Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine

Objective

To quantify the incidence of postoperative voice, swallowing, and other problems, including time to resolution following anterior transcervical approaches to the cervical spine, and to assess surgical factors associated with outcomes.

Study Design

Historical cohort study.

Setting

Academic medical center.

Subjects and Methods

One hundred eighty-eight consecutive patients with cervical spine disease who underwent an anterior transcervical approach to the spine by a single head and neck surgeon over a 4-year time period. Rather than primary, single-level approaches, all patients in this study had multilevel, high-cervical (above C4), low-cervical (below C6), and/or revision approaches. Postoperative voice, swallowing, and other complaints were measured as well as time to resolution using Kaplan-Meier method. Surgical factors related to outcomes were analyzed using regression analysis.

Results

Follow-up was available for 129 patients, with average and median time of 35 months. Seventy-seven patients (60%) had a postoperative issue, including 35 patients (27%) with postoperative voice complaint, 62 patients (48%) with postoperative swallowing complaint, and 16 patients (12%) with other problems. Swallowing and voice complaints persisted beyond 1 year in 28% and 9% of patients, respectively. Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors significantly related to voice and swallowing problems.

Conclusion

There is a high incidence of subjective voice and swallowing complaints following transcervical anterior approaches to the spine, and such complaints can persist beyond 1 year in many patients. Exposure of more than 3 spinal levels or above level C4 are 2 factors significantly associated with outcome.

Beyond pregnancy--the neglected burden of mortality in young women of reproductive age in Bangladesh: a prospective cohort study

OBJECTIVE

To describe proportionate mortality and causes of death unrelated to pregnancy.

DESIGN

Prospective cohort study.

SETTING

Rural northwest Bangladesh.

POPULATION

A cohort of 133,617 married women of reproductive age.

METHODS

Verbal autopsies were conducted for women who died whilst under surveillance in the cohort trial. Physician-assigned causes of death based on verbal autopsies were used to categorise deaths.

MAIN OUTCOME MEASURES

The proportion of deaths due to non-communicable diseases, infectious diseases, injury or pregnancy.

RESULTS

Of the 1107 deaths occurring among women between 2001 and 2007, 48% were attributed to non-communicable diseases, 22% to pregnancy, 17% to infections, 9% to injury and 4% to other causes.

CONCLUSIONS

Although focus on pregnancy-related mortality remains important, more attention is warranted on non-communicable diseases among women of reproductive age.

Outcomes of temporal bone resection for locally advanced parotid cancer

This study was conducted to report outcomes and identify factors predictive of survival and recurrence in patients undergoing lateral temporal bone resection (LTBR) as part of an extended radical parotidectomy for parotid cancer. This is a retrospective cohort study which includes all patients undergoing LTBR for parotid cancer between 1994 and 2010 at two affiliated academic centers. Survival and recurrence rates were analyzed using the Kaplan-Meier method and Cox multivariate regression. A total of 12 patients with median follow-up duration of 30.6 months were included: 6 de novo cases and 6 patients referred after local recurrence. Actuarial locoregional control at 2 years was 73%. Most patients (11; 92%) developed disease recurrence with distant metastases the most common site of first failure (83%). Overall and disease-specific survival rates were 80% at 2 years and 22.5% at 5 years. Recurrence-free survival (RFS) was 67% at 2 years and 8.3% at 5 years. On multivariate analysis, surgical margin status was an independent predictor of RFS (hazard ratio = 3.85, p = 0.045). In advanced parotid cancer, LTBR with a goal of gross total resection offers good locoregional control with an acceptable complication rate. The benefits of this surgery must be balanced with the morbidity and low likelihood of long-term survival, with most patients ultimately experiencing disease recurrence and death.

The non-human primate model of tuberculosis

Non-human primates (NHPs) are used to model human disease owing to their remarkably similar genomes, physiology, and immune systems. Recently, there has been an increased interest in modeling tuberculosis (TB) in NHPs. Macaques are susceptible to infection with different strains of Mycobacterium tuberculosis (Mtb), producing the full spectrum of disease conditions, including latent infection, chronic progressive infection, and acute TB, depending on the route and dose of infection. Clearly, NHPs are an excellent model of human TB. While the initial aim of the NHP model was to allow preclinical testing of candidate vaccines and drugs, it is now also being used to study pathogenesis and immune correlates of protection. Recent advances in this field are discussed in this review. Key questions such as the effect of hypoxia on the biology of Mtb and the basis of reactivation of latent TB can now be investigated through the use of this model.

