Computed Tomography Measurements in Assessment of Idiopathic Vocal Fold Paralysis

OBJECTIVE

Our study aimed to both identify the incidence and clinical presentation of patients presenting with idiopathic vocal fold paralysis (IVFP). Secondarily we aimed to assess the radiographic findings of computed tomography (CT) studies along the course of the vagus and recurrent laryngeal nerves (RLN), specifically measuring for potential areas of compression at the skull base and mediastinum. We hypothesized that a proportion of patients diagnosed with IVFP would have significant differences in measurements when compared to age-gender matched controls on CT imaging.

STUDY DESIGN

Institutional review board approved retrospective cohort study METHODS: We assessed patients presenting to a tertiary voice care center between 2003 and 2019 with diagnosis of vocal fold paralysis. Data collected includes demographics, clinical exam findings, and CT measurements including dimensions at bilateral jugular foramen, aortopulmonary (AP) window and surrounding vascular structures. Statistical analysis was then performed using Pearson χ², and Mann Whitney U tests to determine differences variables of interest.

RESULTS

A total of 606 patients were reviewed. Of these patients 60 (9.9%) patients were determined to have IVFP. Left-sided VFP was seen more commonly in 78.3% (N = 47) of idiopathic patients. Our IVFP group had an overall higher incidence of cardiovascular disease [OR = 3.378, 95%CI 1.907-5.941, P < 0.001] compared to those with identified causes for paralysis. Specifically, IVFP patients showed a higher incidence of combined cardiovascular co-morbidities (P < 0.001), mitral valve stenosis (P = 0.007), pulmonary hypertension (P < 0.0001) and congestive heart failure (P < 0.001). When evaluating CT imaging, the AP window was mentioned in only 2 (3.3%) of our idiopathic patients CT reports. The IVFP cohort had a lower median AP window volume (P = 0.020) when compared to age-gender matched controls. This significantly smaller AP window volume was also seen when only left sided IVFP compared to both right-sided paralysis (P < 0.001) and age matched control patients (P < 0.001).

CONCLUSION

The significance of cardiovascular comorbidities combined with findings of statistically narrowed AP window may help provide an explanation of a subset of patients diagnosed with IVFP.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap

BACKGROUND

Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion.

METHODS

A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time.

RESULTS

One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union.

CONCLUSION

This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Use of a Nonexercise Estimate for Prestroke Peak Vo2 During the Acute Stroke Hospital Stay

PURPOSE

For individuals with acute stroke, it is difficult to conduct an exercise test to assess peak oxygen consumption (peak Vo₂). Therefore, the purpose of this study was to use a clinically feasible tool for assessing prestroke peak Vo₂ using a nonexercise estimation equation to test whether estimated prestroke peak Vo₂ was related to the functional outcome measures at discharge from the hospital in individuals after an acute stroke. We hypothesized that the estimated prestroke peak Vo₂ would be significantly related to discharge Physical Performance Test (PPT), 6-minute walk test (6MWT), and lower extremity Fugl-Meyer (LEFM) assessment.

METHODS

Estimated prestroke peak Vo₂ was calculated using a previously validated prediction equation using the following variables: body mass index, age, sex, resting heart rate, and a self-reported measure of physical activity. Outcome measures were assessed 4 days after enrollment or immediately before discharge (whichever occurred first).

RESULTS

Thirty-four participants (mean age = 56.0, SD = 12.6 years; 20 men) with acute stroke were enrolled within 48 hours of admission. For all individuals, mean estimated prestroke peak Vo₂ was 27.3 (SD = 7.4) mL·kg^-1·min^-1 and had a weak, nonsignificant relationship with the PPT (r = 0.19; P = .28), 6MWT (r = 0.10; P = .56), and LEFM (r = 0.32; P = .06). However, when considering sex, women, but not men, had a significant relationship with LEFM (r = 0.73; P = .005) and moderate but nonsignificant relationship with PPT (r = 0.53; P = .06) and 6MWT (r = 0.47; P = .10).

CONCLUSIONS

Within 48 hours of stroke admission, we were able to administer a nonexercise equation to estimate prestroke peak Vo₂. For the entire sample, functional measures conducted at discharge were not related to estimated prestroke peak Vo₂. However, when considering sex, the relationship between prestroke Vo₂ and the functional measures was strengthened.

Understanding and modulating opalescence and viscosity in a monoclonal antibody formulation

Opalescence and high viscosities can pose challenges for high concentration formulation of antibodies. Both phenomena result from protein-protein intermolecular interactions that can be modulated with solution ionic strength. We studied a therapeutic monoclonal antibody (mAb) that exhibits high viscosity in solutions at low ionic strength ( approximately 20 cP at 90 mg/mL and 23 degrees C) and significant opalescence at isotonic ionic strength (approximately 100 nephelometric turbidity units at 90 mg/mL and 23 degrees C). The intermolecular interactions responsible for these effects were characterized using membrane osmometry, static light scattering, and zeta potential measurements. The net protein-protein interactions were repulsive at low ionic strength ( approximately 4 mM) and attractive at isotonic ionic strengths. The high viscosities are attributed to electroviscous forces at low ionic strength and the significant opalescence at isotonic ionic strength is correlated with attractive antibody interactions. Furthermore, there appears to be a connection to critical phenomena and it is suggested that the extent of opalescence is dependent on the proximity to the critical point. We demonstrate that by balancing the repulsive and attractive forces via intermediate ionic strengths and by increasing the mAb concentration above the apparent critical concentration both opalescence and viscosity can be simultaneously minimized.

Highly Concentrated Monoclonal Antibody Solutions: Direct Analysis of Physical Structure and Thermal Stability

Virtually all current analytical methods employed in the development of highly concentrated monoclonal antibody (MAb) formulations require dilution of the sample before acquiring data. Thus, there is an unmet need for methods to study proteins directly at high concentration, since extrapolation of stability indicating parameters obtained from dilute studies may not be representative of the high concentration solution. Only slight or no modifications of biophysical methods including fluorescence, UV absorbance, circular dichroism, and FTIR (ATR and transmittance) spectroscopies as well as differential scanning calorimetry (DSC) are described here that permit the direct study of immunoglobulins (and other proteins) at high concentrations. Although FTIR spectra show differences that are dependent upon sampling geometry, other spectroscopic data from two different recombinant MAbs suggests that structure of each antibody exists in a physically similar state in the concentration range of 0.1-190 mg/mL in 40 mM pH 6 citrate-phosphate buffer. Upon thermally stressing these proteins, spectroscopic techniques that probe tertiary structure demonstrate a decrease in the apparent thermal melting temperature of approximately 5-20 degrees C of both proteins with increasing concentration. In contrast, DSC thermograms and CD thermal experiments suggest a minor degree of stabilization (approximately 2 degrees C) for both antibodies although protein association could be responsible for these observations. Empirical phase diagrams produced from spectroscopic data also suggest (1) the existence of similar structural states at low temperatures independent of concentration and (2) a decrease in the temperature at which phase changes are observed with increasing concentration. The decrease in structural stability observed in these studies is probably the result of aggregation or self-association of the recombinant MAbs upon heating in crowded solutions and not due to a decrease in the intrinsic structural stability of the MAbs.