Clinical outcomes of functional endoscopic sinus surgery in cystic fibrosis patients - a single centre experience

BACKGROUND

Endoscopic sinus surgery (ESS) is an established surgical option for cystic fibrosis (CF) patients with chronic rhinosinusitis that is refractory to conventional medical management. Objective and subjective evidence of benefit of ESS in this cohort of patients is currently conflicting in the literature.

METHODOLOGY

A single center retrospective study was undertaken of all CF patients (transplanted and non-transplanted) over the age of 16 who underwent an ESS over a six-year period from 2015 to 2021. Patients on triple-therapy CFTR modulators were excluded. Data was collected on demographics, clinical management, and outcome measures. The objective outcome measures were lung function (%predicted FEV1), pulmonary exacerbations (total number of days of IV antibiotics- both ambulatory and in hospital). The subjective outcome measure was SNOT-22 scores preand 6 months post-operatively. A minimally clinical important difference (MCID) in SNOT-22 scores of 9 points was used.

RESULTS

55 patients were included in our study, with a median age of 31 and 53% females. Median Lund-Mackay scores for the cohort was 13 (3- 24). There was a significant improvement in lung function at 1-year post-surgery, and a significant MCID reduction in SNOT-22 scores at 6 months post-surgery across the cohort. Sub-group analysis revealed a sustained MCID reduction in SNOT-22 scores in both lung-transplanted and native lung groups, and in patients with primary ESS or previous ESS. However, there was no post-operative pulmonary function improvement in lung transplanted patients and patients with previous ESS. There was no impact on the rate of pulmonary exacerbations across the cohort. 2 patients in the cohort died secondary to pulmonary disease.

CONCLUSIONS

There was a demonstrated clinical and symptomatic benefit of ESS in CF patients in this study. Stricter guidelines for indications for ESS need to be established with regards to CF patients who will undergo ESS in the future.

Revisiting the Great Ormond Street Hospital protocol for ward decannulation of children with tracheostomy

INTRODUCTION

Tracheostomy decannulation is an important and final step in managing patients once the underlying issue requiring a tracheostomy resolves. However, no consensus exists on the optimal method to decannulate a paediatric patient. We revisit the Great Ormond Street Hospital (GOSH) tracheostomy decannulation protocol, a 5-day process involving downsizing the tracheostomy tube, capping, and observation, to evaluate its effectiveness and assess if changes to the protocol are required.

METHOD

This is a retrospective study, reviewing patient records between April 2018 and April 2023 from a single quaternary care centre. Data extracted include comorbidities, age at the time of decannulation, duration of tracheostomy, reason for tracheostomy insertion, whether a decannulation attempt was successful or not, and the timings of decannulation failure.

RESULTS

66 patients that met the selection criteria underwent a decannulation trial between April 2018 and April 2023. 32 patients were male, and 34 patients were female. Age at attempted decannulations ranged from 1 year to 18 years, with an average age of 6.1 years. There were a total of 93 attempts at decannulation, with 51 (54.8%) successful attempts, 35 (56.5%) first decannulation attempt successes, and 42 (45.2%) unsuccessful attempts. 17 patients had 2 attempts at decannulation, and 4 patients had 3 or more attempts at decannulation. Of the unsuccessful attempts, patients mostly failed on capping of the tracheostomy tube with 33 failures (35.5%).

CONCLUSION

The GOSH protocol achieved similar success rates to comparable protocols. The protocol's multi-step approach provides thorough evaluation and support for patients during the decannulation process, and its success on a complex patient cohort supports its continued use.

Resolving the Extragalactic γ-Ray Background above 50 GeV with the Fermi Large Area Telescope

The Fermi Large Area Telescope (LAT) Collaboration has recently released a catalog of 360 sources detected above 50 GeV (2FHL). This catalog was obtained using 80 months of data re-processed with Pass 8, the newest event-level analysis, which significantly improves the acceptance and angular resolution of the instrument. Most of the 2FHL sources at high Galactic latitude are blazars. Using detailed Monte Carlo simulations, we measure, for the first time, the source count distribution, dN/dS, of extragalactic γ-ray sources at E>50  GeV and find that it is compatible with a Euclidean distribution down to the lowest measured source flux in the 2FHL (∼8×10^{-12}  ph cm^{-2} s^{-1}). We employ a one-point photon fluctuation analysis to constrain the behavior of dN/dS below the source detection threshold. Overall, the source count distribution is constrained over three decades in flux and found compatible with a broken power law with a break flux, S_{b}, in the range [8×10^{-12},1.5×10^{-11}]  ph cm^{-2} s^{-1} and power-law indices below and above the break of α_{2}∈[1.60,1.75] and α_{1}=2.49±0.12, respectively. Integration of dN/dS shows that point sources account for at least 86_{-14}^{+16}% of the total extragalactic γ-ray background. The simple form of the derived source count distribution is consistent with a single population (i.e., blazars) dominating the source counts to the minimum flux explored by this analysis. We estimate the density of sources detectable in blind surveys that will be performed in the coming years by the Cherenkov Telescope Array.

