Lymphoma recurrence presenting as vocal cord fixation

Lymphomas of the larynx are a rare finding. Those with lymphoma of the larynx often present with symptoms such as vocal hoarseness, throat pain, dysphagia, and weight loss. This is a case of a 74-year-old man who presents with new onset of hoarseness and dysphagia. He has a previous history of diffuse large B-cell lymphoma (DLBCL) but was thought to be in remission at the time of presentation. On nasolaryngoscopy, there was a large, right sided, sub-mucosal mass with right vocal cord fixation. Physical exam and computed topography of the neck did not identify any adenopathy. Biopsy confirmed the recurrence of DLBCL isolated to the larynx at the time of diagnosis. The patient was treated with chemotherapy and fully recovered his vocal cord motion with resolution of his hoarseness and dysphagia. Physicians should consider lymphoma in patients presenting with laryngeal complaints especially in patients with a history of lymphoma.

Objective Quantification of Opioid Usage After Thyroid Surgery

Introduction  It is well established that America is in the midst of an opioid crisis with 46 people dying every day from overdoses involving prescription opioids. In the last 2 years, multiple articles have been published indicating that the amount of opioid pain medication needed after discharge from thyroid and parathyroid surgery is low.

Objective  To objectively examine the amount of opioid pain medication required by patients in our practice after thyroid surgery.

Methods  Patients were given a standardized discharge prescription of 30 pills with a combination of 7.5 mg of hydrocodone and 325 mg of acetaminophen after thyroid surgery. They were asked to log the number of pills consumed per day and the level of pain per day using the Wong-Baker faces pain scale. We used in-office pill counts to ensure accuracy of the logs.

Results  While reaching a similar conclusion, the present study is the first to objectively examine the quantity of opioid pain medication consumed between postoperative discharge and office follow-up. Our study objectively demonstrates that 85% of patients consumed less than 75.0 morphine milligram equivalent (MME) after thyroid surgery using in-office pill counts.

Conclusion  Recent multimodality anesthesia research appears promising to dramatically reduce or even eliminate the need for opioid prescriptions upon postoperative discharge.

Case report: Traumatic lingual hematoma

We describe a case of traumatic lingual hematoma in a patient on dual antiplatelet therapy. After securing the airway, bilateral lingual artery embolization successfully halted expanding hematoma formation. Patient subsequently required tracheostomy for continued airway edema. Although patient course was wrought with postoperative complications, we review this case to illustrate how prompt hematoma evacuation and embolization can resolve significant vasovagal bradycardia and hypotension secondary to expansile lingual hematoma.

Correlating regional emergency epistaxis visits with internet search activity

PURPOSE

To investigate the correlation between internet search activity and epistaxis-related Emergency Department visits.

MATERIALS AND METHODS

Data from Google Trends were obtained (www.google.com/trends) for the search term "nosebleed" in Erie County, Pennsylvania during a five-year period. All epistaxis-related CPT code events were obtained from one hospital in this county during the same period. Google total counts were cross tabulated with the following month's ED visits. Graphical analysis and correlation were used to assess the relationship between ED visits and search engine activity.

RESULTS

A strong positive correlation was observed between epistaxis-related ED visits and search engine activity for the term "nosebleed" (r = 0.655).

CONCLUSION

Search engine activities for the term "nosebleed" correlates strongly with epistaxis-related ED visits. This study demonstrates the usefulness of utilizing Google Trends search data to assess regional disease burdens, which may provide a means for epidemiological study that is quicker than conventional methods.

Validity of longitudinal sections for determining the apical constriction

AIM

To validate the use of longitudinal sections against cross sections using micro-CT for disclosing the topography and location of the apical constriction.

METHODOLOGY

Seventy extracted human teeth with 117 completely developed roots were micro-CT scanned and reconstructed at a voxel size of 27 μm. The 3DSlicer program was used to navigate the longitudinal sections parallel to the long axis of the canal and also to rotate and tilt the views. Each root canal was evaluated in both mesio-distal and bucco-lingual planes. Constriction topographies were identified as described in the literature. In each canal, the number of different topographies detected was recorded. Further, serial cross-sectional analysis of the apical portion of the canal was performed. Reconstructed plots of canal areas were assessed to locate the constriction and determine its form. A descriptive analysis of both longitudinal and cross section methods was conducted. In each canal, the frequency of constriction forms was calculated in the mesio-distal or bucco-lingual aspects and the 99% confidence interval was computed.