Dengue fever evolving into systemic lupus erythematosus and lupus nephritis: a case report

Dengue viremia may be the trigger for immune complex formation in patients who are predisposed to developing autoimmune disease. We report a rare case of dengue virus infection evolving into systemic lupus erythematosus (SLE) and lupus nephritis. To the best of our knowledge this is the first case of dengue fever evolving into lupus nephritis. A 22 year old female presented with having had high grade fever, skin rash, breathlessness, retro-orbital pain, abdominal pain, arthralgias and myalgias for 10 days. She tested positive for dengue immunoglobulin M (IgM). She was given supportive treatment and was subsequently discharged. Four weeks later she developed recurrent fever, arthralgia, rash and anasarca. She was suspected as having SLE with active lupus nephritis. Antinuclear antibody (ANA), and anti double stranded deoxyribonucleic acid (anti dsDNA) titers were positive and complements were low. Renal biopsy showed diffuse proliferative glomerulonephritis grade IV. She was treated with steroids and immunosuppressants to which she responded. Dengue viremia incites antibody production, which if excessive causes deposition of viral antigen-antibody immune complexes. This could possibly lead to renal tubular damage and glomerulonephritis in susceptible individuals. Dengue fever leading to development of glomerulonephritis is rarely seen. Our patient developed dengue fever and after a month presented with manifestations of SLE and lupus nephritis. Both dengue fever and SLE have common manifestations of fever, arthralgia, rash, leucopenia with thrombocytopenia and serositis. Bacterial and viral infections may act as a 'trigger' for starting or relapsing lupus activity in genetically predetermined individuals. In our case it may be possible that dengue virus could have triggered a dysfunctional immune response, resulting in the developing of autoimmunity and SLE with lupus nephritis.

Predictors of survival and recurrence after temporal bone resection for cancer

BACKGROUND

The purpose of this study was to identify factors predictive of outcome in patients undergoing temporal bone resection (TBR) for head and neck cancer.

METHODS

This was a retrospective study of 72 patients undergoing TBR. Factors associated with survival and recurrence were identified on multivariable regression.

RESULTS

Most tumors were epithelial (81%), commonly (69%) involving critical structures. Cervical metastases were uncommon (6%). Squamous cell carcinoma (SCC) of the external auditory canal carried a high rate of parotid invasion (25%) and parotid nodal metastases (43%). The 5-year rate of overall survival (OS) was 62%; disease-specific survival (DSS), 70%; recurrence-free survival (RFS), 46%. Factors independently associated with outcome on multivariable analysis were margin status and extratemporal spread of disease to the parotid, mandible, or regional nodes. Recurrence was common (72%) in cT3-4 tumors.

CONCLUSIONS

Margin status and extratemporal disease spread are the strongest independent predictors of survival and recurrence. In SCC of the external auditory canal, high rates of parotid involvement support adjunctive parotidectomy. Risk of recurrence in T3-T4 tumors may support a role for adjuvant therapy.

Case Series with Endoscopic Findings of a Novel Nasal Irrigation Protocol for Refractory Chronic Rhinosinusitis

Objective: Present an innovative treatment protocol for refractory chronic rhinosinusitis (CRS) in order for practitioners to 1) learn of a new topical treatment regimen, 2) be able to apply this protocol to their own patients, and 3) understand the proposed mechanism of its action.

Method: Case series of 20 patients with refractory CRS treated with a novel topical sinus regimen that included diluted baby shampoo between June 2009 and June 2010 with analysis of patient, disease, and treatment characteristics. Treatment endpoints include subjective improvement of nasal symptoms and objective improvements on nasal endoscopy.

Results: Our novel treatment protocol involves gentamicin 20 mg per 240 mL (8 ounces), Johnson’s Baby Shampoo 1 drop per 240 mL, and pulmicort respules 1 mg per 240 mL. Patients are advised to use 120 mL via a 240 mL squeeze bottle. We then remove the gentamicin, pulmicort, or both, and track patient progress based on symptomatic improvement and improvements seen on nasal endoscopy. All patients had positive response using this treatment protocol after failed medical and surgical management with a variety of other topical and systemic therapies. Two notable cases are presented with endonasal photos to illustrate the positive response achieved using this treatment protocol.

Conclusion: This novel sinus irrigation treatment protocol is effective in the treatment of CRS as documented by subjective improvements in nasal symptoms as well as significant improvement in nasal endoscopic findings. This protocol is well tolerated by patients and should be considered by otolaryngologists and allergists treating refractory CRS.

Molecular characterization of MHC class II region in guinea fowl

1. The MHC class II gene was amplified, cloned and sequenced in guinea fowl. 2. The NumeMHC II sequence of 754 nucleotides included complete exon 1 (91 nt), exon 2 (270 nt), exon 3 (282 nt) and exon 4 (110 nt). 3. The size of β(1) and β(2), domains were 89 and 93 amino acids, respectively in guinea fowl. 4. High amino acid variability (38·2%) was observed within guinea fowl in β(1) domain, while in β(2) domain, amino acid variability (6·3%) was low. 5. Among poultry species, the percent amino acid identity between guinea fowl and chicken, quail, pheasant and duck was 38·8, 42·2, 44·4 and 58·8 in β(1) domain; and 13·8, 17·0, 13·8 and 27·6 in β(2) domain, respectively. 6. Sequence alignment with mammalian and avian MHC showed that many of the conserved features of MHC class II glycoprotein was conserved in guinea fowl. 7. Within-species genetic distances (Poisson correction) based on cumulative amino acid variability in β(1) domain and β(2) domains was 0·141 in guinea fowl. 8. Guinea fowl showed low and similar genetic distances with all the poultry species (0·255-0·268) except duck (0·456). 9. Guinea fowl made separate branch within the major cluster having chicken, quail and pheasant, showing equal distance from these poultry species, whereas duck MHC II clustered separately.

Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles

OBJECT

The endoscopic endonasal approach has become the preferred technique for CSF leak and encephalocele repair of the anterior skull base. The purpose of this study is to identify patient characteristics; review adjunctive perioperative treatments, reconstruction techniques, and outcomes; and identify risk factors for failure in patients undergoing endoscopic endonasal repair of anterior skull base CSF leaks and encephaloceles.

METHODS

This is a prospective observational study of patients undergoing endoscopic endonasal repair of a CSF leak between October 2004 and May 2009. Twenty-eight consecutive patients underwent 32 procedures. Twenty-two of the patients were women, which represents a statistically significant trend toward the female sex (p < 0.05). The average body mass index (33.9) was significant for obesity. The origin of the skull base defect included the cribriform plate (in 9 cases), fovea ethmoidalis (in 7), combined fovea ethmoidalis/cribriform plate (in 2), lateral sphenoid sinus (in 6), sella (in 4), clivus (in 3), and frontal sinus (in 1).

RESULTS

The overall endonasal closure rate was 93.8% (30 of 32 procedures). One failure occurred due to overaggressive postoperative debridement, while the other recurred along the posterior wall of the frontal sinus, and endoscopic repair would have occluded the recess.

CONCLUSIONS

The endoscopic endonasal approach for the treatment of CSF leaks and encephaloceles of the anterior skull base is the preferred method of repair in the vast majority of cases. The authors' 93.8% closure rate in a variety of anatomical locations compares favorably with the transcranial approach and echoes the results of other endoscopic series.

Long-term efficacy of tiotropium in relation to smoking status in the UPLIFT trial

UPLIFT (Understanding Potential Long-Term Improvements in Function with Tiotropium), a 4-yr trial of tiotropium in chronic obstructive pulmonary disease, allowed for assessment of smoking status on long-term responses to maintenance bronchodilator therapy. 5,993 patients were randomised (tiotropium/placebo). Lung function, St George's Respiratory Questionnaire, exacerbations and adverse events were followed. Patients were characterised as continuing smokers (CS), continuing ex-smokers (CE), or intermittent smokers (IS) based on self-reporting smoking behaviour. 60%, 14% and 26% of patients were CE, CS and IS, respectively. The rate of forced expiratory volume in 1 s (FEV(1)) decline for placebo patients was most rapid in CS (-52+/-4, -37+/2 and -23+/2 mL.yr(-1) in CS, IS, and CE, respectively). Tiotropium did not alter FEV(1) decline, but was associated with significant improvements in pre- and post-bronchodilator FEV(1) over placebo that persisted throughout the 4-yr trial for each smoking status (pre-bronchodilator: 127, 55 and 97 mL at 48 months in CS, IS and CE, respectively; p< or =0.0003). Tiotropium reduced exacerbation risk in CS (HR (95% CI) 0.80 (0.67-0.95)), in CE (0.85 (0.79-0.92)) and trended towards significance in IS (0.89 (0.79-1.00)). At 4 yrs, St George's Respiratory Questionnaire for tiotropium patients improved the most in CS (-4.63 units, p = 0.0006) and the least in IS (-0.60 units, p = 0.51), [corrected] compared with control. Tiotropium provided long-term benefits irrespective of smoking status, although differences among categories were observed.

An audit of the UK national cancer referral guidelines for suspected oral mucosal malignancy

BACKGROUND AND OBJECTIVE

This study aimed to assess the effectiveness of the UK National Guidelines for identifying patients with potentially malignant oral disease which were introduced in 2000.

DESIGN

Retrospective audit.

SETTING

The oral medicine unit in a university teaching hospital in London.

METHODS

All new referrals over a one year period were retrospectively reviewed in a departmental audit to evaluate guideline effectiveness. Reasons for referral and final diagnosis were compared in a randomly selected sub-population.

RESULTS

Four hundred and eighty-seven of 901 new patients referred were classified as having potentially malignant disease from the referral letter. In a randomly selected subgroup of 241 patients, 18 actually had malignant (8) or dysplastic lesions (10). Of 75 patients referred with a persistent oral ulcer, only nine were actually malignant or dysplastic. Eight of 116 patients referred with a white patch and none with red patches were found to have dysplastic or malignant lesions. The criteria failed to identify three carcinomas and two severely dysplastic lesions (15% of the malignant or dysplastic lesions). All of the latter had been referred by primary care physicians with orofacial pain of unknown cause.

CONCLUSIONS

UK National Guidelines discriminate poorly between potentially malignant and other oral mucosal disease.

Rifampicin induced thrombocytopenia

Thrombocytopenia is an uncommon but potentially life threatening complication of certain anti-tubercular drugs and is characterized by rapid destruction of platelets whenever an offending drug is taken by a susceptible person. Here is a case report of Rifampicin induced Thrombocytopenia. This case is being reported for purpose of its rare occurrence and documentation.