Measurement of the high-energy gamma-ray emission from the Moon with the Fermi Large Area Telescope

We have measured the gamma-ray emission spectrum of the Moon using the data collected by the Large Area Telescope onboard the Fermi satellite during its first seven years of operation, in the energy range from 30 MeV up to a few GeV. We have also studied the time evolution of the flux, finding a correlation with the solar activity. We have developed a full Monte Carlo simulation describing the interactions of cosmic rays with the lunar surface. The results of the present analysis can be explained in the framework of this model, where the production of gamma rays is due to the interactions of cosmic-ray proton and helium nuclei with the surface of the Moon. Finally, we have used our simulation to derive the cosmic-ray proton and helium spectra near Earth from the Moon gamma-ray data.

Sudden onset unilateral sensorineural hearing loss after rabies vaccination

A 33-year-old man developed profound sudden onset right-sided hearing loss with tinnitus and vertigo, within 24 h of pretravel rabies vaccination. There was no history of upper respiratory tract infection, systemic illness, ototoxic medication or trauma, and normal otoscopic examination. Pure tone audiograms (PTA) demonstrated right-sided sensorineural hearing loss (thresholds 90-100 dB) and normal left-sided hearing. MRI internal acoustic meatus, viral serology (hepatitis B, C, HIV and cytomegalovirus) and syphilis screen were normal. Positive Epstein-Barr virus IgG, viral capsid IgG and anticochlear antibodies (anti-HSP-70) were noted. Initial treatment involved a course of high-dose oral prednisolone and acyclovir. Repeat PTAs after 12 days of treatment showed a small improvement in hearing thresholds. Salvage intratympanic steroid injections were attempted but failed to improve hearing further. Sudden onset sensorineural hearing loss (SSNHL) is an uncommon but frightening experience for patients. This is the first report of SSNHL following rabies immunisation in an adult.

An ingested foreign body: two sides of the same coin?

A 2-year-old child presented to the emergency department with an acute onset of dysphagia and stertor. A plain anteroposterior chest X-ray revealed a single circular opacity in the middle third of the oesophagus consistent with an ingested coin. The child was taken to the theatre for rigid pharyngo-oesophagoscopy and removal of the coin. After the first coin was removed subsequent endoscopic examination revealed a second coin at the same location. This extremely rare case of two ingested coins becoming impacted with perfect radiological alignment emphasises the importance of thorough examination on endoscopy and the potential limitations of an X-ray in initial assessment of an ingested foreign body.

Nuclides.net: a computational environment for nuclear data and applications in radioprotection and radioecology

An interactive multimedia tool, Nuclides.net, has been developed at the Institute for Transuranium Elements. The Nuclides.net "integrated environment" is a suite of computer programs ranging from a powerful user-friendly interface, which allows the user to navigate the nuclides chart and explore the properties of nuclides, to various computational modules for decay calculations, dosimetry and shielding calculations, etc. The product is particularly suitable for environmental radioprotection and radioecology. Detailed descriptions of Nuclides.net and some potential applications in radioprotection and radioecology are presented.

Broad energy spectrum of laser-accelerated protons for spallation-related physics

A beam of MeV protons, accelerated by ultraintense laser-pulse interactions with a thin target foil, is used to investigate nuclear reactions of interest for spallation physics. The laser-generated proton beam is shown (protons were measured) to have a broad energy distribution, which closely resembles the expected energy spectrum of evaporative protons (below 50 MeV) produced in GeV-proton-induced spallation reactions. The protons are used to quantify the distribution of residual radioisotopes produced in a representative spallation target (Pb), and the results are compared with calculated predictions based on spectra modeled with nuclear Monte Carlo codes. Laser-plasma particle accelerators are shown to provide data relevant to the design and development of accelerator driven systems.

