological evidence of recent parvovirus B19 infection. The patient required transfusion and subsequently improved rapidly, with maintenance of pre-infective haemoglobin levels. To our knowledge this is the first reported case in which infection with parvovirus has caused pancytopenia in an acquired chronic mechanical haemolytic anaemia.

A community health report card: comprehensive assessment for tracking community health (CATCH)

A systematic method for assessing the health status of communities has been under development at the University of South Florida since 1991. The system, known as CATCH, draws 226 indicators from multiple sources and uses an innovative comparative framework and weighted evaluation criteria to produce a rank-ordered community problem list. The CATCH results from II Floridian counties have focused attention on high priority health problems and provided a framework for measuring the impact of health expenditures on community health status outcomes. The method and plans to create an automated data warehouse to support its expansion and enrichment are described.

Comparison of two computational formulas for a WAIS-R seven subtest short form

Several validity studies for a seven subtest WAIS-R short form have been conducted with patients from different populations as participants. All of these studies demonstrated high correlations between the short form IQ estimates and the actual VIQs, PIQs, and FSIQs (i.e., .90 to .98). In general, there also were small mean differences in the short form versus actual IQs across samples. There currently are two computational formulas for the seven subtest short form. The original weighted formula and a revised proration formula. This study investigated the accuracy of the two short form computational formulas in samples of patients with brain impairment. It was found that the two formulas produced nearly identical results from both statistical and clinical perspectives. Given that the formulas produce nearly identical results and the majority of published studies with this short form have used the weighted formula, we recommend that future investigators use the original weighted formula to maintain clinical and scientific consistency.

The indirect association of lactation with subsequent perimenopausal body weight

OBJECTIVE

We aimed to estimate the relationship of prior breastfeeding to perimenopausal body mass index (BMI) (kg/m2). While most long-term studies of women's body weight after reproductive experience have found a negative relationship between lactation and body weight, most short-term studies found either no impact of lactation on body weight, or decelerated postpartum weight loss among breastfeeding women.

DESIGN

We performed a retrospective cohort study.

SETTING

The study was done in The Netherlands between 1987 and 1990.

SUBJECTS

The 1067 singleton females who were born around the time of the Dutch famine (1 August 1944 through 15 April 1946) at The University of Amsterdam Teaching Hospital were all traced and accounted for. This analysis refers to the 671 who were interviewed and for whom all data elements were available.

ANALYSIS

We related parity and number of children breastfed at least 1 week to BMI at age 45 and at the time of marriage, both calculated from respondents: recall of weight and height, by linear multiple regression analysis, adjusting for potentially confounding variables.

RESULTS

Among parous women, each additional live birth was associated with a BMI increase of 0.69 kg/m2 (CI = 0.24 to 1.13, P = 0.003), and for each additional child breastfed, the BMI was lower by 0.41 kg m2 (CI = -0.77 to -0.04, P = 0.03) at age 45. However, BMI before any reproductive experience was 0.39 kg/m2 greater (CI = 0.08 to 0.71, P = 0.01) with each additional subsequent birth, and for each additional infant breastfed, 0.34 kg/m2 lower (CI = - 0.60 to - 0.09, P = 0.008).

CONCLUSIONS

The negative relationship of prior breastfeeding to perimenopausal weight was probably not causally related to breastfeeding, since the relationship was present before any reproductive experience. The results could also arisen in part because of biased recall of weight; however, the relationship of parity to perimenopausal BMI was far less attenuated by adjusting for prior BMI than was the association with breastfeeding, lending support to an indirect association of breast- feeding with later BMI.

Hepatitis C virus infection in multi-transfused children with haematological malignancy

Transmission of hepatitis C virus (HCV) is an important hazard of blood transfusion and may result in chronic liver disease. 98 children from Nottingham and Sheffield with haematological malignancies were studied to determine the prevalence of HCV infection by enzyme immunoassay and RT/PCR techniques. The children had been exposed to up to 184 donors through red cell and platelet transfusion, the majority prior to routine testing for HCV infection in blood donors. Only one sample showed evidence of HCV infection being both ELISA and RT/PCR positive. None of the samples taken since donor screening were positive. This provides reassurance as to the low rate of HCV acquisition in multi-transfused patients in this part of the U.K. compared to other parts of the world.