RESULTS

When both aspects of the longitudinal sections were pooled, all root canals had two or more topographies and consequently different locations of the apical constriction. In contrast, cross-sectional analysis constantly yielded one constriction form per canal.

CONCLUSION

Compared to cross-sectional analysis, longitudinal sections of the root canal conveyed inconsistent results regarding the topography and the location of the apical constriction.

Maturational, comorbid, maternal and discharge domain impact on preterm rehospitalizations: a comparison of planned and unplanned rehospitalizations

OBJECTIVE

To determine the predictive value of (1) maternal, (2) maturational, (3) comorbid and (4) discharge domains associated with preterm infant rehospitalization.

STUDY DESIGN

Retrospective, cohort study of preterm infants discharged home from a level IV neonatal intensive care unit. Rates of unplanned and planned 6-month readmissions were assessed. The four domains were modeled incrementally and separately to predict relative and combined contributions to the readmission risk.

RESULT

Out of 504 infants, 5% had 30-day readmissions (22 unplanned, three planned). By 6 months, 13% were rehospitalized (52 unplanned, 15 planned). Sixty-seven infants had 96 readmission events with 30% of readmission events elective. The four domains together predicted 78% of total 1-month, all 6-month and unplanned 6-month readmissions. Discharge complexity was as predictive as comorbidity in all models.

CONCLUSION

These four-domain models were more predictive than single domains. Many total readmission events were planned, suggesting parsing planned and unplanned rehospitalizations may benefit quality-improvement efforts.

Innocuous-related sural nerve-evoked and finger-evoked potentials generated in the primary somatosensory and supplementary motor cortices

OBJECTIVE

Our earlier work revealed two components of the somatosensory evoked potential, which we have labeled SP1 and SP4a, that appear to be generated by neurons involved in the innocuous aspects of somatosensation. The objective of the present study was to examine a hypothesis developed in our earlier work, namely that SP1 and SP4a are generated in the primary somatosensory cortex.

METHODS

The dipole source localization method was applied to SP1 and SP4a evoked by electrical stimulation of the fingers and of the sural nerve in 20 subjects. The subjects rated the subjective magnitude of each stimulus on a 9 point scale.

RESULTS

The finger-evoked and sural nerve-evoked SP1 were best-fit by single sources located in the primary somatosensory cortex (SI) hand and foot areas, respectively. Both the finger-evoked and the sural nerve-evoked SP4a, on the other hand, were best-fit by a single source located in the supplementary motor area (SMA).

CONCLUSIONS

These results are consistent with our hypothesis that SP1 reflects the activity of SI neurons that are involved in innocuous somatosensation. SP4a is not generated in SI as we originally hypothesized, but rather in the SMA. The SP4a amplitude-stimulus intensity function and the dependence of the SP4a source location on the evoking stimulus site and not the hand registering the magnitude rating suggests that SP4a reflects the response of SMA neurons to afferent input from the innocuous somatosensory pathways. Hence, SP4a may be generated by SMA activity involved in the sensory-guided selection and/or generation of motor responses.

Evidence that the anterior cingulate and supplementary somatosensory cortices generate the pain-related negative difference potential

OBJECTIVE

The pain-related negative difference potential (NDP) is derived by subtracting sural nerve-evoked somatosensory evoked potentials elicited at the pain threshold level from those elicited at supra-pain threshold levels. This experiment evaluated a hypothesis derived from our earlier work, namely that the NDP is generated by pain-related activity in the primary somatosensory (SI) cortex.

METHODS

The dipole source localization method was applied to NDPs evoked by electrical stimulation of the finger and of the sural nerve in 20 subjects.

RESULTS

Comparison of several one-, two- and three-source configurations demonstrated that both the finger-evoked NDP and the sural nerve-evoked NDP are best-fit by two sources, with one located in or near the anterior cingulate cortex and the other in or near the supplementary somatosensory area.

CONCLUSIONS

Both the anterior cingulate cortex and the supplementary somatosensory area receive afferent projections from medial thalamic nuclei that receive nociceptive inputs, and both have been shown to respond to noxious stimulation. Hence, although the results of this experiment did not confirm our hypothesis that the NDP is generated in SI, they are consistent with the hypothesis that the NDP is generated in the supraspinal pain pathways.