Alcohol use following liver transplantation: a comparison of follow-up methods

Alcoholic cirrhosis is one of the most common indications for liver transplantation. Previous researchers have studied rates of return to drinking following transplantation, however, few have employed prospective measures of alcohol use. The authors prospectively studied the alcohol use of patients transplanted for alcoholic liver disease. The authors improved the accuracy of monitoring alcohol use by using various methods for tracking patient's alcohol consumption, and we report on the time to first alcohol use after transplantation comparing these different methods. The authors found that alcohol use can occur very early after transplantation, even within the first 3 months posttransplant. Thirty-eight percent of the patients consumed any alcohol after transplantation. The clinical interviews by the psychiatrist were the most successful method for identifying posttransplant alcohol use. Posttransplant alcohol use was significantly associated with prior nonalcohol substance use (P < 0.025), family history of alcoholism in a first-degree relative (P < 0.025), and prior alcohol rehabilitation experience (P < 0.05) but not with a prior psychiatric history or less than 6 months of pretransplant sobriety. The authors indicate that prospective monitoring, using a combination of methods, is the most accurate approach to identify alcohol consumption. With this type of accuracy, risk factors can be identified and alcohol use can be compared with alcohol-related morbidity posttransplant.

Alcohol use following liver transplantation: a comparison of follow-up methods

Alcoholic cirrhosis is one of the most common indications for liver transplantation. Previous researchers have studied rates of return to drinking following transplantation, however, few have employed prospective measures of alcohol use. The authors prospectively studied the alcohol use of patients transplanted for alcoholic liver disease. The authors improved the accuracy of monitoring alcohol use by using various methods for tracking patient's alcohol consumption, and we report on the time to first alcohol use after transplantation comparing these different methods. The authors found that alcohol use can occur very early after transplantation, even within the first 3 months posttransplant. Thirty-eight percent of the patients consumed any alcohol after transplantation. The clinical interviews by the psychiatrist were the most successful method for identifying posttransplant alcohol use. Posttransplant alcohol use was significantly associated with prior nonalcohol substance use (P < 0.025), family history of alcoholism in a first-degree relative (P < 0.025), and prior alcohol rehabilitation experience (P < 0.05) but not with a prior psychiatric history or less than 6 months of pretransplant sobriety. The authors indicate that prospective monitoring, using a combination of methods, is the most accurate approach to identify alcohol consumption. With this type of accuracy, risk factors can be identified and alcohol use can be compared with alcohol-related morbidity posttransplant.

Use of a high-risk alcohol relapse scale in evaluating liver transplant candidates

BACKGROUND

Methods to improve assessment, selection, and monitoring of patients with alcoholic cirrhosis who pursue liver transplantation are sought continuously. We chose to investigate the use of the High-Risk Alcohol Relapse (HRAR) scale in our transplant population in the hope that it would improve our ability to identify and follow patients at highest risk for alcohol relapse.

METHODS

Detailed alcohol histories of 207 patients evaluated for liver transplantation were collected and graded for severity by using the HRAR. The HRAR provides information on the duration of alcohol use (a measure of chronicity), daily quantity of alcohol use, and rehabilitation experiences (treatment responsiveness). Posttransplant alcohol use was monitored through clinical follow-up in the transplant clinic.

RESULTS

Although men and women had similar years of heavy drinking pretransplant, women's daily alcohol consumption was significantly less than men's. HRAR scores did not distinguish those listed for transplant from those not listed or those who drank posttransplant from those who did not. Transplant patients were predominantly in the low-risk group (83% had an HRAR score <4).

CONCLUSIONS

The HRAR did not have predictive ability in our transplant population. Few of our patients were rated as high risk, and few drank posttransplant. Nevertheless, identifying patients at high risk may improve clinical care and decrease the rate of posttransplant alcohol consumption.

Photonuclear physics when a multiterawatt laser pulse interacts with solid targets

When a laser pulse of intensity 10(19) W cm(-2) interacts with solid targets, electrons of energies of some tens of MeV are produced. In a tantalum target, the electrons generate an intense highly directional gamma-ray beam that can be used to carry out photonuclear reactions. The isotopes 11C, 38K, (62,64)Cu, 63Zn, 106Ag, 140Pr, and 180Ta have been produced by (gamma,n) reactions using the VULCAN laser beam. In addition, laser-induced nuclear fission in 238U has been demonstrated, a process which was theoretically predicted at such laser intensities more than ten years ago. The ratio of the 11C and the 62Cu beta(+) activities yields shot-by-shot temperatures of the suprathermal electrons at laser intensities of approximately 10(19) W cm(-2).

Psychiatric evaluations of small intestine transplantation patients

We are gaining experience in small intestine transplantation, however, the procedure is still experimental. Morbidity and mortality can be significant with frequent rehospitalizations. The indications for small intestine transplantation are varied though most patients have developed short gut syndrome requiring total parenteral nutrition (TPN) for nutritional support. Patients may present with a chronic illness (such as Crohn's disease), chronic pain, and psychiatric comorbidity that may need to be addressed during the perioperative period. Faced with the complicated postoperative course, transplant recipients develop a range of endogenous and organic psychiatric disorders. Psychiatric treatment may be complicated by these factors in addition to the nutritional, biochemical, and metabolic abnormalities of a transplanted small intestine.

Concerns, affect, and cognitive disruption following completion of radiation treatment for localized breast or prostate cancer

PURPOSE/OBJECTIVES

To describe concerns, cognitive disruption, and affect following the completion of radiation treatment (RT) for localized breast or prostate cancer.

DESIGN

Cross-sectional, descriptive.

SETTING

Two RT centers associated with a university hospital.

SAMPLE

Patients who completed RT for prostate (n = 9) or breast cancer (n = 11). The mean age of the sample is 64 years. Ninety percent are Caucasian, 80% are married, 50% are of Latter-day Saint faith, and 50% are retired. All had early stage disease, with a mean of 20 months post-RT.

METHODS

One-time interview using qualitative methods and the Life Orientation Test, Revised Impact of Events Scale, state scale of the Positive and Negative Affect Schedule, satisfaction items of the Sarason Social Support Questionnaire, and Side Effect Severity Checklist.

MAIN RESEARCH VARIABLES

Frequency of intrusive thoughts or avoidant behavior, positive and negative affect, dispositional optimism, satisfaction with social support, severity of side effects, and themes extracted from semistructured interviews.

FINDINGS

Most subjects had unexpected intrusive thoughts about cancer; more than one-third avoided reminders of cancer. The level of positive affect was high, as was optimism. The level of negative affect was low. Subjects' satisfaction level with social support was high. Fatigue was the most frequently reported continuing side effect. Relative optimism, acceptance, vigilance, and trust of healthcare providers were major themes. Avoidance, comparison, maintaining normalcy, and information seeking were common coping strategies.

CONCLUSIONS

Subjects perceived themselves to be doing well. Fatigue was the most common long-term side effect. Subjects continued to seek information. Symptom vigilance and interpretation were important, as were having a positive outlook and maintaining normalcy.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must acknowledge the potential for concerns about symptoms and continuing side effects and what they mean for the patient. Clinicians need to provide accurate information about common post-treatment experiences. Clinicians also must remember that subjects have vivid recollections of both positive and negative interactions with healthcare providers.

The self-esteem of adolescents with cerebral palsy

This paper examined the self-esteem of 22 adolescents with cerebral palsy (CP) (11 girls, 11 boys) who were matched by sex, school, age, and IQ with 22 nondisabled adolescents. Subjects completed the Tennessee Self-Concept Scale (TSCS), the Family Adaptability and Cohesion Evaluation Scale II (FACES II), and a demographic questionnaire. Multivariate analysis of variance revealed that the girls with CP scored significantly lower than the boys with CP, the nondisabled boys, and nondisabled girls on physical self-esteem, and the nondisabled girls and boys with CP on social self-esteem. The scores of the boys with CP were similar to those of the nondisabled groups. This differential effect of disability on males and females is discussed in terms of the interactionist theory and the implications for occupational therapy.

Single subject research designs in occupational therapy literature

This paper examines two years (1982-1983) of publications appearing in four occupational therapy journals in order to determine the type and proportion of articles which are descriptive, survey, correlational, case studies (including single subject design), quasi-experimental, or practical. In addition, a detailed analysis of articles using single subject methodology in occupational therapy is reported. The appropriateness of several single subject research designs in occupational therapy is discussed.

Outbreak of Mycoplasma pneumoniae infection among hospital personnel

An outbreak of illness due to Mycoplasma pneumoniae occurred among employees of a large hospital. The spectrum of disease ranged from severe upper respiratory infection to multilobed pneumonia. No unusual increase in the incidence of respiratory illness due to this organism was observed in the surrounding community during the period under investigation. It was not possible to identify any single area of the hospital frequented by enough of the involved personnel to explain the spread of the infection among the hospital's employees. This is the first outbreak of M pneumoniae disease to be reported among hospital personnel.

Helplessness, hope, and the occupational therapist

This article examines how the loss of perceived control over one's environment (i.e. “helplessness”) can result in anxiety, depression, or death in people who otherwise appear to have favorable prognoses. Particular reference is made to the role of helplessness as a potentially life threatening condition in the older patient. Four effects of helplessness are discussed along with their implications for treatment. The paper presents seven specific treatment strategies for combatting the condition of helplessness, all of which are compatible with the skills possessed by an occupational therapist.