The pain-related negative difference potential: a direct measure of central pain pathway activity or of interactions between the innocuous somatosensory and pain pathways?

Negative difference potential (NDP) is a sural nerve-evoked scalp potential derived by subtracting potentials elicited at the pain threshold level from those elicited at supra-pain threshold levels. Our recent work examined the possibility that the NDP reflects a pain-related inhibition of neurons in the innocuous somatosensory pathways. Although failing to find any evidence for this inhibition, these studies do present the possibility that the NDP reflects an attention- and/or task-related decrease in the innocuous somatosensory activity that is elicited by the noxious electrical stimulus. To test this hypothesis, 35 healthy subjects were given three attention/task relevance conditions presented in counterbalanced order: rate the subjective magnitude of the painful aspects of the noxious electrical stimulus; rate the subjective magnitude of the non-painful aspects of the noxious electrical stimulus; and, ignore the stimulus. Neither changes in attention nor the task relevance of the non-painful aspects of the stimulus had any effect on NDP amplitude. These data demonstrate that the NDP does not reflect an attention- or task-related modulation of innocuous somatosensory activity. Rather, our evidence to date suggests that the NDP is generated by activity in the central pain pathways.

Allogeneic bone marrow transplantation for acute leukemia refractory to induction chemotherapy

This article compares the outcome of 14 patients with primary refractory acute leukemia who underwent bone marrow transplantation from human leukocyte antigen (HLA)-identical donors with that of 18 age-matched control patients who received chemotherapy. Complete clearing of leukemia was seen in all 14 transplanted patients. Five of the transplanted patients are alive 98 to 1790 days posttransplant, and four are free of leukemia. Nine patients have died, eight with severe graft-versus-host disease associated with interstitial pneumonia or systemic infections and one with relapse from chemotherapy-associated infections. Engraftment was seen in all patients. Severe graft-versus-host disease (grades III and IV) was seen in ten patients and resolved in three patients following high-dose corticosteroid treatment. Three of the 18 control patients are alive, none of them in complete remission. It appears that the combination of piperazinedione and total-body irradiation followed by allogeneic transplant is effective induction treatment for primary refractory acute leukemia and will be considered in the future as first salvage treatment for patients failing induction treatment.

Obstructive lung disease after allogeneic bone marrow transplantation

We report the cases of 3 patients with marked dyspnea and an obstructive ventilation disorder associated with chronic graft-versus-host disease after allogeneic bone marrow transplantation. This disorder was characterized by recurrent pulmonary infections and colonization of the lower respiratory tract by Pseudomonas aeruginosa. Two patients have shown rapidly progressive deterioration with death following due to respiratory failure. Intensive therapy with antibiotics, bronchodilators, high-dose steroids, and azathioprine was not effective in arresting the malignant course of this disorder.

Results in patients with breast cancer treated by radical mastectomy and postoperative irradiation with no adjuvant chemotherapy

In 1963 an electron beam became available, making irradiation of the chest wall technically easy. In addition to peripheral lymphatic irradiation in patients with positive axillary nodes and/or the tumor in the inner quadrants or centrally located, patients with tumor larger than 5 cm or with grave signs and/or a significant incidence of positive axillary nodes received chest wall irradiation. None of the patients has received elective chemotherapy. Disease-free survival rates at ten years are 54% for the overall group, 79% for the patients with negative nodes, 44% for patients with positive nodes, 61% for patients with 1-3 positive nodes, and 33% for patients with four or more positive nodes. The incidence of peripheral lymphatic failures is low as well as the incidence of failures on the chest wall in the patients having had chest wall irradiation. With the availability of electron beam and adjustments in doses, complications are nonexistent. The incidence of treatment failures, local-regional, or distant, that have appeared by ten years are compared with the incidence of failures that were experienced by the placebo patients in the clinical trial of the NSABP of thio-TEPA versus placebo. The clearly lesser incidence of treatment failures in the U.T.M.D. Anderson Hospital patients either suggests that postoperative irradiation may have survival benefits or that the data of the NSABP series are not representative of all series.

Visceral Kaposi's sarcoma presenting as colitis

An unusual example of Kaposi's sarcoma is reported in which the patient presented with a history of intractable diarrhea of 18 months duration. The roentgenographic and endoscopic findings were those of a segmental colitis. The diagnosis was established following the appearance of skin lesions and after a subtotal colectomy was performed. Kaposi's sarcoma was present in both the skin and colon.